LI-RADS category is associated with treatment outcomes of small single HCC: surgical resection vs. radiofrequency ablation

OBJECTIVES

To assess whether the Liver Imaging Reporting and Data System (LI-RADS) category is associated with the treatment outcomes of small single hepatocellular carcinoma (HCC) after surgical resection (SR) and radiofrequency ablation (RFA).

METHODS

This retrospective study included 357 patients who underwent SR (n = 209) or RFA (n = 148) for a single HCC of ≤ 3 cm between 2014 and 2016. LI-RADS categories were assigned. Overall survival (OS), recurrence-free survival (RFS), and local tumor progression (LTP) rates after treatment were compared according to the LI-RADS category (LR-4/5 vs. LR-M) before and after propensity score matching (PSM). Prognostic factors for treatment outcomes were assessed.

RESULTS

In total, 357 patients (mean age, 59 years; men, 272) with 357 HCCs (294 LR-4/5 and 63 LR-M) were included. After PSM (n = 78 in each treatment group), there were 10 and 11 LR-M HCCs in the SR and RFA group, respectively. There were no significant differences in OS or RFS. However, SR provided a lower 5-year LTP rate than RFA (1.4% vs. 14.9%, p = 0.001). SR provided a lower 5-year LTP rate than RFA for LR-M HCCs (0% vs. 34.4%, p = 0.062) and LR-4/5 HCCs (1.5% vs. 12.0%, p = 0.008). The LI-RADS category was the sole risk factor associated with poor OS (hazard ratio [HR] 3.79, p = 0.004), RFS (HR 2.12; p = 0.001), and LTP (HR 2.89; p = 0.032).

CONCLUSION

LI-RADS classification is associated with the treatment outcome of HCC, supporting favorable outcomes of SR over RFA for LTP, especially for HCCs categorized as LR-M.

CLINICAL RELEVANCE STATEMENT

Liver Imaging Reporting and Data System category has a potential prognostic role, supporting favorable outcomes of surgical resection over radiofrequency ablation for local tumor progression, especially for hepatocellular carcinoma categorized as LR-M.

KEY POINTS

• SR provided a lower 5-year LTP rate than RFA for HCCs categorized as LR-M (0% vs. 34.4%, p = 0.062) and HCCs categorized as LR-4/5 (1.5% vs. 12.0%, p = 0.008). • There is a steeply increased risk of LTP within 1 year after RFA for LR-M HCCs, compared to SR. • The LI-RADS category was the sole risk factor associated with poor OS (HR 3.79, p = 0.004), RFS (HR 2.12; p = 0.001), and LTP (HR 2.89; p = 0.032) in patients with HCC of ≤ 3 cm treated with SR or RFA.

Radionuclide-Labeled Microspheres for Radio-Immunotherapy of Hepatocellular Carcinoma

Brachytherapy, including radioactive seed implantation (RSI) and transarterial radiation therapy embolization (TARE), is an important treatment modality for advanced hepatocellular carcinoma (HCC), but the inability of RSI and TARE to treat tumor metastasis and recurrence limits their benefits for patients in the clinic. Herein, indoleamine 2,3-dioxygenase 1 (IDO1) inhibitors-loaded alginate microspheres (IMs) are developed as radionuclide carriers with immunomodulatory functions to achieve effective radio-immunotherapy. The size and swelling properties of IMs can be facilely tailored by adjusting the calcium source during emulsification. Small/large IMs(SIMs/LIMs) are biocompatible and available for RSI and TARE, respectively, after 177 Lu labeling. Among them, 177 Lu-SIMs completely eliminated subcutaneous HCC in mice after intratumoral RSI. Moreover, in combination with anti-PD-L1, 177 Lu-SIMs not only eradicate primary tumors by RSI but also effectively inhibit the growth of distant tumors, wherein the potent abscopal effect can be ascribed to the immune stimulation of RSI and the modulation of the tumor immune microenvironment (TIME) by IDO1 inhibitors. In parallel, LIMs demonstrate excellent embolization efficiency, resulting in visible necrotic lesions in the central auricular artery of rabbits, which are promising for TARE in future studies. Collectively, a versatile therapeutic agent is provided to synchronously modulate the TIME during brachytherapy for efficient radio-immunotherapy of advanced HCC.

Clinical feasibility of radiofrequency ablation using novel adjustable separable electrodes with a multipurpose needle for treating small hepatocellular carcinomas: a prospective single center study

BACKGROUND

The novel separable clustered electrode system with two adjustable active tips (ICAEs) and a fine multipurpose needle (MPN) for in situ temperature monitoring and adjuvant agent injection was developed and validated in an animal study. The purpose of this study was to evaluate the technical efficacy and complication of the novel electrode system for patients who have small HCC.

METHODS

In this prospective, single-center clinical trial, ten participants with 14 small (≤ 2 cm, BCLC 0-A) HCCs referred for RFA were enrolled. A novel electrode system consisting of two ICAEs and one MPN with a thermometer and side holes was used for RFA. The RF energy was delivered using a multichannel RF system combining bipolar and switching monopolar modes. Technical success, efficacy, and complications were evaluated on immediate and one-month follow-up CT.

RESULTS

Technical success was achieved in 92.9% (13/14) of tumors. One participant withdrew consent after RFA, and technical efficacy was achieved in 91.7% (11/12) of tumors. None showed thermal injury to nontarget organs. All patients were discharged the day after RFA without major complications. The active electrode lengths were adjusted in 60% (6/10) of patients during the procedure to tailor the ablation zone (83.3%, n = 5) or treat two tumors with different sizes (16.7%, n = 1). MPN was capable of continuous temperature monitoring during all ablations (100%, 14/14).

CONCLUSIONS

RFA using a novel electrode system showed acceptable technical efficacy and safety in patients with small HCCs. Further comparative studies are needed for the investigation of the system's potential benefits compared to conventional electrodes.

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.

Long-term outcome of percutaneous radiofrequency ablation for periportal hepatocellular carcinoma: tumor recurrence or progression, survival and clinical significance

Background/aim

Recent studies have suggested that periportal location of percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is considered as one of the independent risk factors for local tumor progression (LTP). However, the long-term therapeutic outcomes of percutaneous RFA as the first-line therapy for single periportal HCCand corresponding impacts on tumor recurrence or progression are still unclear.

Materials and methods

From February 2011 to October 2020, a total of 233 patients with single nodular HCC ≤ 5 cm who underwent RFA ± transarterial chemoembolization (TACE) as first-line therapy was enrolled and analyzed, including 56 patients in the periportal group and 177 patients in the nonperiportal group. The long-term therapeutic outcomes between the two groups were compared, risk factors of tumor recurrence or progression were evaluated.

Results

The LTP rates at 1, 3, and 5 years were significantly higher in the periportal group than those in the nonperiportal group (15.7, 33.7, and 46.9% vs 6.0, 15.7, and 28.7%, respectively, P = 0.0067). The 1-, 3- and 5-year overall survival (OS) rates in the periportal group were significantly worse than those in the nonperiportal group (81.3, 65.1 and 42.9% vs 99.3, 90.4 and 78.1%, respectively, P<0.0001). In the subgroup of single HCC ≤ 3 cm, patients with periportal HCC showed significantly worse LTP P = 0.0006) and OS (P<0.0001) after RFA than patients with single nonperiportal HCC; The univariate and multivariate analyses revealed that tumor size, periportal HCC and AFP ≥ 400ug/ml were independent prognostic factors for tumor progression after RFA. Furthermore, patients with single periportal HCC had significantly higher risk for IDR(P = 0.0012), PVTT(P<0.0001) and extrahepatic recurrence(P = 0.0010) after RFA than those patients with single nonperiportal HCC. .

Conclusion

The long-term therapeutic outcomes of RFA as the first-line therapy for single periportal HCC were worse than those for single nonperiportal HCC, an increased higher risk of tumor recurrence or progression after RFA was significantly associated with periportal HCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40644-021-00442-2.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation-part one: curative intention

Hepatocellular carcinoma (HCC) offers unique management challenges as it commonly occurs in the setting of underlying chronic liver disease. The management of HCC is directed primarily by the clinical stage. The most commonly used staging system is the Barcelona-Clinic Liver Cancer system, which considers tumor burden based on imaging, liver function and the patient's performance status. Early-stage HCC can be managed with therapies of curative intent including surgical resection, liver transplantation, and ablative therapies. This manuscript reviews the various treatment options for HCC with a curative intent, such as locablative therapy types, surgical resection, and transplant. Indications, contraindications and outcomes of the various treatment options are reviewed. Multiple concepts relating to liver transplant are discussed including Milan criteria, OPTN policy, MELD exception points, downstaging to transplant and bridging to transplant.

Outcome of No-Touch Radiofrequency Ablation for Small Hepatocellular Carcinoma: A Multicenter Clinical Trial

Background Recently introduced no-touch radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) has the potential to improve local tumor control. Purpose To evaluate midterm clinical outcomes of monopolar no-touch RFA in single HCCs 2.5 cm or smaller. Materials and Methods In this multicenter clinical trial (ClinicalTrials.gov: NCT03375281), participants were evaluated for eligibility from November 2017 to January 2019. Patients with single HCCs 2.5 cm or smaller planning to be treated with no-touch RFA were enrolled. The rate of successful no-touch RFA, defined as performing RFA without violation of the tumor itself, was recorded. Multivariable logistic regression analysis was used to determine associated factors for failure of no-touch RFA. Development of major complication after no-touch RFA was also recorded. Cumulative incidence of local tumor progression (LTP) and recurrence-free survival were estimated by using the Kaplan-Meier method. Results A total of 140 participants (mean age, 62 years ± 9 [standard deviation]; 106 men) were evaluated. No-touch RFA was successfully performed in 128 participants (128 of 140; 91.4%), and conversion to tumor puncture RFA was undertaken in 12 participants because of the lack of a safe access route. By using either no-touch RFA or conversion to tumor puncture RFA, all participants achieved technical success of RFA, which was defined as complete coverage of target tumor by ablation zone. Insufficient peritumoral parenchyma (<5 mm width around more than half portion of tumor; odds ratio, 74; 95% CI: 18, 309; P < .001) was the only significant predictive factor for failure of the no-touch technique. Among the 140 participants, LTP developed in two participants, and the estimated 1- and 2-year cumulative incidence of LTP was 0.7% and 1.6%, respectively. The estimated 1- and 2-year recurrence-free survival was 82.8% and 74.1%, respectively. Conclusion No-touch radiofrequency ablation was an effective and safe treatment method for small hepatocellular carcinomas (≤2.5 cm), with 1.6% of cumulative incidence of local tumor progression at 2 years. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Soulen and García-Mónaco in this issue.

Radiofrequency ablation of hepatocellular carcinoma: Prognostic factors and recent advances

With the improvement of technology and diagnostic level, radiofrequency ablation (RFA) has made rapid progress in the treatment of primary hepatocellular carcinoma (HCC) in the past two decades. Especially, the overall survival after the treatment of small HCCs by RFA can be comparable to that achieved by hepatic resection. The 10-year survival rates of RFA for HCC were 27.3%-46.1%, and for solitary HCC less than 3 cm, the 10-year survival rate is about 74.0%. RFA combined with other therapies can expand the indications of RFA treatment and benefit the survival of patients with HCC. The prognostic model of RFA for HCC provides a powerful tool for individualized clinical diagnosis and treatment.

Factors associated with health-related quality of life in papillary thyroid microcarcinoma patients undergoing radiofrequency ablation: a cross-sectional prevalence study

PURPOSE

To explore the association of demographic characteristics, clinical symptoms and the fear of the disease progression factors with the physical and mental summary components of the health-related of life (HRQoL) of the papillary thyroid microcarcinoma (PTMC) patients undergoing radiofrequency ablation (RFA).

METHODS

123 PTMC survivors undergoing RFA were enrolled in this study from October 2019 to March 2020. Demographic, clinical symptoms and the fear of the disease progression data were collected. SF-36, THYCA-QoL and FoP-Q-SF were used to evaluate the HRQoL of patients, clinical symptoms and the fear of disease progression. A multivariate regression model was performed to evaluate the association between the independent variable and the HRQoL variable.

RESULTS

The average self-reported HRQoL score was 81.17 ± 15.48 for the PCS and 73.40 ± 18.03 for the MCS. The multivariate linear regression model shows that the factors related to a poorer PCS were dependent for the female patients, the symptoms of neuromuscular and the throat/mouth, the fear of disease progression; the psychological disorder, symptoms of throat/mouth, inability to concentrate were related to worse scores for the MCS. The condition that was most strongly related to a poorer HRQoL (in both PCS and MCS) was the fear of their physical health.

CONCLUSIONS

The factors related to significantly worse HRQoL scores across PCS and MCS for PTMC survivors include the female gender, the symptoms of neuromuscular and the throat/mouth, the psychological disorder, inability to concentrate, and the fear of their own physical health. Identification, management, and prevention of these factors are critical to improving the HRQoL of patients.

Rim-arterial enhancing primary hepatic tumors with other targetoid appearance show early recurrence after radiofrequency ablation

OBJECTIVES

To evaluate early (≤ 2 years) local tumor progression (LTP), intrahepatic distant metastasis (IDR), and extrahepatic metastasis (EM) of primary hepatic malignant tumors with arterial rim enhancement (RE) after RFA in comparison with non-RE tumors.

METHODS

Three hundred forty-nine patients who underwent RFA for primary hepatic malignant tumors between January 2009 and December 2016 were included. The patients' tumors were classified into non-RE, RE only (RO), and RE plus other targetoid appearances (REoT). Cumulative LTP, IDR, and EM rates at 1 and 2 years after RFA were calculated using the Kaplan-Meier method and compared using the log-rank test. Prognostic factors for the outcomes were assessed using a Cox proportional hazards model.

RESULTS

There were 303 non-RE, 19 RO, and 27 REoT tumors. The REoT tumors had a significantly higher rate of IDR and EM than non-RE (p = 0.04 for IDR; and p < 0.01 for EM, respectively) at 1 year after RFA. At 2 years, LTP and EM rates were significantly higher for REoT than for non-RE (p = 0.001 for LTP; and p = 0.444 for EM, respectively). The RO tumors did not have different outcomes than non-RE at 1 and 2 years after RFA. Multivariable analysis verified that REoT was a significant factor for IDR (p = 0.04) and EM (p = 0.01) at 1 year and LTP (p = 0.02) at 2 years.

CONCLUSIONS

Tumors with REoT had poor LTP, IDR, and EM within 2 years after RFA than non-RE tumors. However, tumors with RO showed similar results as non-RE tumors.

KEY POINTS

• Tumors with Rim enhancement plus other targetoid appearances (REoT) had a significantly higher rate of recurrence than non-rim enhancing (RE) tumors at 1 and 2 years after RFA. • Tumors with rim enhancement only did not have different outcomes than non-RE at 1 and 2 years after RFA.

Laparoscopic Liver Resection versus Percutaneous Radiofrequency Ablation for Small Single Nodular Hepatocellular Carcinoma: Comparison of Treatment Outcomes

BACKGROUND

Treatment outcomes of laparoscopic liver resection (LLR) and percutaneous radiofrequency ablation (p-RFA) for small single hepatocellular carcinomas (HCCs) have not yet been fully compared. The aim of this study was to compare LLR and p-RFA as first-line treatment options in patients with single nodular HCCs ≤3 cm.

METHODS

From January 2014 to December 2016, a total of 566 patients with single nodular HCC ≤3 cm treated by either LLR (n = 251) or p-RFA (n = 315) were included. The recurrence-free survival (RFS) and cumulative incidence of local tumor progression (LTP) were estimated using Kaplan-Meier methods and compared using the log-rank test. Treatment outcome of 2 treatment modalities was compared in the subgroup of patients according to the tumor location.

RESULTS

There were no significant differences in overall survival between LLR and p-RFA (p = 0.160); however, 3-year RFS was demonstrated to be significantly higher after LLR (74.4%) than after p-RFA (66.0%) (p = 0.013), owing to its significantly lower cumulative incidence of LTP (2.1% at 3 years after LLR vs. 10.0% after p-RFA, p < 0.001). The complication rate of p-RFA was significantly lower than that of LLR (5.1 vs. 10.0%, p = 0.026). LLR also provided significantly better local tumor control than p-RFA for subscapular tumors (3-year LTP rates: 1.9 vs. 8.8%, p = 0.012), perivascular tumors (3-year LTP rates: 0.0 vs. 17.2%, p = 0.007), and tumors located in anteroinfero-lateral liver portions (3-year LTP rates: 0.0 vs. 10.7%, p < 0.001). However, there were no significant differences in LTP rates between LLR and p-RFA for non-subcapsular and non-perivascular tumors (p = 0.482) and for tumors in postero-superior liver portions (p = 0.380).

CONCLUSIONS

LLR can provide significantly better local tumor control than p-RFA for small single HCCs in subcapsular, perivascular, and anteroinferolateral liver portions and thus may be the preferred treatment option for these tumors.

The efficacy of transarterial chemoembolization combined with microwave ablation for unresectable hepatocellular carcinoma: a systematic review and meta-analysis

Purpose: To evaluate the clinical value of transarterial chemoembolization (TACE) combined with microwave ablation (MWA) for unresectable hepatocellular carcinoma (HCC).Patients and methods: Eligible studies were identified using PubMed, MedLine, Embase, the Cochrane Library, and Web of Science, investigating the synergistic effect of TACE + MWA in the treatment of advanced HCC. Endpoints were the 1-, 2- and 3-year survival rates, local control rate (LCR), objective remission rate (ORR), and adverse event (AE). Odds ratio (OR) with 95% confidence interval (CI) was used to determine the effect size.Results: Nine studies including 351 patients in the TACE + MWA group and 653 patients in the TACE group were enrolled in this meta-analysis. The pooled OR for the 1-, 2-, and 3-year survival rates were in favor of TACE + MWA (OR = 3.29, 95% CI 2.26-4.79; OR = 2.82, 95% CI 2.01-3.95; OR = 4.50, 95% CI 2.96-6.86; respectively). The pooled OR for the ORR and LCR were also in favor of TACE + MWA (OR = 4.64, 95%CI 3.11-6.91; OR = 3.93, 95% CI 2.64-5.87; respectively). No significant difference in the incidence of severe AE was observed between TACE + MWA group and TACE group (p > .05). However, subgroup analysis showed that patients with tumor size >5 cm were more likely to be benefited from TACE + MWA, rather than patients with tumor size ≤5 cm.Conclusion: With the current data, we concluded that combination TACE and MWA was safe, and should be strongly recommended to unresectable patients with tumor size >5 cm, but TACE alone was enough for unresectable patients with tumor size ≤5 cm. However, the conclusion needs further validation.

Ultrasound-Guided Radiofrequency Ablation Versus Surgery for Low-Risk Papillary Thyroid Microcarcinoma: Results of Over 5 Years' Follow-Up

Background: Papillary thyroid microcarcinoma (PTMC) typically carries an excellent prognosis regardless of the treatment option pursued. Radiofrequency ablation (RFA) for thyroid disease has been utilized for benign lesions and in patients who are poor surgical candidates for thyroid cancers with compression symptoms, but the efficacy and limitations of RFA as first-line therapy for PTMC has not been described in adequate detail. The purpose of our study was to investigate RFA versus thyroidectomy in terms of efficacy, oncologic outcomes, quality of life, complications, and costs over a 5-year period of follow-up. Methods: From January 2013 to November 2013, 174 consecutive patients with an isolated, solitary intrathyroidal PTMC were identified in a Chinese teaching hospital. Those with more aggressive or advanced PTMCs were not included. Ninety-four patients elected RFA and 80 patients elected surgery for treatment of these PTMC. Nodules were confirmed to be PTMC without an aggressive histological type by core needle biopsy in the RFA group and by final surgical pathology in the surgery group. The extent of surgery was decided based on patient preferences in consultation with the surgeons. Of all the patients, 58 (72.5%) underwent lobectomy, 22 (27.5%) underwent total thyroidectomy, and 53 (66.3%) underwent lymph node dissection. Pre- and post-treatment variables were compared between the two groups, including demographics, tumor characteristics, treatment, local tumor progression, lymph node metastasis, distant metastasis, local recurrence, complications, and quality-of-life findings. Results: Patient-specific variables were similar between groups, as were oncologic outcomes after 5 years of follow-up. When compared with RFA, surgery took longer, had a longer hospitalization time, and was costlier (all p < 0.001). The surgery group had three complications, with 2 (2.5%) permanent recurrent laryngeal nerve injuries and 1 (1.3%) case of permanent hypoparathyroidism, while none was reported in the RFA group (p = 0.095). The surgery group had a lower post-treatment thyroid-related quality of life. Conclusions: For carefully selected low-risk intrathyroidal PTMC, RFA was not oncologically inferior to open surgery, and it was associated with a higher quality of life and lower overall costs.

Updated 10-year outcomes of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm: emphasis on association of local tumor progression and overall survival

OBJECTIVES

The purpose of this study was to evaluate the 10-year overall survival and local tumor progression (LTP) of percutaneous radiofrequency ablation (RFA) for single nodular hepatocellular carcinoma (HCC) < 3 cm using a large longitudinal hospital registry and clinical factors associated with overall survival and LTP.

METHODS

A total of 467 newly diagnosed patients with single nodular HCC < 3 cm who underwent RFA as first-line therapy between January 2008 to December 2016 were analyzed. Overall survival and LTP were estimated using the Kaplan-Meier method. Cox regression and competing risks Cox regression analysis were performed to identify prognostic factors for overall survival and LTP, respectively.

RESULTS

The 5- and 10-year overall survival rates after RFA were 83.7% and 74.2%, respectively. LTP (hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.19-3.47) was one of the important factors for overall survival after RFA. The 5- and 10-year LTP rates after RFA were 20.4% and 25.1%, respectively. Periportal location (subdistribution HR, 2.29; 95% CI, 1.25-4.21), subphrenic location (2.25, 1.34-3.86), size ≥ 1.5-< 2.0 cm (1.88, 1.05-3.39), and size ≥ 2.0 cm (2.10, 1.14-3.86) were independent factors for LTP.

CONCLUSION

Ten-year therapeutic outcomes of percutaneous RFA as first-line therapy were excellent for single HCC < 3 cm. LTP was an important prognostic factor for overall survival after RFA. Periportal and subphrenic location of HCCs and tumor size were predictors for the development of LTP after RFA.

KEY POINTS

• Updated 10-year survival outcome of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm was higher than previously reported. • Local tumor progression was an important prognostic factor for overall survival after percutaneous radiofrequency ablation. • Periportal and subphrenic location of hepatocellular carcinomas and tumor size were predictors for the development of local tumor progression after percutaneous radiofrequency ablation.

Dual Modality Radiation With External Beam Radiation Therapy and Transarterial Radioembolization for Hepatocellular Carcinoma With Gross Vascular Invasion

OBJECTIVES

Patients with hepatocellular carcinoma (HCC) and gross vascular invasion (GVI) have poor outcomes with systemic therapy such as sorafenib. Both external beam radiation therapy (EBRT) and transarterial radioembolization (TARE) have been utilized for this patient population. We sought to compare outcomes using dual modality radiation (EBRT+TARE) versus EBRT alone in patients with HCC and GVI.

MATERIALS AND METHODS

Between 2011 and 2017, 45 patients with HCC and GVI were treated with EBRT±TARE at our institution. Progression-free survival (PFS) and overall survival (OS) were assessed and compared using Kaplan-Meier method and log-rank test. Univariable and multivariable Cox proportional hazards regression was used to assess the impact of the variables stage, etiology of cirrhosis, Child-Pugh (CP) score, and Karnofsky Performance Score (KPS) on PFS and OS.

RESULTS

Patient characteristics were well-balanced except for KPS (80 vs. 90) and CP score. Median OS for patients receiving EBRT+TARE was 263 days (95% confidence interval [CI]: 167, -) versus 193 days (95% CI: 51, 262) for EBRT alone (P=0.049). However, this did not hold up on MVA. When EBRT and TARE were delivered within 2 months as planned (n=12), median PFS was 218 days (95% CI: 44, -) for dual modality radiation versus 63 days (95% CI: 38, 137) for EBRT alone (P=0.048). When EBRT and TARE were delivered within 6 months, the difference in PFS was no longer seen (P=NS), because some patients received TARE as a salvage therapy.

CONCLUSIONS

Dual modality radiation with EBRT and TARE may be associated with improved OS in patients with HCC and GVI. Dual modality radiation may be associated with improved PFS in patients with HCC and GVI compared with EBRT alone when EBRT and TARE are delivered within 2 months of each other as part of a planned dual modality treatment strategy. However, since this is a retrospective study with inherent selection bias, these findings need further validation in a prospective clinical trial for patients with HCC and GVI.

Small masses (≤3 cm) diagnosed as hepatocellular carcinoma on pre-treatment imaging: comparison of therapeutic outcomes between hepatic resection and radiofrequency ablation

OBJECTIVE

To compare therapeutic outcomes between hepatic resection (HR) and radiofrequency ablation (RFA) for small hepatic masses diagnosed as hepatocellular carcinoma (HCC) on pre-treatment imaging study.

METHODS

Our institutional review board approved this retrospective study, and informed consent was waived. Patients with a single (≤3 cm) mass diagnosed as HCC on pre-treatment imaging study between January 2008 and December 2009 who underwent HR (n = 145) or RFA (n = 178) were included. Recurrence-free survival (RFS) and overall survival (OS) were assessed. In the HR group, the false-positive rate for imaging diagnosis was calculated. For the RFA group, the local tumor progression rate was calculated.

RESULTS

RFS rates at 5 years were 59.3% for the HR group and 32.2% for the RFA group. OS rates at 5 years were 85.4% for the HR group and 76.8% for the RFA group. In the RFA group, cumulative local tumor progression rates were 8.3 and 20.2% at 1 and 3 years. Treatment modality was not an independent prognostic factor for either RFS or OS on multivariate analysis. The false-positive rate for HCC diagnosis based on imaging criteria was 4.8% in the HR group.

CONCLUSION

The imaging criteria for diagnosis of HCC have a high positive predictive value. Multivariate analysis showed that RFS and OS rates were not significantly different between HR and RFA for small hepatic masses diagnosed as HCC on pre-treatment imaging.

ADVANCES IN KNOWLEDGE

Treatment modality (hepatic resection vs RFA) was not an independent prognostic factor for both RFS and OS for small masses (≤3 cm) diagnosed as hepatocellular carcinoma on pre-treatment imaging.

Contrast-enhanced ultrasound features of hepatocellular carcinoma in dogs

Background

This study aimed to describe the contrast-enhanced ultrasound (CEUS) features of canine hepatocellular carcinoma (HCC) in relation to cellular differentiation and lesion size.

Methods

Sixty dogs with a cytological diagnosis of HCC and that underwent a CEUS examination were retrospectively selected. The wash-in and wash-out patterns of contrast enhancement, along with the time to wash-in and the time to wash-out, of each lesion were recorded. A dimensional cut-off value of 3 cm was adopted for classification.

Results

Cellular differentiation had a significant influence on both wash-in (chi-squared=16.99; P<0.001) and wash-out (chi-squared=10.9; P=0.004) patterns of contrast enhancement. Lesion size had a lower, but still significant, influence on both wash-in (chi-squared=12.7; P=0.005) and wash-out (chi-squared=7.42; P=0.024) patterns. A homogeneous hyperenhancement in the arterial phase followed by homogeneous wash-out were suggestive of a well-differentiated HCC. The cellular differentiation of lesions with inhomogeneous hyperenhancement or hypoenhancement/no enhancement as well as an inhomogeneous wash-out or no wash-out could not be inferred.

Conclusions

No significant difference in the time to wash-in and the time to wash-out in relation to cellular differentiation or lesion size was evident. CEUS has the potential to improve efficiency in the diagnosis of HCCs in dogs.

Radiofrequency Ablation Following Downstaging of Hepatocellular Carcinoma by Using Transarterial Chemoembolization: Long-term Outcomes

Background Transarterial chemoembolization (TACE) is an effective downstaging procedure for hepatocellular carcinoma (HCC). However, knowledge of the effectiveness of radiofrequency ablation (RFA) after downstaging of HCC is currently lacking. Purpose To evaluate the clinical outcomes of RFA after downstaging of HCC by using TACE. Materials and Methods This retrospective study investigated a cohort of patients who underwent RFA with curative intent after downstaging with TACE to meet Milan criteria (one lesion up to 5 cm or no more than three lesions ≤3 cm without vascular invasion or extrahepatic metastasis) from January 2012 to July 2017. A control group of patients initially meeting the Milan criteria also underwent RFA as first-line treatment in the same period. Overall survival (OS), disease-free survival (DFS), and major complication rates were compared by using the log-rank test. To reduce potential bias, a propensity score analysis was also performed. Results There were 72 patients (median age, 56.5 years; range, 30-78 years; 67 men) in the downstaging group and 357 patients meeting the Milan criteria (median age, 58.0 years; range, 25-87 years; 313 men) included in this study. After propensity score matching, the 1-, 3-, and 5-year OS rates were 99%, 80%, and 66%, respectively, for the patients in the downstaging group and 94%, 84%, and 69%, respectively, for the patients in the Milan criteria group. The 1-, 3-, and 5-year DFS rate were 73%, 34%, and 24% for the downstaging group and 74%, 43%, and 37% for the Milan criteria group. There were no differences in the OS, DFS, or major complication rates between the two groups (P = .74, P = .39, P = .73, respectively). Conclusion The long-term patient survival and major complication rates of radiofrequency ablation following transarterial chemoembolization downstaging for hepatocellular carcinoma were similar to that of patients initially meeting the Milan criteria. © RSNA, 2019 See also the editorial by vanSonnenberg and Mueller in this issue.

Predictive factors of treatment outcomes after percutaneous ablation of hepatocellular carcinoma in the caudate lobe: a retrospective study

Background

Hepatocellular carcinomas (HCC) arising in the caudate lobe is rare and the treatment is difficult. The aim of this study is to summarize the experience of ultrasound-guided percutaneous ablation therapy for HCC located in the caudate lobe and to investigate the predictive factors of the treatment outcomes.

Methods

From August 2006 to June 2017, 73 patients (63 males and 10 females; mean age, 54.9 ± 11.6 years; age range, 25–79 years) with 73 caudate lobe HCCs (mean size, 2.6 ± 1.1 cm; size range, 1.0–5.0 cm) were treated with percutaneous ablation, including 33 patients with radiofrequency ablation (RFA), 23 patients with ethanol ablation (EA), and 17 patients with combination of RFA and EA. The treatment outcome and survival after ablation for caudate lobe HCC were assessed and the predictive factors were calculated by univariate and multivariate analyses.

Results

A total of 72 patients achieved complete ablation after the first or second session of ablation. The treatment effectiveness was 98.6% (72/73). During the follow-up, 16 tumors developed local tumor progression (LTP) and a total of 61 patients (61/73, 83.6%) were detected distant recurrence (DR). According to univariate and multivariate analyses, tumor size > 2 cm (hazard ratio[HR] = 3.667; 95% confidence interval[CI], 1.043–12.889; P = 0.043) was a significant prognostic factor of LTP after ablation for HCC in the caudate lobe, while tumor number (HR = 2.245; 95%CI, 1.168–4.317; P = 0.015) was a significant prognostic factor of DR. The mean overall survival time after ablation was 28.7 ± 2.8 months, without independent predictive factors detected. Four patients (4/73, 5.5%) were detected treatment-related major complications, without independent predictive factor detected.

Conclusion

Ultrasound-guided percutaneous ablation is a feasible treatment for a selected case with HCC in the caudate lobe. Tumor size > 2 cm increases the risk of LTP and intrahepatic tumor number is associated with DR after ablation.

Whole tumor ablation of locally recurred hepatocellular carcinoma including retained iodized oil after transarterial chemoembolization improves progression-free survival

OBJECTIVES

To evaluate and compare clinical outcomes of two different radiofrequency ablation (RFA) methods for locally recurred hepatocellular carcinoma (LrHCC) after locoregional treatment.

METHODS

Our institutional review board approved this study with a waiver of informed consent. A total of 313 patients previously treated with transarterial chemoembolization (TACE) (n = 167) and RFA (n = 146) with a single LrHCC ≤ 3 cm was included from five tertiary referral hospitals. RFA was done for LrHCCs using either viable tumor alone ablation (VTA) method (VTA: n = 61 in the TACE group and n = 127 in the RFA group) or whole tumor ablation (WTA) method which includes both viable tumor and retained iodized oil or previously ablated zone (WTA: n = 106 in the TACE group and n = 19 in the RFA group). Local tumor progression (LTP)-free survival as well as progression-free survival (PFS) were estimated using the Kaplan-Meier method, and prognostic factors were evaluated using the Cox proportional hazards regression model.

RESULTS

In 167 patients with LrHCC who underwent TACE, the 5-year LTP-free survival after RFA was significantly higher with the VTA method than with the WTA method (26.9% vs. 87.8%; p < 0.001; hazard ratio (HR) = 8.53 [4.16-17.5]). The estimated 5-year PFS after RFA for LrHCC after TACE using the VTA method was 5.7%, which was significantly lower than that with the WTA method (26.4%) (p = 0.014; HR = 1.62 [1.10-2.38]). However, in 146 patients with LrHCC after initial RFA, there were no significant differences in cumulative incidence of LTP (p = 0.514) or PFS (p = 0.905) after RFA between the two ablation methods.

CONCLUSIONS

For RFA of LrHCC after TACE, the WTA method including both viable tumor and retained iodized oil could significantly lower LTP and improve PFS than VTA.

KEY POINTS

• Whole tumor ablation (WTA) could provide significantly better local tumor control for locally recurred HCC (LrHCC) after TACE than viable tumor alone ablation (VTA). • WTA for LrHCC after TACE could also provide significantly better progression-free survival than VTA. • Regarding LrHCC after RFA, VTA would provide a comparable clinical outcome to WTA.