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Klubien J, Knøfler LA, Poulsen AR, Larsen PN, Pless T, Knudsen AR, Nielsen SD, Pommergaard HC. Technique efficacy and complications after ablation as first surgical intervention for hepatocellular carcinoma: A nationwide database study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108366. [PMID: 38692100 DOI: 10.1016/j.ejso.2024.108366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Despite limited evidence, technique efficacy and complications may be important short-term outcomes after ablation for hepatocellular carcinoma (HCC). We aimed to report these outcomes after ablation as the first surgical intervention for HCC. METHODS This nationwide cohort study was based on data from the Danish Liver and Biliary Duct Cancer Database and medical records. Variables associated with outcomes were investigated using logistic regression. RESULTS From 2013 to 2023, 433 patients were included of which 79% were male, 73% had one tumor, and 90% had cirrhosis. Complete ablation was achieved after percutaneous, laparoscopic, and open approach in 84%, 100%, and 96% of the procedures, respectively. Most patients did not experience complications (76%). Open ablation compared with percutaneous was associated with higher risk of complications in multivariable adjusted analysis (Clavien-Dindo grade 2-5 (odds ratio 5.34, 95% confidence interval [2.36; 12.08]) and 3B-5 (5.70, [2.03; 16.01]), and lower risk of incomplete ablation (0.19 [0.05; 0.65]). Number of tumors ≥3 was associated with a higher risk of incomplete ablation (3.88, [1.45; 10.41]). Tumor diameter ≥3 cm was associated with increased risk of complications grade 2-5 (2.84, [1.29; 6.26]) and 3B-5 (4.44, [1.62; 12.13]). Performance status ≥2 was associated with risk of complications grade 3B-5 (5.98, [1.58; 22.69]). Tumor diameter was not associated with technique efficacy. CONCLUSION Open ablation had a higher rate of complete ablation compared with percutaneous but was associated with a higher risk of complications. Tumor diameter ≥3 cm and performance status ≥2 were associated with a higher risk of complications.
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Affiliation(s)
- Jeanett Klubien
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Hepatic Malignancy Surgical Research Unit (HEPSURU), Department of Surgery and Transplantation, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Esther Møllers Vej 6, 2100, Copenhagen, Denmark
| | - Lucas Alexander Knøfler
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Hepatic Malignancy Surgical Research Unit (HEPSURU), Department of Surgery and Transplantation, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Esther Møllers Vej 6, 2100, Copenhagen, Denmark
| | - Andreas Runge Poulsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Peter Nørgaard Larsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Torsten Pless
- Department of Surgery, Odense University Hospital, J. B. Winsløwsvej 4, 5000, Odense C, Denmark
| | - Anders Riegels Knudsen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus, Denmark
| | - Susanne Dam Nielsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Hepatic Malignancy Surgical Research Unit (HEPSURU), Department of Surgery and Transplantation, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Esther Møllers Vej 6, 2100, Copenhagen, Denmark; Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Esther Møllers Vej 6, 2100, Copenhagen, Denmark; Institute for Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Hans-Christian Pommergaard
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Hepatic Malignancy Surgical Research Unit (HEPSURU), Department of Surgery and Transplantation, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark; Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Esther Møllers Vej 6, 2100, Copenhagen, Denmark; Institute for Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
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Montalti R, Cassese G, Zidan A, Rompianesi G, Cesare Giglio M, Campanile S, Arena L, Maione M, Troisi RI. Local recurrence risk factors and outcomes in minimally invasive thermal ablation for liver tumors: a single-institution analysis. HPB (Oxford) 2024; 26:682-690. [PMID: 38342647 DOI: 10.1016/j.hpb.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Minimally Invasive thermal ablation (MITA) of liver tumors is a commonly performed procedure, alone or in combination with liver resection. Despite being a first-option strategy for small lesions, it is technically demanding, and many concerns still exist about local disease control. METHODS Consecutive patients undergoing MITA from 1-2019 to 12-2022 were retrospectively enrolled. Risk factors of local recurrence were investigated through univariate and multivariable cox regression analysis. RESULTS At the multivariable analysis of the 207 nodules undergoing MITA, RFA was associated with worse local Recurrence Free Survival (lRFS) than MWA (HR 2.87 [95 % CI 0.96-8.66], p = 0.05), as well as a concomitant surgical resection (HR 3.89 [95 % CI 1.06-9.77], p = 0.02). A concomitant surgical resection showed worse lRFS in the subgroup analysis of both HCC (HR 3.98 [95 % CI 1.16-13.62], p = 0.02) and CRLM patients (HR 2.68 [95 % CI 0.66-5.92], p = 0.04). Interestingly, a tumor size between 30 and 40 mm was not associated to worse lRFS. CONCLUSION MWA may reduce the risk of local recurrence in comparison to RFA, while MITA associated to liver resection may face an increased risk of local recurrence. Further prospective studies are needed to confirm such results.
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Affiliation(s)
- Roberto Montalti
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy; Department of Public Health, Federico II University, Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy.
| | - Ahmed Zidan
- Department of Surgery, Assiut University Hospital, Assiut, Egypt
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Silvia Campanile
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Lorenza Arena
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Marco Maione
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
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Muglia R, Marra P, Pinelli D, Dulcetta L, Carbone FS, Barbaro A, Celestino A, Colledan M, Sironi S. Technical and Clinical Outcomes of Laparoscopic-Laparotomic Hepatocellular Carcinoma Thermal Ablation with Microwave Technology: Case Series and Review of Literature. Cancers (Basel) 2023; 16:92. [PMID: 38201536 PMCID: PMC10778313 DOI: 10.3390/cancers16010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
PURPOSE To evaluate technical and clinical outcomes of intraoperative (laparoscopic/laparotomic) microwave ablation on HCC. MATERIALS AND METHODS This is a retrospective single-center study evaluating consecutive patients treated for very early/early-stage HCC with intraoperative microwave ablation from 1 July 2017 to 30 June 2023. In these patients, a percutaneous US-guided approach was excluded due to the nodule's suboptimal visibility or harmful location and liver resection for a deep position or adherences. Data about the clinical stage, surgical approach, liver pathology and nodules characteristics, technical success, complications, and follow-up were collected. Technical success was intended as the absence of locoregional persistence at follow-up CT/MRI controls. RESULTS A total of 36 cirrhotic patients (M:F = 30:6, median age 67 years) were enrolled; 18/36 (50%) had a single nodule, 13/36 (36%) had two, 4/36 had three (11%), and 1/36 had four (3%). Among the patients, 24 (67%) were treated with laparoscopy, and 12/36 (33%) with a laparotomic approach. Sixty HCCs of 16.5 mm (6-50 mm) were treated for 7 min (2-30 min) with 100 W of power. A total of 55 nodules (92%) were treated successfully and showed no residual enhancement at the first postoperative follow-up; the other 5/60 (8%) underwent chemo/radioembolization. There was one complication (3%): a biliary fistula treated with percutaneous drainage and glue embolization. The average hospital stay was 3.5 days (1-51 days), and patients were followed up on average for 238 days (13-1792 days). During follow-up, 5/36 patients (14%) underwent liver transplantation, 1/36 (2%) died during hospitalization and 1 after discharge. CONCLUSIONS Laparoscopic/laparotomic intraoperative HCC MW ablation is feasible in patients unsuitable for percutaneous approach or hepatic resection, with rare complications and with good technical and clinical outcomes.
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Affiliation(s)
- Riccardo Muglia
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Paolo Marra
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Domenico Pinelli
- Department of General Surgery, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (D.P.); (M.C.)
| | - Ludovico Dulcetta
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
| | - Francesco Saverio Carbone
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
| | - Alessandro Barbaro
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Antonio Celestino
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Michele Colledan
- Department of General Surgery, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (D.P.); (M.C.)
| | - Sandro Sironi
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
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Martin RCG, Woeste M, Egger ME, Scoggins CR, McMasters KM, Philips P. Patient Selection and Outcomes of Laparoscopic Microwave Ablation of Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:cancers15071965. [PMID: 37046625 PMCID: PMC10093561 DOI: 10.3390/cancers15071965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/12/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Laparoscopic microwave ablation (MWA) of hepatocellular carcinoma is underutilized and predictors of survival in this setting are not well characterized. Methods: The prognostic value of clinicopathologic variables was evaluated on progression-free survival (PFS) and overall survival (OS) by univariate and multivariate analyses. The aim of this study was to evaluate a preferred laparoscopic MWA approach in HCC patients that are not candidates for percutaneous ablation and further classify clinicopathologic factors that may predict survival outcomes following operative MWA in the setting of primary HCC. Results: 184 patients with HCC (median age 66, (33–86), 70% male) underwent laparoscopic MWA (N = 162, 88% laparoscopic) compared to 12% undergoing open MWA (N = 22). Median PFS was 29.3 months (0.2–170) and OS was 44.2 months (2.8–170). Ablation success was confirmed in 100% of patients. Ablation recurrence occurred in 3% (6/184), and local/hepatic recurrence occurred in 34%, at a median time of 19 months (9–18). Distant progression was noted in 8%. Median follow up was 34.1 months (6.4–170). Procedure-related complications were recorded in six (9%) patients with one 90-day mortality. Further, >1 lesion, AFP levels ≥ 80 ng/mL, and an “invader” on pre-operative radiology were associated with increased risk of progression (>1 lesion HR 2.92, 95% CI 1.06 –7.99, p = 0.04, AFP ≥ 80 ng/mL HR 4.16, 95% CI 1.71–10.15, p = 0.002, Invader HR 3.16, 95% CI 1.91–9.15, p = 0.002 ) and mortality (>1 lesion HR 3.62, 95% CI 1.21–10.81, p = 0.02], AFP ≥ 80 ng/mL HR 2.87, 95% CI 1.12–7.35, p = 0.01, Invader HR 3.32, 95% CI 1.21–9.81, p = 0.02). Conclusions: Preoperative lesion number, AFP ≥ 80 ng/mL, and an aggressive imaging characteristic (Invader) independently predict PFS and OS following laparoscopic operative MWA.
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Zou YW, Ren ZG, Sun Y, Liu ZG, Hu XB, Wang HY, Yu ZJ. The latest research progress on minimally invasive treatments for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2023; 22:54-63. [PMID: 36041973 DOI: 10.1016/j.hbpd.2022.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 08/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Due to the high prevalence of hepatitis B virus (HBV) infection in China, the incidence of HCC in China is high, and liver cirrhosis caused by chronic hepatitis also brings great challenges to treatment. This paper reviewed the latest research progress on minimally invasive treatments for HCC, including percutaneous thermal ablation and new nonthermal ablation techniques, and introduced the principles, advantages, and clinical applications of various therapeutic methods in detail. DATA SOURCES The data of treatments for HCC were systematically collected from the PubMed, ScienceDirect, American Chemical Society and Web of Science databases published in English, using "minimally invasive" and "hepatocellular carcinoma" or "liver cancer" as the keywords. RESULTS Percutaneous thermal ablation is still a first-line strategy for the minimally invasive treatment of HCC. The effect of microwave ablation (MWA) on downgrading treatment before liver transplantation is better than that of radiofrequency ablation (RFA), while RFA is more widely used in the clinical practice. High-intensity focused ultrasound (HIFU) is mainly used for the palliative treatment of advanced liver cancer. Electrochemotherapy (ECT) delivers chemotherapeutic drugs to the target cells while reducing the blood supply around HCC. Irreversible electroporation (IRE) uses a microsecond-pulsed electric field that induces apoptosis and necrosis and triggers a systemic immune response. The nanosecond pulsed electric field (nsPEF) has achieved a good response in the ablation of mice with HCC, but it has not been reported in China for the treatment of human HCC. CONCLUSIONS A variety of minimally invasive treatments provide a sufficient survival advantage for HCC patients. Nonthermal ablation will lead to a new wave with its unique advantage of antitumor recurrence and metastasis.
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Affiliation(s)
- Ya-Wen Zou
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Key Laboratory of Pulsed Power Translational Medicine of Zhejiang Province, 2959 Yuhangtang Road, Hangzhou 310000, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Zhi-Gang Ren
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Key Laboratory of Pulsed Power Translational Medicine of Zhejiang Province, 2959 Yuhangtang Road, Hangzhou 310000, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Ying Sun
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Key Laboratory of Pulsed Power Translational Medicine of Zhejiang Province, 2959 Yuhangtang Road, Hangzhou 310000, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Zhen-Guo Liu
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Key Laboratory of Pulsed Power Translational Medicine of Zhejiang Province, 2959 Yuhangtang Road, Hangzhou 310000, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Xiao-Bo Hu
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Hai-Yu Wang
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Zu-Jiang Yu
- Department of Infectious Diseases, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Gene Hospital of Henan Province; Precision Medicine Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
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Zhong H, Hu R, Jiang YS. Evaluation of short- and medium-term efficacy and complications of ultrasound-guided ablation for small liver cancer. World J Clin Cases 2022; 10:4414-4424. [PMID: 35663080 PMCID: PMC9125264 DOI: 10.12998/wjcc.v10.i14.4414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/19/2021] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To ensure clinical efficacy and prolong patient survival, treatments such as surgery and microwave ablation (MWA) are used for early liver cancer. MWA is preferred because it effectively preserves the normal liver tissue and causes transient coagulation necrosis of local liver tumor cells. However, due to technical limitations, the cancerous liver tissue cannot be completely ablated; therefore, the probability of local tumor recurrence is high. AIM To investigate the clinical efficacy and safety of ultrasound-guided percutaneous MWA in the treatment of small liver cancer. METHODS A total of 118 patients treated for small liver cancer in The Central Hospital of Yongzhou from January 2018 to April 2019 were selected. Sixty-six patients received ultrasound-guided percutaneous MWA (MWA group) and 52 received laparoscopic surgery (laparoscope group). The operation time, blood loss, hospital stay, and medical expenses of both groups were statistically analyzed. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), albumin (ALB), alpha fetal protein (AFP), carcinoembryonic antigen (CEA), and peripheral blood regulatory T lymphocytes (Treg) levels were evaluated pre- and post-operatively. The cross-sectional area of tumors measured before and after ablation was analyzed statistically; the therapeutic effect was compared between both groups in terms of surgical complications, 2-year progression-free survival rate, and overall survival rate. RESULTS The operation time, blood loss, hospital stay, and medical expenses in the MWA group were lower than those of the laparoscope group, and the differences were significant (P < 0.05); these parameters, and ALT, AST, TBIL, and ALB levels were compared preoperatively between both groups, and there was no significance (P > 0.05). The operation time, blood loss, hospital stay, and medical expenses for 2 d and 1 wk after surgery, the ALT and AST of the MWA group were lower than those of the laparoscope group, and the difference was significant (P < 0.05). The operation time, blood loss, hospital stay, and medical expenses, and serum AFP, CEA, and Treg levels were measured preoperatively and 4 and 8 wk postoperatively, and there were no significant differences between the two groups (P > 0.05). Compared with preoperative levels, serum AFP, CEA, and Treg levels in both groups were decreased (P < 0.05). The lesion in the MWA group had a maximum area of 4.86 ± 0.90 cm2, 1.24 ± 0.57 cm2, and 0.31 ± 0.11 cm2 preoperatively, 1 and 3 mo postoperatively, respectively. Fifty-eight of them achieved complete response and eight achieved a partial response. After 2 years of follow-up, the progression-free and overall survival rates in the MWA group were 37.88% and 66.67%, respectively, compared with 44.23% and 76.92% in the laparoscope group, with no significant difference (P > 0.05). CONCLUSION The effects of ultrasound-guided percutaneous MWA in the treatment of small liver cancer are similar to those of laparoscopic surgery. However, ablation causes less trauma and liver dysfunction.
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Affiliation(s)
- Hua Zhong
- Department of Ultrasound Medicine, The Central Hospital of Yongzhou, Yongzhou 425000, Hunan Province, China
| | - Rong Hu
- Department of Ultrasound Medicine, The Central Hospital of Yongzhou, Yongzhou 425000, Hunan Province, China
| | - Yun-Shan Jiang
- Department of Ultrasound Medicine, The Central Hospital of Yongzhou, Yongzhou 425000, Hunan Province, China
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Zanus G, Tagliente G, Rossi S, Bonis A, Zambon M, Scopelliti M, Brizzolari M, Grossi U, Romano M, Finotti M. Pulsed Microwave Liver Ablation: An Additional Tool to Treat Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14030748. [PMID: 35159014 PMCID: PMC8833939 DOI: 10.3390/cancers14030748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the seventh most frequent neoplasm and the second most common oncologic cause of death, mostly in patients with end-stage liver disease. HCC treatment is complex and different solutions are available, ranging from liver transplants to local therapies. In this study, we analyze the role of pulsed microwave liver ablation as an additional treatment option. Abstract This study aimed to analyze the outcomes of HCC patients treated with a novel technique—pulsed microwave ablation (MWA)—in terms of safety, local tumor progression (LTP), intrahepatic recurrence (IHR), and overall survival (OS). A total of 126 pulsed microwave procedures have been performed in our center. We included patients with mono- or multifocal HCC (BCLC 0 to D). The LTP at 12 months was 9.9%, with an IHR rate of 27.8% at one year. Survival was 92.0% at 12 months with 29.4% experiencing post-operative complications (28.6% Clavien–Dindo 1–2, 0.8% Clavien–Dindo 3–4). Stratifying patients by BCLC, we achieved BCLC 0, A, B, C, and D survival rates of 100%, 93.2%, 93.3%, 50%, and 100%, respectively, at one year, which was generally superior to or in line with the expected survival rates among patients who are started on standard treatment. The pulsed MWA technique is safe and effective. The technique can be proposed not only in patients with BCLC A staging but also in the highly selected cases of BCLC B, C, and D, confirming the importance of the concept of stage migration. This procedure, especially if performed with a minimally invasive technique (laparoscopic or percutaneous), is repeatable with a short postoperative hospital stay.
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Affiliation(s)
- Giacomo Zanus
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Giovanni Tagliente
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Serena Rossi
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Alessandro Bonis
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Mattia Zambon
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Michele Scopelliti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Marco Brizzolari
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Ugo Grossi
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Maurizio Romano
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Michele Finotti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
- Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75204, USA
- Correspondence:
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Percutaneous ablation versus surgical ablation and resection of liver tumors: medicare volume and physician reimbursement trends from 2010 to 2018. Abdom Radiol (NY) 2021; 46:4056-4061. [PMID: 33772616 DOI: 10.1007/s00261-021-03054-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this study is to analyze trends in Medicare volume and physician reimbursement for percutaneous ablation, surgical ablation, and resection of liver tumors from 2010 to 2018. METHODS Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the CPT codes for percutaneous and surgical ablation of liver tumors and surgical liver resection. Total procedural volume and physician payment were analyzed by procedure and physician specialty. RESULTS From 2010 to 2018, the volume of percutaneous ablation of liver tumors increased 94.3% from 1630 to 3168 procedures, and the volume of surgical ablations increased 86.2% from 593 to 1104 procedures. In contrast, there was a 16.8% decrease in liver resections from 10,807 to 8994 procedures. Physician reimbursement for percutaneous ablation decreased from $702.41 to $610.11 (- 13.1%). Conversely, reimbursement for resection increased from $849.18 to $1015.06 (19.5%). Reimbursement for surgical ablation also increased from $722.36 to $744.25 (3.0%). In 2018, physician reimbursement for resection and surgical ablation were 66% and 22% more than that for percutaneous ablation. CONCLUSION An increasing number of patients with liver tumors were treated with percutaneous ablation from 2010 to 2018. Despite higher morbidity, a dwindling set of theoretical advantages over percutaneous ablation, and higher overall costs, the volume of surgical ablation also increased over this time period. The findings of this study suggest that a reevaluation of practice and referral patterns for surgical ablation of liver tumors is warranted in many institutions.
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Preel A, Hermida M, Allimant C, Assenat E, Guillot C, Gozzo C, Aho-Glele S, Pageaux GP, Cassinotto C, Guiu B. Uni-, Bi- or Trifocal Hepatocellular Carcinoma in Western Patients: Recurrence and Survival after Percutaneous Thermal Ablation. Cancers (Basel) 2021; 13:2700. [PMID: 34070800 PMCID: PMC8197823 DOI: 10.3390/cancers13112700] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022] Open
Abstract
Multifocality is usually reported as a pejorative factor after percutaneous thermal ablation (PTA) of HCC but little is known in Western series. Recurrence and survival were extracted from a prospective database of all patients who underwent PTA for ≤3 cm HCC. From January 2015 to April 2020, we analyzed 281 patients with unifocal (n = 216), bifocal (n = 46) and trifocal (n = 16) HCC. PTA of bi- and trifocal HCC resulted in a high risk of very early (<6 months) distant recurrence (38.8% and 50%, respectively). Median RFS was 23.3 months (95% CI:18.6-30.4), 7.7 months (95% CI:5.1-11.43, p = 0.002) and 5.2 months (95% CI:3-12.3, p = 0.015), respectively, for uni-, bi- and trifocal HCC groups. In a multivariate analysis, both bifocal (HR = 2.46, p < 0.001) and trifocal (HR = 2.70, p = 0.021) vs. unifocal HCC independently predicted shorter RFS. Median OS in trifocal HCC group was 30.3 months (95 CI:19.3-not reached). Trifocal vs. unifocal HCC independently predicted shorter OS (HR = 3.30, p = 0.008), whereas bifocal vs. unifocal HCC did not (p = 0.27). Naïve patient (HR = 0.42, p = 0.007), AFP > 100 ng/mL (HR = 3.03, p = 0.008), MELD > 9 (HR = 2.84, p = 0.001) and steatotic HCC (HR = 0.12, p = 0.038) were also independent predictors of OS. In conclusion, multifocal HCCs in a Western population have a dramatically increased risk of distant recurrence. OS after PTA of trifocal HCC is significantly below what was expected after a curative treatment.
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Affiliation(s)
- Ancelin Preel
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Margaux Hermida
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Carole Allimant
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Eric Assenat
- Department of Oncology, St-Eloi University Hospital, 34295 Montpellier, France;
| | - Chloé Guillot
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Cecilia Gozzo
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Serge Aho-Glele
- Department of Epidemiology & Biostatistics, Dijon University Hospital, 21000 Dijon, France;
| | | | - Christophe Cassinotto
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital, 34980 Montpellier, France; (A.P.); (M.H.); (C.A.); (C.G.); (C.G.); (C.C.)
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Baimas-George M, Watson M, Sulzer J, Salibi P, Murphy KJ, Levi D, Martinie JB, Vrochides D, Baker EH, Ocuin L, Iannitti DA. Pathologic response translates to improved patient survival after locoregional treatment for hepatocellular carcinoma: the importance of minimally invasive microwave ablation. Surg Endosc 2020; 35:3122-3130. [PMID: 32588344 DOI: 10.1007/s00464-020-07747-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatectomy or transplantation can serve as curative treatment for early-stage hepatocellular carcinoma (HCC). Unfortunately, as progression remains a reality, locoregional therapies (LRT) for curative or bridging intent have become common. Efficacy on viability, outcomes, and accuracy of imaging should be defined to guide treatment. METHODS Patients with HCC who underwent minimally invasive (MIS) microwave ablation (MWA), transarterial chemoembolization (TACE), or both (MIS-MWA-TACE) prior to hepatectomy or transplantation were identified. Tumor response and preoperative computed tomography (CT) accuracy were assessed and compared to pathology. Clinical and oncologic outcomes were compared between MIS-MWA, TACE, and MIS-MWA-TACE. RESULTS Ninety-one patients, with tumors from all stages of the Barcelona Clinic Liver Cancer (BCLC) staging, were identified who underwent LRT prior to resection or transplant. Fourteen patients underwent MIS-MWA, 46 underwent TACE, and 31 underwent both neoadjuvantly. TACE population was older; otherwise, there were no differences in demographics. Fifty-seven percent of MIS-MWA patients had no viable tumor on pathology whereas only 13% of TACE patients and 29% of MIS-MWA-TACE patients had complete destruction (p = 0.004). The amount of remaining viable tumor in the explant was also significantly different between groups (MIS-MWA: 17.2%, TACE: 48.7%, MIS-MWA-TACE: 18.6%; p ≤ 0.0001). Compared with TACE, the MIS-MWA and MIS-MWA-TACE groups had significantly improved overall survival (MIS-MWA: 99.94 months, TACE: 75.35 months, MIS-MWA-TACE: 140 months; p = 0.017). This survival remained significant with stratification by tumor size. CT accuracy was found to be 50% sensitive and 86% specific for MIS-MWA. For TACE, CT had an 82% sensitivity and 33% specificity and for MIS-MWA-TACE, there was a 42% sensitivity and 78% specificity. CONCLUSION The impact of locoregional treatments on tumor viability is distinct and superior with MIS-MWA alone and MIS-MWA-TACE offering significant advantage over TACE alone. The extent of this effect may be implicated in the improved overall survival.
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Affiliation(s)
- Maria Baimas-George
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Jesse Sulzer
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Patrick Salibi
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Levi
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC, 28204, USA.
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Shi D, Shi Y, Kaseb AO, Qi X, Zhang Y, Chi J, Lu Q, Gao H, Jiang H, Wang H, Yuan D, Ma H, Wang H, Li Z, Zhai B. Chimeric Antigen Receptor-Glypican-3 T-Cell Therapy for Advanced Hepatocellular Carcinoma: Results of Phase I Trials. Clin Cancer Res 2020; 26:3979-3989. [PMID: 32371538 DOI: 10.1158/1078-0432.ccr-19-3259] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/17/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Our preclinical studies demonstrated the potential of chimeric antigen receptor (CAR)-glypican-3 (GPC3) T-cell therapy for hepatocellular carcinoma (HCC). We report herein the first published results of CAR-GPC3 T-cell therapy for HCC. PATIENTS AND METHODS In two prospective phase I studies, adult patients with advanced GPC3+ HCC (Child-Pugh A) received autologous CAR-GPC3 T-cell therapy following cyclophosphamide- and fludarabine-induced lymphodepletion. The primary objective was to assess the treatment's safety. Adverse events were graded using the Common Terminology Criteria for Adverse Events (version 4.03). Tumor responses were evaluated using the RECIST (version 1.1). RESULTS A total of 13 patients received a median of 19.9 × 108 CAR-GPC3 T cells by a data cutoff date of July 24, 2019. We observed pyrexia, decreased lymphocyte count, and cytokine release syndrome (CRS) in 13, 12, and nine patients, respectively. CRS (grade 1/2) was reversible in eight patients. One patient experienced grade 5 CRS. No patients had grade 3/4 neurotoxicity. The overall survival rates at 3 years, 1 year, and 6 months were 10.5%, 42.0%, and 50.3%, respectively, according to the Kaplan-Meier method. We confirmed two partial responses. One patient with sustained stable disease was alive after 44.2 months. CAR T-cell expansion tended to be positively associated with tumor response. CONCLUSIONS This report demonstrated the initial safety profile of CAR-GPC3 T-cell therapy. We observed early signs of antitumor activity of CAR-GPC3 T cells in patients with advanced HCC.
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Affiliation(s)
- Donghua Shi
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaoping Shi
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xingxing Qi
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Zhang
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiachang Chi
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Lu
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Hua Jiang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | | | - Hong Ma
- CARsgen Therapeutics Corp., Houston, Texas
| | - Hongyang Wang
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Zonghai Li
- CARsgen Therapeutics Ltd., Shanghai, China. .,State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Zhai
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Altman AM, Coughlan A, Shukla DM, Schat R, Spilseth B, Marmor S, Hui JYC, Tuttle TM, Jensen EH. Minimally invasive microwave ablation provides excellent long‐term outcomes for otherwise inaccessible hepatocellular cancer. J Surg Oncol 2020; 121:1218-1224. [DOI: 10.1002/jso.25924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/06/2020] [Accepted: 03/03/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Dip M. Shukla
- Department of SurgeryUniversity of MinnesotaMinneapolis Minnesota
| | - Robben Schat
- Department of RadiologyUniversity of MinnesotaMinneapolis Minnesota
| | | | - Schelomo Marmor
- Department of SurgeryUniversity of MinnesotaMinneapolis Minnesota
| | - Jane Y. C. Hui
- Department of SurgeryUniversity of MinnesotaMinneapolis Minnesota
| | - Todd M. Tuttle
- Department of SurgeryUniversity of MinnesotaMinneapolis Minnesota
| | - Eric H. Jensen
- Department of SurgeryUniversity of MinnesotaMinneapolis Minnesota
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Santambrogio R, Barabino M, D'Alessandro V, Galfrascoli E, Zappa MA, Piccolo G, Zuin M, Opocher E. Laparoscopic thermoablation for hepatocellular carcinoma in patients with liver cirrhosis: an effective procedure for tricky tumors. Med Oncol 2020; 37:32. [PMID: 32193636 DOI: 10.1007/s12032-020-1342-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/28/2020] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
| | - Matteo Barabino
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy.
| | | | | | | | - Gaetano Piccolo
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy
| | - Massimo Zuin
- Hepato-Gastroenterology Unit, San Paolo Hospital, University of Milan, Milan, Italy
| | - Enrico Opocher
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy
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Zhu J, Xu Y, Lu XJ. Stereotactic Body Radiation Therapy and Ablative Therapies for Solid Tumors: Recent Advances and Clinical Applications. Technol Cancer Res Treat 2019; 18:1533033819830720. [PMID: 30922170 PMCID: PMC6444407 DOI: 10.1177/1533033819830720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Jing Zhu
- 1 Department of General Surgery, Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,2 The Sparkfire Scientific Research Group of Nanjing Medical University, Nanjing, China
| | - Yong Xu
- 3 Department of Nephrology, Huai'an Second People's Hospital and The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, China
| | - Xiao-Jie Lu
- 1 Department of General Surgery, Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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