Laparoscopic US-Guided Radiofrequency Ablation of Unresectable Hepatocellular Carcinoma in Liver Cirrhosis: Feasibility and Clinical Outcome

Laparoscopic thermoablation for hepatocellular carcinoma in patients with liver cirrhosis: an effective procedure for tricky tumors

The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are amenable to this option. Percutaneous radiofrequency interstitial thermal ablation (TA) proved to be effective in the treatment of unresectable HCC. Recent advances in laparoscopic ultrasound have improved the accuracy in detecting small intrahepatic HCC nodules missed by pre-operative imaging techniques. Our objective was to evaluate an operative combination of laparoscopic ultrasound with laparoscopic thermoablation (LTA) in the treatment of HCC not amenable to liver resection. The aim of our review was to evaluate the advantages and limits of the laparoscopic approach according the criteria of the evidence-based medicine. LTA of HCC proved to be a safe and effective technique both in the short- and long-term follow-up period. This technique may be indicated in selected cases when the percutaneous approach to the lesion is very difficult or contraindicated.

Videolaparoscopic microwave ablation in patients with HCC at a European high-volume center: Results of 815 procedures

BACKGROUND

Videolaparoscopic (VL) microwave ablation (MWA) is not included in most of the international guidelines as a therapeutic option for hepatocellular carcinoma (HCC). Aim of this study was to assess the safety of VL MWA in patients with HCC for whom resection or percutaneous ablation is unsuitable.

METHODS

A retrospective analysis was performed on a prospective database of patients with HCC treated with VL MWA at our institution from 2009 to 2016. Patient demographics, operational characteristics, and complications were recorded. Statistical analysis was performed to identify safety profile, overall survival and recurrence rate.

RESULTS

A total of 815 VL MWA were performed in 674 patients with a mean age of 64 years. Patients had a mean Model for End-stage Liver Disease score of 10 (±3); 32.8% were Child B, 44.1% Barcelona Clinic Liver Cancer B-C. Perioperative mortality was 0.4%. Overall morbidity was 30.8%, with Dindo-Clavien complications ≥3 in 2%. The median length of stay was 2 days. In 43.1% VL MWA was the first-line therapy. Overall 1-, 3-, and 5-year survival rates were 81.9%, 54.9%, and 35.9%.

CONCLUSIONS

The present is the largest series of VL ablation and the bigger number of patients with HCC treated with MW reported nowadays. It confirms the safety of a minimally invasive procedure for patients with HCC when resection or percutaneous ablation is not feasible.

Individualized laparoscopic B-ultrasound-guided microwave ablation for multifocal primary liver cancer

Introduction

Liver cancer is one of the most common malignancies of the digestive system. Minimally invasive ablation procedures have become one of the major means for treating unresectable multifocal liver cancer and have been extensively applied in primary and metastatic liver cancer treatment. Laparoscopic B-ultrasound-guided microwave ablation is an example of the progress made in this field.

Aim

To analyze and summarize the results of and experience with laparoscopic B-ultrasound-guided microwave ablation for multifocal primary liver cancer; moreover, the ablation effects were compared between tumors of different sizes.

Material and methods

Laparoscope-guided needle ablation was conducted on 84 lesions from 32 patients with primary liver cancer based on tumor size, quantity, and location. Moreover, the perioperative data, ablation effects according to tumor size, and long-term follow-up results were analyzed.

Results

Among the 84 nodules treated via microwave ablation, tumors measuring ≤ 3 cm demonstrated complete ablation upon imaging analysis conducted 1 month after surgery. Moreover, 5 of the tumors measuring > 3 cm demonstrated incomplete ablation. In these cases, a second procedure was performed, until imaging studies confirmed that complete ablation was achieved.

Conclusions

Laparoscopic microwave ablation allows for precise puncture positioning, an effective ablation range, and safe and feasible surgery, which is especially suitable for liver tumors located in sites difficult to access.

CT-guided versus laparoscopic radiofrequency ablation in recurrent small hepatocellular carcinoma against the diaphragmatic dome

Computed tomography-guided radiofrequency ablation (CT-RFA) and laparoscopic RFA (L-RFA) have been used to treat intrahepatic recurrent small hepatocellular carcinoma (HCC) against the diaphragmatic dome. However, the therapeutic safety, efficacy, and hospital fee have never been compared between the two techniques due to scarcity of cases. In this retrospective study, 116 patients were divided into two groups with a total of 151 local recurrent HCC lesions abutting the diaphragm. We compared overall survival (OS), local tumor progression (LTP), postoperative complications, and hospital stay and fee between the two groups. Our findings revealed no significant differences in 5-year OS (36.7% vs. 44.6%, p = 0.4289) or 5-year LTP (73.3% vs. 67.9%, p = 0.8897) between CT-RFA and L-RFA. The overall hospital stay (2.8 days vs. 4.1 days, p < 0.0001) and cost (¥ 19217.6 vs. ¥ 25553.6, p < 0.0001) were significantly lower in the CT-RFA in comparison to that of L-RFA. In addition, we elaborated on the choice of percutaneous puncture paths depending on the locations of the HCC nodules and 11-year experience with CT-RFA. In conclusion, CT-RFA is a relatively easy and economic technique for recurrent small HCC abutting the diaphragm, and both CT-RFA and L-RFA are effective techniques.

Microwave ablation of liver malignancies: comparison of effects and early outcomes of percutaneous and intraoperative approaches with different liver conditions : New advances in interventional oncology: state of the art

Liver thermal ablation is an alternative treatment for hepatocellular carcinoma (HCC) and secondary liver malignancies. Microwave ablation (MWA) produces large ablation zones (AZ) in short time; however, AZ prediction is based on preclinical ex vivo models, rising concerns about reproducibility and safety in humans. We aimed to investigate the effects produced by a new-generation MWA system on human liver in vivo with different approaches (percutaneous or intraoperative) and liver conditions (cirrhosis or previous chemotherapy treatment), in comparison with manufacturer-provided predictions based on ex vivo animal models. Complete tumor ablation (CA) and early clinical outcomes were also assessed. From October 2014, 60 consecutive patients (cirrhotic = 31; non-cirrhotic = 10; chemotherapy-treated = 19) with 81 liver nodules (HCC = 31; mets = 50) underwent MWA procedures (percutaneous = 30; laparotomic = 18; laparoscopic = 12), with a 2450 MHz/100 W generator with Thermosphere™ Technology (Emprint™, Medtronic). A contrast-enhanced CT or MR was performed after one month to assess CA and measure AZ. A linear correlation between AZ volumes and ablation times was observed in vivo, without differences from manufacturer-provided ex vivo predictions in all operative approaches and liver conditions. Other independent variables (sex, age, nodule location) showed no relationship when added to the model. Median (IQR) longitudinal and transverse roundness-indexes of the AZs were, respectively, 0.77(0.13) and 0.93(0.11). CA at 1 month was 93% for percutaneous and 100% for intraoperative procedures (p = 0.175). Thirty-day morbidity and mortality were 3% and 0%. MWA with Thermosphere™ Technology produces predictable AZs on human liver in vivo, according to manufacturer-provided ex vivo predictions. In our experience, this new-generation MWA system is effective and safe to treat liver malignancies in different operative and clinical settings.

Laparoscopic resection vs laparoscopic radiofrequency ablation for the treatment of small hepatocellular carcinomas: A single-center analysis

AIM

To compare survival and recurrence after laparoscopic liver resection (LLR) and laparoscopic radiofrequency ablation (LRFA) for the treatment of small hepatocellular carcinoma (HCC).

METHODS

Between June 1, 2005 and November 30, 2010, 46 patients (62.26 ± 8.55 years old; female/male: 12/34) treated for small HCC were enrolled following strict criteria. Patients with better liver function and larger tumors were referred for LLR (n = 24), while those with poorer liver function and multiple tumors were referred for LRFA (n = 22), and they were then followed for similar durations (44.74 ± 21.3 mo for LLR vs 40.27 ± 30.8 mo for LRFA).

RESULTS

The LLR and LRFA groups were homogeneous with regard to age, sex, etiology of liver cirrhosis, and AFP levels. The overall survival (OS) and disease-free survival (DFS) probability was 0.354 and 0.260, respectively. A significantly higher OS was observed in the LLR group (LLR: 0.442; LRFA: 0.261; P = 0.048), whereas no statistical difference was found for DFS (LLR: 0.206; LRFA: 0.286; P = 0.205). In the LRFA group was treated a greater number of nodules (LLR: 1.41 ± 0.77; LRFA: 2.72 ± 1.54; P < 0.001). Cox regression analysis found the number of intraoperative HCC nodules as the unique variable statistically significant for OS (hazard ratio: 2.225; P < 0.001). The rank-hazard plot showed a steeper increase of relative hazard for intraoperative nodules > 2.

CONCLUSION

Our preliminary results confirm the superiority of hepatic resection on thermoablation in the treatment of small HCC in selected patients, when both approaches are made laparoscopically. LLR showed better results compared to LRFA in terms of OS. These data need to be confirmed by further studies on a larger number of patients.

The procedure outcome of laparoscopic resection for 'small' hepatocellular carcinoma is comparable to vlaparoscopic radiofrequency ablation

BACKGROUND

The aim of this study was to compare the effectiveness of laparoscopic liver resection (LLR) and laparoscopic radiofrequency ablation (LRFA) in the treatment of small nodular hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We enrolled 50 cirrhotic patients with similar baseline characteristics that underwent LLR (n = 26) or LRFA (n = 24), in both cases with intraoperative ultrasonography. Operative and peri-operative data were retrospectively evaluated.

RESULTS

LLR included anatomic resection in eight cases and non-anatomic resection in 18. In LRFA patients, a thermoablation of 62 nodules was achieved. Between LLR and LRFA groups, a significant difference was found both for median diameters of treated HCC nodules (30 vs. 17.1 mm; P < 0.001) and the number of treated nodules/patient (1.29 ± 0.62 vs. 2.65 ± 1.55; P < 0.001). A conversion to laparotomy occurred in two LLR patient (7.7%) for bleeding. No deaths occurred in both groups. Morbidity rates were 26.9% in the LLR group versus 16.6% in the LRFA group (P = 0.501). Hospital stay in the LLR and LRFA group was 8.30 ± 6.52 and 6.52 ± 2.69 days, respectively (P = 0.022). The surgical margin was free of tumour cells in all LLR patients, with a margin <5 mm in only one case. In the LRFA group, a complete response was achieved in 90.3% of thermoablated HCC nodules at the 1-month post-treatment computed tomography evaluation.

CONCLUSIONS

LLR for small peripheral HCC in patients with chronic liver disease represents a valid alternative to LRFA in terms of patient toleration, surgical outcome of the procedure, and short-term morbidity.

Results of laparoscopic radiofrequency ablation for HCC. Could the location of the tumour influence a complete response to treatment? A single European centre experience

INTRODUCTION

In selected patients, radiofrequency ablation (RFA) is a well-established treatment for hepatocellular carcinoma (HCC). However, subcapsular or lesions close to adjacent viscera preclude a percutaneous approach. In this setting laparoscopic-RFA (LRFA) is a potential alternative. The aim of this study was to analyse the safety and feasibility of LRFA in patients with HCC.

PATIENTS AND METHODS

Retrospective study of patients with HCC meeting strict inclusion criteria who underwent LRFA at a single Institution from December 2000 to March 2013.

RESULTS

Forty-one patients underwent 42 LRFA of 51 nodules. The median size of the nodule was 2.5 (range 1.2-4.7) cm. Thirty-one tumours were subcapsular and 17 located near the gallbladder. Major complications occurred in 17 patients. The initial complete response (ICR) rate was 94% and was lower among tumours located adjacent to the gallbladder. At the end of the follow-up period, the sustained complete response (SCR) rate was 70% and was lower in tumours adjacent to the gallbladder while increased for subcapsular tumours. The 1-, 3- and 5-year overall survival rate was 92.6%, 64.5% and 43%, respectively.

CONCLUSION

LRFA of HCC is safe, feasible and achieves excellent results in selected patients. LRFA should be the first-line technique for subcapsular lesions as it minimizes the risk of tumoural seeding and improves ICR. Proximity to gallbladder interferes in treatment efficacy (lower rate of ICR and lower rate of SCR).

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.

Laparoscopic approach for down-staging in hepatocellular carcinoma patients who are candidates for liver transplantation

INTRODUCTION

The aim of this study was to assess the impact of laparoscopic thermoablation (LTA) and laparoscopic resection (LR) as neoadjuvant therapy before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC).

METHODS

From June 2005 to November 2010, 50 consecutive patients affected by HCC with liver cirrhosis were treated with LTA under ultrasound guidance or LR. Of them, 10 patients (mean age, 58.3 ± 5.59 years; male:female, 8:2) underwent OLT. They were mostly Child-Pugh class A (80%).

RESULTS

A LTA of 12 nodules was achieved in 7 patients and an LR of 3 HCC nodules in the other 3 subjects. The mean length of surgery was 163 minutes (range; 60-370). The mean hospital stay was 6.1 days. Transient mild postoperative liver failure was reported in 1 case. Complete tumor necrosis was observed in 10 thermoablated nodules (83.3%) via spiral computerized tomographic scan at 1 month after treatment; the resected patients showed absence of recurrence. All patients underwent OLT after a mean interval of 7 months. The histology of the native liver showed complete necrosis in 9/12 thermoablated nodules (75%); a recurrence at surgical site occurred in 1 patient in the resection group.

CONCLUSIONS

Laparoscopic ultrasound can be used in potential OLTs candidates to accurately stage HCC in advanced cirrhosis with minimal morbidity. LTA and LR proved to be safe and effective techniques for HCC patients, representing a valid "bridge" to OLT.

Position paper of the Italian Association for the Study of the Liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma

Patients with hepatocellular carcinoma should be managed with a multidisciplinary approach framed in a network where all the diagnostic techniques and therapeutic resources are available in order to provide the optimal level of care. Given this assumption, the Coordinating Committee of the Italian Association for the Study of the Liver nominated a panel of experts to elaborate practical recommendations for the multidisciplinary management of hepatocellular carcinoma aiming to provide: (1) homogeneous and efficacious diagnostic and staging work-up, and (2) the best treatment choice tailored to patient status and tumour stage at diagnosis. The 2010 updated American Association for the Study of Liver Disease Guidelines for hepatocellular carcinoma were selected as the reference document. For each management issue, the American Association for the Study of Liver Disease recommendations were briefly summarised and discussed, according to both the scientific evidence published after their release and the clinical expertise of the Italian centres taking care of these patients. The Italian Association for the Study of the Liver expert panel recommendations are finally reported.

Laparoscopic ablation of hepatocellular carcinoma in cirrhotic patients unsuitable for liver resection or percutaneous treatment: a cohort study

The aim of this study was to demonstrate the safety and efficacy of laparoscopic ablation for cirrhotic HCC patients. Between January 2004 and December 2009, laparoscopic ablation was applied prospectively in 169 consecutive HCC patients (median age 62 years, 43% hepatitis C positive) considered ineligible for liver resection and/or percutaneous ablation. There was clinically relevant portal hypertension in 72% of cases. A significant proportion of subjects (50%) had multinodular tumors or nodules larger than 25 mm. The main ablation techniques used were radiofrequency in 103 patients (61%), microwave ablation in 8 (5%), and ethanol injection in 58 (34%). The primary endpoint was 3-year survival. There was no perioperative mortality. The overall morbidity rate was 25%. The median postoperative hospital stay was 3 days (range 1–19 days). Patients survived a median 33 months with a 3-year survival rate of 47%. Cox's multivariate analysis identified patient age, presence of diabetes, albumin ≤37 g/l, and alpha-fetoprotein >400 µg/l as significant preoperative predictors of survival, while the chance to undergo liver transplantation and postoperative ascites were the only independent postoperative predictor of survival. Laparoscopic ablation is a safe and effective therapeutic option for selected HCC patients ineligible for liver resection and/or percutaneous ablation.

Oblique approach for CT-guided liver radiofrequency ablation using multiplanar reformation images in hepatocellular carcinoma

PURPOSE

To evaluate the feasibility and safety of CT-guided radiofrequency (RF) ablation by caudal-cranial oblique insertion using multiplanar reformation (MPR) images for hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

Twenty-two HCCs in 19 patients that were difficult to demonstrate on ultrasound (mean tumor diameter was 17.5 mm) were treated with CT-guided RF ablation by caudal-cranial oblique insertion to avoid pneumothorax, using MPR images after transcatheter arterial chemoembolization. The insertion point and direction of insertion, avoiding aerated lung parenchyma, bones, large vessels, and intestine, were sought on the MPR images. Technical success was defined as complete eradication of tumor enhancement in the contrast-enhanced CT. Local tumor progression was defined by the appearance of enhanced tumor adjacent to the zone of ablation. The technical success rate, local tumor progression, and complications were investigated.

RESULTS

The coronal plane was used for insertion in 18 tumors, the sagittal plane in 3 tumors, and the oblique plane in 1 tumor. RF electrode placement was successful and complete necrosis was obtained in all cases. During the mean follow-up period of 38.0 months, local tumor progression was not detected in any of the patients. There were no major complications, including pneumothorax.

CONCLUSION

CT-guided RF ablation by caudal-cranial oblique insertion using MPR images is a feasible and safe therapeutic option.

Management of hepatocellular carcinoma in the age of liver transplantation

Hepatocellular carcinoma is one of the most frequently encountered malignancies worldwide. Its association with cirrhosis increases the difficulty of diagnosis and therapy. Different approaches, ranging from medical treatment to highly complex ablative and surgical therapies, including liver resection and transplantation have significantly improved the outcome of this disease. This article reviews the current diagnostic challenges and the available surveillance and classification protocols. Available therapeutic approaches, indications, contraindications and outcome of liver resection, liver transplantation, living donor liver transplantation, are outlined in detail. Ablative procedures and their role and efficiency as "bridging" methods to liver transplantation are included in the review.