Microwave coagulation therapy for hepatocellular carcinoma

Functionalized Nanomaterials for Inhibiting ATP-Dependent Heat Shock Proteins in Cancer Photothermal/Photodynamic Therapy and Combination Therapy

Phototherapies induced by photoactive nanomaterials have inspired and accentuated the importance of nanomedicine in cancer therapy in recent years. During these light-activated cancer therapies, a nanoagent can produce heat and cytotoxic reactive oxygen species by absorption of light energy for photothermal therapy (PTT) and photodynamic therapy (PDT). However, PTT is limited by the self-protective nature of cells, with upregulated production of heat shock proteins (HSP) under mild hyperthermia, which also influences PDT. To reduce HSP production in cancer cells and to enhance PTT/PDT, small HSP inhibitors that can competitively bind at the ATP-binding site of an HSP could be employed. Alternatively, reducing intracellular glucose concentration can also decrease ATP production from the metabolic pathways and downregulate HSP production from glucose deprivation. Other than reversing the thermal resistance of cancer cells for mild-temperature PTT, an HSP inhibitor can also be integrated into functionalized nanomaterials to alleviate tumor hypoxia and enhance the efficacy of PDT. Furthermore, the co-delivery of a small-molecule drug for direct HSP inhibition and a chemotherapeutic drug can integrate enhanced PTT/PDT with chemotherapy (CT). On the other hand, delivering a glucose-deprivation agent like glucose oxidase (GOx) can indirectly inhibit HSP and boost the efficacy of PTT/PDT while combining these therapies with cancer starvation therapy (ST). In this review, we intend to discuss different nanomaterial-based approaches that can inhibit HSP production via ATP regulation and their uses in PTT/PDT and cancer combination therapy such as CT and ST.

Oncological Outcomes of Operative Microwave Ablation for Intermediate Stage Hepatocellular Carcinoma: Experience in 246 Consecutive Patients

BACKGROUND

Few clinical studies concerning the efficacy of microwave ablation for intermediate stage hepatocellular carcinoma have been published. Our purpose was to examine perioperative and long-term outcomes after operative microwave ablation for intermediate stage hepatocellular carcinoma.

METHODS

This retrospective study included 246 patients who had undergone operative microwave ablation for intermediate stage hepatocellular carcinoma in our institute between January 2001 and December 2017. We analyzed overall and recurrence-free survival and used the Cox proportional hazard model to evaluate potential prognostic factors.

RESULTS

The overall median follow-up time was 51 months. The 1-, 3-, 5-, and 10-year overall survival rates were 98%, 74%, 51%, and 28%, respectively, whereas the 1-, 3-, 5-, and 10-year recurrence-free survival rates were 80%, 32%, 18%, and 10%, respectively. The major complication rate (Clavien-Dindo classification IIIa or above) after operative microwave ablation was 7%, with no procedure-related mortality. Multivariate analysis identified beyond up-to-7 criteria (the sum of the largest tumor's diameter in cm and the total number of tumors), Child-Pugh grade B, and serum alpha-fetoprotein concentration ≥ 100 ng/mL as independent risk factors for overall survival after operative microwave ablation. The overall survival of patients within up-to-7 and Child-Pugh grade A was better than that of the remaining patients, 5-year overall survivals being 67% and 37%, respectively (P < 0.001).

CONCLUSIONS

Operative microwave ablation is safe and effective in patients with intermediate stage hepatocellular carcinoma. In particular, patients within up-to-7 and Child-Pugh grade A can be expected to have better long-term outcomes after operative microwave ablation.

How Did Conventional Nanoparticle-Mediated Photothermal Therapy Become "Hot" in Combination with Cancer Immunotherapy?

Simple Summary

Photothermal therapy (PTT) has become effective through the development of nanoparticle-based photoabsorbers with various functions, such as targeting properties, high light-to-heat conversion, and photostability. Conventional nanoparticle-mediated PTT has attained localized efficiency in cancer treatment by heat-induced apoptosis or necrosis of cancer cells. Currently, such treatment methods evolve into cancer immunotherapy through the induction of immunogenic cell death (ICD). Damage-associated molecular patterns from dead cells by nanoparticle-mediated PTT activate immune cells for systemic anti-cancer effect. In this review, we investigate various nanoparticle-based PTT and compare its methodology to clarify how it undergoes a transition from thermotherapy to immunotherapy.

Abstract

One of the promising cancer treatment methods is photothermal therapy (PTT), which has achieved good therapeutic efficiency through nanoparticle-based photoabsorbers. Because of the various functions of nanoparticles, such as targeting properties, high light-to-heat conversion, and photostability, nanoparticle-mediated PTT successfully induces photothermal damage in tumor tissues with minimal side effects on surrounding healthy tissues. The therapeutic efficacy of PTT originates from cell membrane disruption, protein denaturation, and DNA damage by light-induced heat, but these biological impacts only influence localized tumor areas. This conventional nanoparticle-mediated PTT still attracts attention as a novel cancer immunotherapy, because PTT causes immune responses against cancer. PTT-induced immunogenic cell death activates immune cells for systemic anti-cancer effect. Additionally, the excellent compatibility of PTT with other treatment methods (e.g., chemotherapy and immune checkpoint blockade therapy) reinforces the therapeutic efficacy of PTT as combined immunotherapy. In this review, we investigate various PTT agents of nanoparticles and compare their applications to reveal how nanoparticle-mediated PTT undergoes a transition from thermotherapy to immunotherapy.

Operative Microwave Ablation for Hepatocellular Carcinoma Within 3 cm and 3 Nodules: Experience in 559 Patients

BACKGROUND

There are few published data regarding long-term outcome survival after microwave ablation (MWA) for hepatocellular carcinoma (HCC) within 3 cm and 3 nodules. The aim of this study was to examine long-term outcomes after operative MWA for HCC within 3 cm and 3 nodules.

METHODS

This cohort of this retrospective study comprised 559 patients who underwent operative MWA for HCC within 3 cm and 3 nodules in our institute between 1996 and 2017. We analyzed overall survival (OS) and recurrence-free survival (RFS), and evaluated factors related to prognosis.

RESULTS

Median follow-up time was 69 months for the entire cohort. OS rates were 1-year: 98%, 3-year: 87%, 5-year: 73%, and 10-year:39%; RFS rates were 1-year: 91%, 3-year: 60%, 5-year: 42%, and 10-year: 21%. Multivariate analysis revealed that hepatitis C virus (HCV)-positive status, ALBI grade 2 or 3, maximum tumor diameter ≥ 20 mm, and multiple nodules were independent risk factors for both OS and RFS. A prognostic staging model using one point for each risk factor provided a well-categorized predictive model. The 5-year OS rates were 93%, 81%, and 57% for scores of 0, 1 or 2, and 3 or 4, respectively (P < 0.001). The 5-year RFS rates were 70%, 48%, and 28% for scores of 0, 1 or 2, and 3 or 4, respectively (P < 0.001).

CONCLUSIONS

Our results revealed good long-term outcomes after operative MWA for HCC within 3 cm and 3 nodules.

Recurrence of Hepatocellular Carcinoma in Hepatitis C Virus (HCV) Liver Transplant Recipients Treated with Pretransplant Direct-Acting Antiviral (DAA) Therapy

Background

Direct-acting antivirals (DAAs) have revolutionized the treatment of hepatitis C virus (HCV). The impact of DAAs on recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) remains uncertain.

Objective

We aimed to evaluate the risk of HCC recurrence in LT recipients cleared of HCV with DAAs at the time of LT compared to a control group of LT recipients who were viremic at the time of LT.

Methods

The study was a single-center, retrospective cohort study of patients undergoing LT for HCV-related HCC from 2002 to 2017. We compared time to post-LT HCC recurrence in patients with a sustained virological response (SVR) from DAAs prior to LT (DAA group) to patients who were viremic at LT (HCV+ group) using Kaplan-Meier analysis. We performed a secondary analysis comparing post-LT HCC recurrence in the DAA group to LT recipients with SVR from interferon-based treatment prior to LT (IFN group).

Results

One hundred fifty-one patients underwent LT for HCC related to HCV: 34 patients in DAA group, 95 patients in HCV+ group, and 22 in IFN group. Kaplan-Meier estimates of being HCC free were 96.2, 96.2, and 78.8% at 6, 12, and 24 months in DAA group, respectively, and 100, 98.6, and 95.8% at 6, 12, and 24 months in the HCV+ group, respectively; p = 0.08. There was no difference observed for HCC recurrence between the DAA and IFN groups. In a multivariate Cox proportional hazards model, DAA use increased the risk of post-LT HCC recurrence (HR 5.2, 95% CI 0.9-29.81, p = 0.07).

Conclusions

A strong trend was observed on both Kaplan-Meier and multivariate analyses toward increased post-LT HCC recurrence in patients who achieved SVR prior to LT with DAAs compared to patients who were viremic at LT. Caution is required when considering pre-LT treatment of HCV with DAAs in patients with HCC.

Enhancement of Photodynamic Cancer Therapy by Physical and Chemical Factors

The viable use of photodynamic therapy (PDT) in cancer therapy has never been fully realized because of its undesirable effects on healthy tissues. Herein we summarize some physicochemical factors that can make PDT a more viable and effective option to provide future oncological patients with better-quality treatment options. These physicochemical factors include light sources, photosensitizer (PS) carriers, microwaves, electric fields, magnetic fields, and ultrasound. This Review is meant to provide current information pertaining to PDT use, including a discussion of in vitro and in vivo studies. Emphasis is placed on the physicochemical factors and their potential benefits in overcoming the difficulty in transitioning PDT into the medical field. Many advanced techniques, such as employing X-rays as a light source, using nanoparticle-loaded stem cells and bacteriophage bio-nanowires as a photosensitizer carrier, as well as integration with immunotherapy, are among the future directions.

The Efficacy and The Safety of Ultrasound-guided Ablation Therapy for Treating Papillary Thyroid Microcarcinoma

The prevalence of papillary thyroid microcarcinoma (PTMC) increases rapidly all around the world, but the management of PTMC hasn't reached a consensus. Recently, ultrasound-guided (US-guided) ablation therapy was introduced as a feasible treatment for low-risk PTMC. The clinical application of US-guided ablation therapy needs doctors' effort to investigate the efficacy and the safety of US-guided ablation in treating PTMC carefully. Although the present evidence showed some limitations, such as short-term study time spans and no randomized control design, in our perspective, US-guided thermal ablation therapy has good short-term efficacy and safety and is a promising PTMC's treatment in future clinical practice.

Actual 10-Year Survival After Surgical Microwave Ablation for Hepatocellular Carcinoma: A Single-Center Experience in Japan

BACKGROUND

Little evidence exists regarding long-term survival after microwave ablation for hepatocellular carcinoma (HCC). The aim of this study is to determine actual 10-year survival and clarify the clinicopathological features of patients surviving ≥ 10 years after surgical microwave ablation.

PATIENTS AND METHODS

This retrospective study identified 459 patients who underwent surgical microwave ablation for HCC with curative intent between 2001 and 2008. We compared 100 patients who survived ≥ 10 years with 321 patients who died within 10 years.

RESULTS

Median overall survival and recurrence-free survival rates were 5.5 and 2.4 years, respectively. The actual 10-year overall survival rate was 23.8%, and the actual 10-year recurrence-free survival rate was 8.1%. Multivariate analysis showed that age > 70 years [odds ratio 1.87, P = 0.029], hepatitis C virus positivity (OR 2.30, P = 0.004), Child-Pugh class B (OR 3.28, P = 0.003), and platelet count < 10 × 10⁴ /µL (OR 1.93, P = 0.033) were independent risk factors for actual 10-year survival. During 10-year follow-up, 66% of the ≥ 10-year survivors developed recurrence, and 91% of these patients underwent further curative treatment, including hepatic resection or local ablation, for HCC recurrence.

CONCLUSION

Ten-year survival after surgical microwave ablation for HCC can be expected in approximately 24% of patients, even though nearly 2/3 of our 10-year survival patients experienced recurrence. Close postoperative follow-up and further curative treatment for recurrence are important for improving long-term survival.

Hepatic resection versus operative microwave ablation for single hepatocellular carcinoma ≤5 cm: A propensity score-matched analysis

BACKGROUND

Little evidence exists regarding the perioperative and oncologic benefits of microwave ablation for hepatocellular carcinoma. The aim of this study was to compare the efficacy of hepatic resection and operative microwave ablation (microwave coagulo-necrotic therapy) for single hepatocellular carcinoma ≤5 cm.

METHODS

Between 1994 and 2015, a total of 551 patients with a single hepatocellular carcinoma ≤5 cm were treated in our institution (hepatic resection: n = 128; microwave coagulo-necrotic therapy: n = 423). We compared overall survival and recurrence-free survival between hepatic resection and microwave coagulo-necrotic therapy. Propensity score matching analysis identified 94 matched pairs of patients to compare outcomes.

RESULTS

After propensity score matching, baseline variables, including liver function and tumor size, were well-balanced between the 2 groups. The 5- and 10-year overall survival rates were 76% and 47% for hepatic resection and 77% and 48% for microwave coagulo-necrotic therapy, respectively (P = .865). The 5- and 10-year recurrence-free survival rates were 55% and 41% for hepatic resection and 47% and 32% for microwave coagulo-necrotic therapy, respectively (P = .377). In the subgroup analysis, the hepatic resection group had better recurrence-free survival than the microwave coagulo-necrotic therapy group in patients with tumor size >3 cm, with 5-year recurrence-free survival rates of 56.5% and 32.4% in the hepatic resection and microwave coagulo-necrotic therapy group, respectively (P = .029).

CONCLUSION

Our propensity score matching study confirmed no statistically significant differences in both overall survival and recurrence-free survival between hepatic resection and microwave coagulo-necrotic therapy for single hepatocellular carcinoma ≤5 cm; however, hepatic resection is recommended for hepatocellular carcinoma with tumor size >3 cm when patients have good liver function.

New Trends in the Surgical Treatment of Colorectal Cancer Liver Metastases

Colorectal cancer is one of the most common solid tumors affecting people around the world. A significant proportion of patients with colorectal cancer will develop or will present with liver metastases. In some of these patients, the liver is the only site of metastatic disease. Thus, surgical treatment approaches are an appropriate and important treatment option in patients with liver-only colorectal cancer metastases. Resection of colorectal cancer liver metastases can produce long-term survival in selected patients, but the efficacy of liver resection as a solitary treatment is limited by two factors. First, a minority of patients with liver metastases have resectable disease. Second, the majority of patients who undergo successful liver resection for colorectal cancer metastases develop recurrent disease in the liver, extrahepatic sites, or both. In this paper, in addition to the results of liver resection for colorectal cancer metastases, we will review the results of cryoablation, heat ablation, and hepatic arterial chemotherapy using a surgically implanted pump. Each of these surgical treatment modalities can produce long-term survival in a subset of patients with liver-only colorectal cancer metastases, whereas systemic chemotherapy used alone rarely results in long-term survival in these patients. While surgical treatments provide the best chance for long-term survival or, in some cases, the best palliation in patients with colorectal cancer liver metastases, it is clear that further improvements in patient outcome will require multimodality therapy regimens.

Prognostic value of carcinoembryonic antigen level in patients with colorectal cancer liver metastasis treated with percutaneous microwave ablation under ultrasound guidance

Thermal ablation is an alternative treatment for colorectal cancer liver metastasis (CRLM). However, prognostic factors in patients with CRLM who have undergone microwave ablation (MWA) have not been clearly defined. Therefore, this study aimed to analyze the risk factors associated with early recurrence in patients with CRLM treated with MWA.Herein, we retrospectively analyzed data for 140 patients with CRLM who underwent MWA from 2013 to 2015 in our institution. Patients were grouped by median pretreatment carcinoembryonic antigen (CEA) level into the high CEA level (>3.7 ng/mL) group and low CEA level (≤3.7 ng/mL) group. Variables that might affect overall survival were subjected to univariable and multivariable Cox regression analysis.Our results showed a median progression-free survival (PFS) and median liver progression-free survival (LPFS) of 9 and 11.5 months, respectively, for the 99 CRLM patients analyzed. Both the median PFS duration (7.5 vs. 12.0 months; hazard ratio [HR]: 1.852; 95% confidence interval [CI]: 1.131-3.034; P = .014) and LPFS duration (7.5 vs 14.0 months; HR: 2.117; 95% CI: 1.247-3.593; P = .005) were significantly shorter in the high CEA level group than in the low level group. In multivariable analysis, high CEA level, >3 tumors, and positive node status for the primary tumor were independent factors for PFS, with corrected HRs of 2.11 (95% CI: 1.257-3.555; P = .005), 2.450 (95% CI: 1.420-4.226; P = .001), and 2.265 (95% CI: 1.304-3.935; P = .004), respectively. However, age, tumor size, regional lymph node were not associated with LPFS.CEA level could be a valuable prognostic factor for early recurrence in patients with CRLM after MWA irrespective of the presence of early local recurrence in the liver or disease progression.

MoS2 nanosheets encapsulated in sodium alginate microcapsules as microwave embolization agents for large orthotopic transplantation tumor therapy

In recent years, it is prevalent to treat various kinds of the tumors through microwave ablation method. However, it is still very difficult to ablate large tumors by the traditional microwave ablation therapy. In this work, an effective microwave embolization agent designed by encapsulating molybdenum sulfide nanosheets in the sodium alginate microcapsules, denoted as MSMCs, was prepared for the effective therapy of large tumor. The toxicity evaluation showed that MSMC had a good biocompatibility in vitro. The in vitro and in vivo experiments demonstrated that the MSMC was an excellent embolic and microwave susceptible agent that could be used for dual-enhanced microwave ablation therapy. As such, the MSMC showed excellent tumor therapeutic effect with 5 times larger ablation zone observed by magnetic resonance (MR) imaging than the microwave alone after 3 days treating. Besides, the tumor is nearly completely ablated and can not be recurrent due to the persistent hyperthermia. Moreover, MSMCs have a good biocompatibility and can be degraded and cleared from the body. It is believed that the MSMC is demonstrated to be a promising multifunctional theranostic agent used for treating the larger tumor via the synergistic therapy of enhanced microwave ablation and transcatheter arterial embolization (TAE).

Radiofrequency ablation versus resection for Barcelona clinic liver cancer very early/early stage hepatocellular carcinoma: a systematic review

Aim

To compare the long-term survival outcomes of radiofrequency ablation and liver resection for single very early/early stage hepatocellular carcinoma (HCC).

Methods

The Cochrane Library (Issue 3, 2015), Embase (1974 to March 15, 2015), PubMed (1950 to March 15, 2015), Web of Science (1900 to March 15, 2015), and Chinese Biomedical Literature Database (1978 to March 15, 2015) were searched to identify relevant trials. Only trials that compared radiofrequency ablation and liver resection for single very early stage (≤2 cm) or early stage (≤3 cm) HCC according to the Barcelona clinic liver cancer (BCLC) staging system were considered for inclusion in this review. The primary outcomes that we analyzed were the 3-year and 5-year overall survival (OS) rates, and the secondary outcomes that we analyzed were the 3-year and 5-year disease-free survival (DFS) rates. Review Manager 5.3 was used to perform a cumulative meta-analysis. Possible publication bias was examined using a funnel plot. A random-effects model was applied to summarize the various outcomes.

Results

Six studies involving 947 patients were identified that compared radiofrequency ablation (n=528) to liver resection (n=419) for single BCLC very early HCC. In these six studies, the rates of 3-year OS, 5-year OS, 3-year DFS, and 5-year DFS were significantly lower in the radiofrequency ablation group than in the liver resection group (risk ratio [RR] =0.90, 95% confidence interval [CI]: 0.83–0.98, P=0.01; RR =0.84, 95% CI: 0.75–0.95, P=0.004; RR =0.77, 95% CI: 0.60–0.98, P=0.04; and RR =0.70, 95% CI: 0.52–0.94, P=0.02, respectively). Ten studies involving 2,501 patients were identified that compared radiofrequency ablation (n=1,476) to liver resection (n=1,025) for single BCLC early HCC. In these ten studies, the rates of 3-year OS, 5-year OS, 3-year DFS, and 5-year DFS were also significantly lower in the radiofrequency ablation group than in the liver resection group (RR =0.93, 95% CI: 0.88–0.98, P=0.003; RR =0.84, 95% CI: 0.75–0.94, P=0.002; RR =0.72, 95% CI: 0.58–0.89, P=0.002; and RR =0.47, 95% CI: 0.33–0.67, P<0.0001, respectively).

Conclusion

The long-term survival outcomes for patients with single BCLC very early/early stage HCC appear to be superior after liver resection compared to radiofrequency ablation.

Gold nanorods and curcumin-loaded nanomicelles for efficient in vivo photothermal therapy of Barrett's esophagus

Aim: Provide an enhanced local drug delivery, nanoparticle(s) to minimize systemic effects and achieve enhanced permeability and drug retention into abnormal cells and stroma. Materials & methods: Here a simultaneous loading of lipophilic gold nanorods (GNRs) and curcumin into polymeric nanomicelles made of biocompatible PLGA-b-PEG copolymer through a double re-emulsification process has been developed. Results: Initial results in vitro on Barrett's esophagus and esophageal adenocarcinoma cell lines demonstrated a significant reduction in cell viability with curcumin and GNRs exposure (p < 0.05). In vivo Barrett's-associated animal model confirmed these results with successful in vivo demonstrated eradication of all high-grade dysplastic premalignant cancer cells. Conclusion: The synthesis of this novel nanosystem containing GNRs and curcumin is safe and effective in treating and eradicating premalignant esophageal adenocarcinoma.

Nanoscale materials for hyperthermal theranostics

Recently, the use of nanoscale materials has attracted considerable attention with the aim of designing personalized therapeutic approaches that can enhance both spatial and temporal control over drug release, permeability, and uptake. Potential benefits to patients include the reduction of overall drug dosages, enabling the parallel delivery of different pharmaceuticals, and the possibility of enabling additional functionalities such as hyperthermia or deep-tissue imaging (LIF, PET, etc.) that complement and extend the efficacy of traditional chemotherapy and surgery. This mini-review is focused on an emerging class of nanometer-scale materials that can be used both to heat malignant tissue to reduce angiogenesis and DNA-repair while simultaneously offering complementary imaging capabilities based on radioemission, optical fluorescence, magnetic resonance, and photoacoustic methods.

Laparoscopic microwave ablation in patients with hepatocellular carcinoma: a prospective cohort study

OBJECTIVES

There are no prospective studies of laparoscopic microwave (MW) ablation in patients with hepatocellular carcinoma (HCC). The aim of this study was to demonstrate the safety and efficacy of laparoscopic MW ablation.

METHODS

A prospective study group of consecutive HCC patients considered ineligible for liver resection and/or percutaneous ablation was conducted from December 2009 to December 2010. Short-term (3-month) outcomes included a centralized revision of radiological response, mortality and morbidity. Mid-term (24-month) outcomes included time to recurrence in the study group compared with that in a cohort of consecutive patients treated with laparoscopic radiofrequency (RF) ablation using propensity score analysis.

RESULTS

A total of 42 patients were enrolled. Their median age was 64 years; 67% were positive for hepatitis C virus; 33% were of Child-Pugh class B status; the median tumour diameter was 2.5 cm, and 48% of patients had multinodular HCC. In 47 of 50 (94%) nodules treated with MW ablation, a complete radiological response was observed at 3 months. There was no perioperative mortality. The overall morbidity rate was 24%. The 2-year survival rate was 79% and the 2-year recurrence rate was 55%. Using propensity score analysis (in 28 MW ablation patients and 28 RF ablation controls), 2-year recurrence rates were 55% in the MW ablation group and 77% in the control group (P = 0.03).

CONCLUSIONS

Laparoscopic MW ablation is a safe and effective therapeutic option for selected HCC patients who are ineligible for liver resection and/or percutaneous ablation.

Gold nanoparticle-mediated photothermal therapy: current status and future perspective

Gold nanoparticles (AuNPs) are attractive photothermal agents for cancer therapy because they show efficient local heating upon excitation of surface plasmon oscillations. The strong absorption, efficient heat conversion, high photostability, inherent low toxicity and well-defined surface chemistry of AuNPs contribute to the growing interest in their photothermal therapy (PTT) applications. The facile tunability of gold nanostructures enables engineering of AuNPs for superior near-infrared photothermal efficacy and target selectivity, which guarantee efficient and deep tissue-penetrating PTT with mitigated concerns regarding side effects by nonspecific distributions. This article discusses the current research findings with representative near-infrared-active AuNPs, which include nanoshell, nanorod, nanocage, nanostar, nanopopcorn and nanoparticle assembly systems. AuNPs successfully demonstrate potential for use in PTT, but several hurdles to clinical applications remain, including long-term toxicity and a need for sophisticated control over biodistribution and clearance. Future research directions are discussed, especially regarding the clinical translation of AuNP photosensitizers.

Multidisciplinary management of hepatocellular carcinoma in clinical practice

Background. Hepatocellular carcinoma (HCC) patients require different treatment strategies according to disease extension, liver function, and patient's fitness. We evaluated HCC multidisciplinary management in clinical practice. Methods. Consecutive patients were followed and treated with tailored medical, locoregional, and surgical treatments, according to disease stage and patient's fitness (age, Cumulative Illness Rating Scale (CIRS)). Activity, efficacy, and safety were evaluated. Results. Thirty-eight patients were evaluated: median age, 74; elderly 92%; CIRS secondary 28 (74%); Child-Pugh A 20 (53%), B 11 (29%); and Barcelona Clinic Liver Cancer (BCLC) 0 2 (5%), A 9 (24%), B 10 (26%), C 13 (34%), and D 4 (11%). Overall survival (OS) was 30 months. At 9 months median follow-up, among 25 unresectable HCC, OS was 10 months; BCLC B–D unfit for sorafenib showed OS 3 months. Ten patients (40%) received sorafenib: Child-Pugh A 5 (50%) and B 5 (50%) and disease control rate 89%, progression-free survival 7 months, and OS 9 months. G3-4 toxicities: anorexia, hypertransaminaemia, hyperbilirubinemia, and hypercreatininemia. Limiting toxicity syndromes were 40%, all multiple sites. Conclusion. HCC patients require multidisciplinary clinical management to properly select tailored treatments according to disease stage, fitness, and liver function. Patients suitable for sorafenib should be carefully selected, monitored for individual safety, and prevalently characterized by limiting toxicity syndromes multiple sites.

Evolving ablative therapies for hepatic malignancy

The liver is a common site for both primary and secondary malignancy. Hepatic resection and transplantation are the two treatment modalities that have been shown to achieve complete cure, but only 10 to 20% of patients are candidates for these treatments. For the remaining patients, tumor ablation has emerged as the most promising alternative modality. In addition to providing local control and improving survival outcomes, tumor ablation also helps to down stage patients for potential curative treatments, both alone as well as in combination with other treatments. While tumor ablation can be achieved in multiple ways, the introduction of newer ablative techniques has shifted the focus from palliation to potentially curative treatment. Because the long-term safety and survival benefits are not substantive at present, it is important that we strive to evaluate the results from these studies using appropriate comparative outcome methodologies.

Fiber-optic combined FPI/FBG sensors for monitoring of radiofrequency thermal ablation of liver tumors: ex vivo experiments

We present a biocompatible, all-glass, 0.2 mm diameter, fiber-optic probe that combines an extrinsic Fabry-Perot interferometry and a proximal fiber Bragg grating sensor; the probe enables dual pressure and temperature measurement on an active 4 mm length, with 40 Pa and 0.2°C nominal accuracy. The sensing system has been applied to monitor online the radiofrequency thermal ablation of tumors in liver tissue. Preliminary experiments have been performed in a reference chamber with uniform heating; further experiments have been carried out on ex vivo porcine liver, which allowed the measurement of a steep temperature gradient and monitoring of the local pressure increase during the ablation procedure.

Sensitivity enhanced nanothermal sensors for photoacoustic temperature mapping

Photoacoustic imaging can be used to guide and validate the therapeutic outcome of nanoparticle-mediated photothermal therapy through its ability to visualize the delivery of nanoparticle contrast agents, image the temperature distribution inside living tissue, and confirm tissue coagulation. In this image-guided process, temperature mapping plays a critical role for thermal dosage control. Therefore, developing a sensitive and accurate photoacoustic technique to quantitatively measure the temperature distribution during thermal therapy is essential. In this study, we investigated and demonstrated that silica-coated gold nanorods, can provide a multi-fold improvement in sensitivity of the photoacoustic temperature mapping compared to gold nanorods without silica coating, and serve as a nanothermal sensor to accurately and quantitatively visualize temperature distributions during photothermal therapy.

Visualizing ex vivo radiofrequency and microwave ablation zones using electrode vibration elastography

PURPOSE

Electrode vibration elastography is a new shear wave imaging technique that can be used to visualize thermal ablation zones. Prior work has shown the ability of electrode vibration elastography to delineate radiofrequency ablations; however, there has been no previous study of delineation of microwave ablations or radiological-pathological correlations using multiple observers.

METHODS

Radiofrequency and microwave ablations were formed in ex vivo bovine liver tissue. Their visualization was compared on shear wave velocity and maximum displacement images. Ablation dimensions were compared to gross pathology. Elastographic imaging and gross pathology overlap and interobserver variability were quantified using similarity measures.

RESULTS

Elastographic imaging correlated with gross pathology. Correlation of area estimates was better in radiofrequency than in microwave ablations, with Pearson coefficients of 0.79 and 0.54 on shear wave velocity images and 0.90 and 0.70 on maximum displacement images for radiofrequency and microwave ablations, respectively. The absolute relative difference in area between elastographic imaging and gross pathology was 18.9% and 22.9% on shear wave velocity images and 16.0% and 23.1% on maximum displacement images for radiofrequency and microwave ablations, respectively.

CONCLUSIONS

Statistically significant radiological-pathological correlation was observed in this study, but correlation coefficients were lower than other modulus imaging techniques, most notably in microwave ablations. Observers provided similar delineations for most thermal ablations. These results suggest that electrode vibration elastography is capable of imaging thermal ablations, but refinement of the technique may be necessary before it can be used to monitor thermal ablation procedures clinically.

Efficacy of surgical microwave therapy in patients with unresectable hepatocellular carcinoma

BACKGROUND

We aimed to evaluate the efficacy and long-term outcome in surgical microwave therapy (MW) for patients with unresectable hepatocellular carcinoma (HCC).

METHODS

An institutional review board approved and single-institutional study of surgical MW of unresectable HCC was conducted from May 2003 to December 2010. The median follow-up period was 19 months (range 1-77 months).

RESULTS

A total of 60 patients underwent 143 surgical MW for unresectable HCC. Of these, 15 patients had initial HCC and 45 had recurrent HCC. The median tumor size of HCC was 1.95 cm (range 0.8-3.3 cm). The median numbers of nodules that underwent surgical MW were 2 (range 1-9). Multinodular type was found in 33 patients (55%). Morbidity was 18.3%, and there was zero mortality. Also, 3 patients (5%) had incomplete MW. Of the 60 patients, 39 (65%) had recurrence, and 7 (11.6%) had local recurrence. The 1- and 3-year recurrence-free survival rates of the patients who underwent surgical MW for initial HCC were 55.1 and 36.7%, respectively, and those for recurrent HCC were 41.6% and 8.8%, respectively. A tumor size ≥ 2.0 cm and multiple nodules were selected as independent and significant indicators for recurrence of the disease. The 1-, 3-, and 5-year overall survival rates after the surgical MW procedure were 93.9, 53.8, and 43.1%, respectively. A level of des-gamma carboxyprothrombin (DCP) was an independent and significant indicator for overall survival.

CONCLUSIONS

Surgical MW is an effective method for treating initial or recurrent unresectable HCC, and it can be undergone safely.

The cancer stem cell marker CD133 is a predictor of the effectiveness of S1+ pegylated interferon α-2b therapy against advanced hepatocellular carcinoma

BACKGROUND

Combination therapy with the oral fluoropyrimidine anticancer drug S1 and interferon is reportedly effective for the treatment of advanced hepatocellular carcinoma (HCC), but selection criteria for this therapy have not been clarified. In this study, we attempted to identify factors predicting the effectiveness of this combination therapy.

METHODS

Pathological specimens of HCC were collected before treatment from 31 patients with advanced HCC who underwent S1+ pegylated-interferon (PEG-IFN) α-2b therapy between January 2007 and January 2009. In these pathological specimens, the expression levels of CD133, thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), and interferon-receptor 2 (IFNR2) proteins were determined by Western blot assay. The presence or absence of p53 gene mutations was determined by direct sequencing. The relationships between these protein expression levels and the response rate (RR), progression-free survival (PFS), and overall survival (OS) were evaluated.

RESULTS

The CD133 protein expression level was significantly lower in the responder group than in the nonresponder group. Comparing the PFS and OS between high- and low-level CD133 expression groups (n = 13 and 18, respectively) revealed that both parameters were significantly prolonged in the latter group. The expression levels of TS, DPD, and IFNR2 protein and the presence of p53 gene mutations did not correlate with the RR.

CONCLUSIONS

CD133 was identified as a predictor of the therapeutic effect of S1+ PEG-IFN α-2b therapy against advanced HCC.

Comparison of efficacy and toxicity of short-course carbon ion radiotherapy for hepatocellular carcinoma depending on their proximity to the porta hepatis

BACKGROUND AND PURPOSE

To compare the efficacy and toxicity of short-course carbon ion radiotherapy (C-ion RT) for patients with hepatocellular carcinoma (HCC) in terms of tumor location: adjacent to the porta hepatis or not.

MATERIALS AND METHODS

The study consisted of 64 patients undergoing C-ion RT of 52.8 GyE in four fractions between April 2000 and March 2003. Of these patients, 18 had HCC located within 2 cm of the main portal vein (porta hepatis group) and 46 patients had HCC far from the porta hepatis (non-porta hepatis group). We compared local control, survival, and adverse events between the two groups.

RESULTS

The 5-year overall survival and local control rates were 22.2% and 87.8% in the porta hepatis group and 34.8% and 95.7% in the non-porta hepatis group, respectively. There were no significant differences (P=0.252, P=0.306, respectively). Further, there were no significant differences in toxicities. Biliary stricture associated with C-ion RT did not occur.

CONCLUSIONS

Excellent local control was obtained independent of tumor location. The short-course C-ion RT of 52.8 GyE in four fractions appears to be an effective and safe treatment modality in the porta hepatis group just as in the non-porta hepatis group.

Compensatory enlargement of the liver after treatment of hepatocellular carcinoma with carbon ion radiotherapy - relation to prognosis and liver function

BACKGROUND AND PURPOSE

To examine whether liver volume changes affect prognosis and hepatic function in patients treated with carbon ion radiotherapy (CIRT) for hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

Between April 1995 and March 2003, among the cases treated with CIRT, 43 patients with HCC limited to the right hepatic lobe were considered eligible for the study. The left lateral segment was defined as the non-irradiated region. Liver volume was measured using contrast CT at 0, 3, 6, and 12 months after CIRT. We examined serum albumin, prothrombin activity, and total bilirubin level as hepatic functional reserve.

RESULTS

After CIRT, the non-irradiated region showed significant enlargement, and enlarged volume of this region 3 months after CIRT 50 cm(3) was a prognostic factor. The 5-year overall survival rates were 48.9% in the larger enlargement group (enlarged volume of non-irradiated region 3 months after CIRT > or =50 cm(3)) and 29.4% in the smaller enlargement group (as above, <50 cm(3)). The larger enlargement group showed better hepatic functional reserve than the smaller enlargement group 12 months after CIRT.

CONCLUSIONS

This study suggests that compensatory enlargement in the non-irradiated liver after CIRT contributes to the improvement of prognosis.

Ultrasound-based relative elastic modulus imaging for visualizing thermal ablation zones in a porcine model

The feasibility of using ultrasound-based elastic modulus imaging to visualize thermal ablation zones in an in vivo porcine model is reported. Elastic modulus images of soft tissues are estimated as an inverse optimization problem. Ultrasonically measured displacement data are utilized as inputs to determine an elastic modulus distribution that provides the best match to this displacement field. A total of 14 in vivo thermal ablation zones were investigated in this study. To determine the accuracy of delineation of each thermal ablation zone using elastic modulus imaging, the dimensions (lengths of long and short axes) and the area of each thermal ablation zone obtained from an elastic modulus image were compared to the corresponding gross pathology photograph of the same ablation zone. Comparison of elastic modulus imaging measurements and gross pathology measurements showed high correlation with respect to the area of thermal ablation zones (Pearson coefficient = 0.950 and p < 0.0001). The radiological-pathological correlation was slightly lower (correlation = 0.853, p < 0.0001) for strain imaging among these 14 in vivo ablation zones. We also found that, on average, elastic modulus imaging can more accurately depict thermal ablation zones, when compared to strain imaging (14.7% versus 22.3% absolute percent error in area measurements, respectively). Furthermore, elastic modulus imaging also provides higher (more than a factor of 2) contrast-to-noise ratios for evaluating these thermal ablation zones than those on corresponding strain images, thereby reducing inter-observer variability. Our preliminary results suggest that elastic modulus imaging might potentially enhance the ability to visualize thermal ablation zones, thereby improving assessment of ablative therapies.

Microwave tissue ablation: biophysics, technology, and applications

Microwave ablation is an emerging treatment option for many cancers, cardiac arrhythmias, and other medical conditions. During treatment, microwaves are applied directly to tissues to produce rapid temperature elevations sufficient to produce immediate coagulative necrosis. The engineering design criteria for each application differ, with individual consideration for factors such as desired ablation zone size, treatment duration, and procedural invasiveness. Recent technological developments in applicator cooling, power control, and system optimization for specific applications promise to increase the utilization of microwave ablation in the future. This article reviews the basic biophysics of microwave tissue heating, provides an overview of the design and operation of current equipment, and outlines areas for future research.

Efficacy of surgical resection in management of isolated extrahepatic metastases of hepatocellular carcinoma

AIM: To clarify the benefit of surgical excision for patients with extrahepatic metastases of hepatocellular carcinoma (HCC).

METHODS: We retrospectively reviewed the medical records of 140 patients with pathologically proven extrahepatic metastases of HCC and evaluated the outcomes of those who had undergone surgical resection (SR) for extrahepatic metastatic lesions. Prognoses made on the basis of extrahepatic metastatic sites were also examined.

RESULTS: The survival rates of patients who underwent SR of extrahepatic metastases were significantly better than those of patients who did not receive SR. For the SR group, 1- and 3-year survival rates were 24% and 7%, respectively, while for the non-resection group, the survival rates were 8% and 0%, respectively (P < 0.0001). Survival rates related to metastatic sites were also significantly superior after SR of extrahepatic metastases: median survivals were 32 mo with lung metastasis, 10 mo with bone metastasis, 6.1 mo with brain metastasis.

CONCLUSION: SR can provide survival benefits for patients with 1 or 2 isolated extrahepatic metastases and who concurrently exhibit good hepatic functional reserve and general performance status as well as successful treatment of intrahepatic HCC.

Safety and efficacy of microwave ablation of hepatic tumors: a prospective review of a 5-year experience

BACKGROUND

This study was designed to evaluate the safety, efficiency, effectiveness, and overall long-term outcome in patients treated with microwave thermal ablation of hepatic tumors. Microwave ablation technology represents the next generation in ablative techniques for the treatment of hepatic malignancies. Currently there have been no large reports of its use in the United States with appropriate long-term follow-up.

METHODS

An institutional review board-approved prospective phase II study of microwave ablation of hepatic malignancies from January 2004 to January 2009 was performed. All complications were recorded up to 90 days from operation and reported using an established five-point grading scale.

RESULTS

One hundred patients underwent 270 ablations for hepatic malignancies. The most tumor types were as follows: metastatic colorectal cancer (50%), hepatocellular carcinoma (17%), metastatic carcinoid (11%), and other metastatic disease (22%). A majority of patents (53%) underwent combination hepatic resection and microwave ablation; 38% underwent ablation alone, 9% underwent ablation and additional organ resection, with 68% open procedures. Median tumor size was 3.0 (range, 0.6-6.0) cm, median number of tumors was 2 (range, 1-18), and median total ablation time was 13 (range, 5-45) min. Overall 90-day mortality was 0% and morbidity was 29%. One patient developed a hepatic abscess and no patients experienced bleeding complications. After a median follow-up of 36 months, 5 patients (5%) had incomplete ablation, 2 (2%) had local recurrence at the ablated site, and 37 (37%) developed intrahepatic recurrence at nonablated sites.

CONCLUSIONS

Microwave ablation of hepatic tumors is a safe and effective method for treating unresectable hepatic tumors, with a low rate of local recurrence.

Liver ablation techniques: a review

BACKGROUND

Ablation techniques for unresectable liver carcinomas have evolved immensely since their introduction. Results of studies involving these techniques are restricted to reports of patient case series, which are often not presented in a standardised manner. This review aims to summarise the major studies in ablation technologies and present them in a way that may make comparison between the major modalities easier.

METHODS

All major databases (Medline, Cochrane, Embase and Pubmed) were searched for studies using microwave, radiofrequency or cryoablation to treat unresectable liver tumours. Only studies with at least 30 patients and 3-year follow-up were included. Complication, recurrence and survival rates of all studies are summarised and presented.

RESULTS AND CONCLUSION

It is difficult to compare ablation modalities, as probe design and energy sources have evolved rapidly over the last decade. Ablation offers an invaluable palliative option and in some cases it may offer rates of cure approaching that of surgical resection with lower morbidity and mortality. Perhaps the time has come, therefore, for prospective large-scale randomised control trials to take place comparing ablation modalities to each other and surgical resection.

Efficacy and safety of microwave ablation for primary and secondary liver malignancies: a systematic review

This article reviews the therapeutic efficacy and complications of microwave ablation (MWA) in the treatment of primary and secondary liver malignancies. A PubMed search using keywords 'microwave', 'liver', 'malignancy', 'cancer' and 'tumour' was performed to identify articles related to MWA of liver malignancies published in English from 1975 to February 2008. MWA is an effective treatment options for both primary and secondary liver malignancies with survivals comparable with those of liver resections. Local recurrences can be managed with further ablation. Small tumour size, well-differentiated tumour and a reduced number of lesions are factors associated with good prognosis. Temporary occlusion of the portal venous and hepatic arterial flow may increase the size of ablation but the safety aspect requires further validation. MWA is a minimally invasive technique that has broadened the therapeutic option for patients with conventionally unresectable liver tumours with promising survival data. Future advances in the applicator design and treatment monitoring may further improve its efficacy and widen the indications.

Endoscopic microwave coagulation therapy for early recurrent T1 nasopharyngeal carcinoma

The result of reirradiation in recurrent T1 (rT1) nasopharyngeal carcinoma (NPC) is unsatisfactory. We sought to study the efficacy and complications of endoscopic microwave coagulation therapy (MCT) in salvaging rT1 NPC after primary radiotherapy. Between August 1994 and April 2005, 55 patients with rT1 NPC were treated with endoscopic MCT. With a median follow-up of 102.1 months, 52 of 55 patients are still alive. Five patients had local failure after retreatment. The overall survival and local progression-free survival were 100% (95% CI, 99.4% to 100%) and 94.5% (95% CI, 94.1% to 94.9%) at 2 years, respectively, and 93.6% (95% CI, 93.5% to 94.4%) and 90.7% (95% CI, 90.2% to 91.2%) at 5 years. The common complications of endoscopic MCT were mild postoperative pain and headache. Nasopharyngeal necrosis was transient in one patient and subsided in 1 month. Endoscopic MCT achieved significant survival and tumour control without severe complications in selective rT1 NPC.

Evaluation of newly developed combination therapy of intra-arterial 5-fluorouracil and systemic pegylated interferon alpha-2b for advanced hepatocellular carcinoma with portal venous invasion: preliminary results

AIM

Prognosis is extremely poor for advanced hepatocellular carcinoma (HCC) in patients with portal invasion. The present study evaluated the efficacy of combined intra-arterial 5-fluorouracil (5-FU) and systemic pegylated interferon (PEG-IFN)alpha-2b in patients with advanced HCC.

METHODS

The subjects comprised nine HCC patients with portal vein thrombosis treated using subcutaneous administration of PEG-IFNalpha-2b (50-100 microg on day 1 of every week, for 4 weeks) and intra-arterial infusion of 5-FU (250 mg/day for 5 h on days 1-5 of every week, for 4 weeks). For four patients with hepatitis C virus (HCV) infection, oral administration of ribavirin (400-800 mg/day) was added. At the end of every cycle, response to therapy was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) guidelines.

RESULTS

Partial response (PR) was observed in seven of nine patients, with stable or progressive disease in the remaining two patients. Tumors were resectable in three patients displaying PR after treatment. Tumor markers decreased significantly after therapy. Serum HCV-RNA titers were markedly decreased and became undetectable in all patients with HCV infection. National Cancer Institute-Common Toxicity Criteria: version 3.0 (NCI-CTC) grade 3 thrombocytopenia was seen in one case at the end of treatment, but was resolved with cessation of treatment. Other adverse effects were manageable.

CONCLUSION

Combination therapy with intra-arterial 5-FU and systemic PEG-IFNalpha-2b may be useful as a palliative treatment for patients with advanced HCC. A prospective controlled trial using a larger population of patients with advanced HCC is needed to evaluate this new combination therapy.

Ultrasound monitoring of a novel microwave ablation (MWA) device in porcine liver: lessons learned and phenomena observed on ablative effects near major intrahepatic vessels

BACKGROUND

Microwave ablation (MWA) is postulated to have several advantages over other thermoablative modalities in the treatment of hepatic tumors. Herein, we use an in vivo porcine model to determine the effect of hepatic blood flow on a novel MWA applicator.

METHODS

Four 100-kg pigs underwent hepatic MWA (2,450 MHz, 100 W, 4 min) using a 5.7-mm diameter applicator (Microsulis Americas, Sulis V) inserted near large intrahepatic blood vessels. Real-time monitoring was performed using 3, 5, and 12 MHz diagnostic ultrasound transducers. The ablated zones were sectioned for gross and histological processing.

RESULTS

Ablation zones were uniform in shape and size (3-4 cm) and related to power deliver only. Gross and microscopic examination revealed direct extension of ablation zones to the margin of major hepatic blood vessels and occasionally beyond the intended target. Of note, a momentary acoustic white-out occurred around the probe at 25 +/- -1 s in every ablation.

DISCUSSION

The Sulis V MWA applicator produced uniform zones of ablation that remain unaffected by convective heat loss. The applicator induced a reproducible but temporary event as seen by ultrasound. Further study is warranted to define the physics, benefits, limits, and clinical safety of this new MWA technology.

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection.

METHODS

A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound.

RESULTS

From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8).

CONCLUSION

Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

Pilot study of combination chemotherapy of S-1, a novel oral DPD inhibitor, and interferon-alpha for advanced hepatocellular carcinoma with extrahepatic metastasis

BACKGROUND

To the authors' knowledge, there is no effective therapy for extrahepatic metastasis of hepatocellular carcinoma (HCC). In a pilot study, the results of combination therapy of S-1, a novel oral dehydropyrimidine dehydrogenase (DPD) inhibitor, and interferon-alpha (IFN-alpha) are reported for HCC patients with extrahepatic metastasis.

METHODS

Twelve patients with extrahepatic metastasis of HCC were enrolled in the pilot study. S-1 was administered orally at a dose based on body surface area, twice daily after a meal, for 4 weeks. IFN-alpha was injected subcutaneously on Days 1, 3, and 5 of each week. One course consisted of consecutive administration for 28 days followed by 14 days rest.

RESULTS

An objective response was observed in 3 (25%) of 12 patients. The overall 1-year survival rate was 61.7%. Grade 3 leukocytopenia was observed in 1 patient (8.3%). No severe toxicity or treatment-related deaths were observed.

CONCLUSIONS

The combination therapy of S-1 and IFN-alpha appears to be highly efficacious, with low toxicity in patients with extrahepatic metastases of HCC. The combination chemotherapy of oral S-1 and subcutaneous IFN-alpha is a potentially promising treatment strategy for advanced HCC with extrahepatic metastasis.

Proton beam therapy for hepatocellular carcinoma adjacent to the porta hepatis

PURPOSE

To evaluate the efficacy and safety of proton beam therapy (PBT) for patients with hepatocellular carcinoma (HCC) located adjacent to the porta hepatis.

METHODS AND MATERIALS

Subjects of the study were 53 patients with HCC located within 2 cm of the main portal vein. All patients had tumor confined to the radiation field with no evidence of metastatic disease. All patients had hepatic function levels of a Child-Pugh score of 10 or less, Eastern Cooperative Oncology Group performance status of 2 or less, and no uncontrolled ascites. Patients underwent PBT of 72.6 GyE in 22 fractions from Sept 2001 to Dec 2004.

RESULTS

After 3 years, the actuarial survival rate was 45.1% and local control rate was 86.0%. Prognostic factors for survival included Child-Pugh score, number of tumors, and alpha-fetoprotein levels. No late treatment-related toxicity of Grade 2 or higher was observed.

CONCLUSIONS

The PBT delivering 72.6 GyE in 22 fractions appears to be effective and safe for HCC adjacent to the porta hepatis.

Microwave ablation of hepatocellular carcinoma

OBJECTIVE

This article reviews the basic principles, equipment, current therapeutic status and future trends of microwave ablation (MWA) in the treatment of hepatocellular carcinoma (HCC).

METHODS

All articles published in English on MWA or MWA as a treatment for HCC were identified with a PubMed search from the 1990s through June 2007. Papers were reviewed on the technical advances of MWA equipment and the clinical applications of MWA including indications, techniques, therapeutic outcomes, complications and combination therapies.

RESULTS

MWA has several advantages, including high thermal efficiency, higher capability of coagulating blood vessels, faster ablation time, and an improved convention profile. MWA can induce large ablation volumes and yield good local tumor control, especially for small HCC. Larger HCC can also be completely ablated by using more effective antenna or simultaneous application of multiple antennae. Long-term survival comparable to that of surgery was obtained for tumors measuring 4 cm or less. Associated complications appear to be low.

CONCLUSIONS

MWA is a promising minimally invasive technique for the treatment of HCC. Future advances are warranted to improve the therapeutic efficacy.

Microwave hepatic ablation: initial experience of safety and efficacy

BACKGROUND

Microwave (MW) ablation is a new treatment modality for hepatic tumors in the United States. Past concerns had been related to small ablation size and efficacy. The aim of this study was to evaluate the safety, operative time, rate of complete ablation, and local recurrence.

METHODS

A prospective Phase II study of MW of hepatic tumors from 1/2004 to 10/2004.

RESULTS

MW ablation was utilized to treat 67 hepatic tumors in 20 patients, with 13 men, 7 women, with a median age of 65 years (range 46-83 years). Tumor types, metastatic colorectal cancer (n = 9), hepatocellular (n = 5), metastatic carcinoid (n = 2), and one patient each with metastatic ovarian, breast, and gastric. MW treated a median of two tumors (range 1-13) per patient, median size of 3 cm (range 1.5-4.5 cm). Total median ablation time was 10 min (range 5-40 min). The overall ablation success at the discharge CT of the abdomen was 100%. Nine patients underwent additional procedures, including partial hepatectomy, colectomy, and gastrectomy. There were no perioperative deaths, while perioperative complications occurred in five patients-none of them related to hepatic ablation. After median follow-up of 19 months there has been one ablation recurrence.

CONCLUSIONS

MW ablation represents a reliable, efficient, and safe technique to perform hepatic tumor ablation. The ability to perform multiple ablations simultaneously allows for a more efficient surgical procedure.