Transcatheter Arterial Chemoembolization With or Without Radiofrequency Ablation: Outcomes in Patients With Barcelona Clinic Liver Cancer Stage B Hepatocellular Carcinoma

Therapeutic analysis of 632 cases treated by transcatheter arterial chemoembolization combined with ablation in hepatocellular carcinoma: A retrospective study

OBJECTIVES

This study aims to analyze the efficacy of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CA) in hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was conducted on 632 patients with HCC at Barcelona Clinic Liver Cancer Staging (BCLC) System stages 0, A, and B from Beijing You'an Hospital affiliated with Capital Medical University. The primary outcomes analyzed were overall survival (OS) and progression-free survival (PFS), while the secondary outcomes included one-, three-, and five-year OS rates among different groups.

RESULTS

The median follow-up period for 632 cases identified with HCC was 52.1 months (range: 3-162 months), while 127 patients died during follow-up. The one-, three-, and five-year OS rates were 97.1 %, 89.5 %, and 80.4 %, respectively. Moreover, the one-, three-, and five-year PFS rates were 58.1 %, 29.3 %, and 19.8 %, respectively. Multivariate analysis revealed that the BCLC stages and complete ablation were independent predictors of OS and PFS (all p < 0.05). Subgroup analysis showed no difference in OS rate among TACE-RFA, TACE-MWA, and TACE-CA groups, but TACE-CA showed better efficacy in improving the PFS rate (all p < 0.05).

CONCLUSIONS

The combination of TACE and ablation is effective in early-stage HCC and BCLC stage B. Complete ablation and BCLC stages are significant prognostic factors for PFS and OS. Further research, including randomized controlled trials, is needed to validate these findings.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada

BACKGROUND

Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.

METHODS

A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.

RESULTS & CONCLUSION

The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

LI-RADS Classification and Outcomes of Hepatocellular Carcinoma Treated With Transcatheter Arterial Chemoembolization Plus Radiofrequency Ablation

AIM

The aim of this study was to clarify the usefulness of the Liver Imaging Reporting and Data System (LI-RADS) for predicting a patient's prognosis after transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (TACE-RFA) for hepatocellular carcinoma (HCC) of Barcelona-Clinic Liver Cancer (BCLC) stage 0 or A.

PATIENTS AND METHODS

We retrospectively analyzed cases of patients with HCC who underwent TACE-RFA (Jan 2005 to Dec 2015). Nodules were categorized based on their LI-RADS v2018 core. The LI-RADS category was assigned to each nodule using dynamic contrast-enhanced computed tomography. LR-3, LR-4 and LR-5 nodules were extracted. The overall (OS) and recurrence-free (RFS) survival was assessed among patients with BCLC 0 and BCLC A disease.

RESULTS

Of the 64 nodules extracted, 22 were LR-3 or -4 (mean±standard deviation=14.8±6.7 mm) and 42 were LR-5 (17.1±6.9 mm). Regarding OS, there was no significant difference between those with LR-3 or -4 and LR-5 (p=0.278). In terms of RFS, there was a significant difference between those with LR-3 or -4 and those with LR-5 (p=0.03). In particular, patients with BCLC A with LR-5 nodules had significantly poorer RFS than those with LR-3 or -4 (p=0.016) nodules.

CONCLUSION

For patients with BCLC A, LR-3 or -4 nodules are associated with a better prognosis than LR-5 nodules.

Combined radiofrequency ablation or microwave ablation with transarterial chemoembolization can increase efficiency in intermediate-stage hepatocellular carcinoma without more complication: a systematic review and meta-analysis

OBJECTIVES

Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely used in combination with transarterial chemoembolization (TACE) for intermediate-stage hepatocellular carcinoma (HCC) in clinical practice. We aim to compare the efficacy and safety of TACE combined with RFA or MWA versus TACE monotherapy for intermediate-stage HCC.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for relevant studies. The outcomes included overall survival (OS), progression-free survival (PFS), local tumor control (LTC) rate, and major complication. Subgroup analysis for different TACE combination therapies was performed.

RESULTS

Ten studies with 1799 patients with intermediate-stage HCC were included. The pooled hazard ratio (HR) for OS was in favor of TACE combination therapy (HR, 0.50, 95% confidence interval [CI], 0.40-0.62). Specifically, the TACE combination therapy was associated with higher 1-, 3-, and 5-year OS rates. Regarding tumor progression, the TACE combination therapy showed significantly better PFS (HR, 0.47, 95% CI, 0.37-0.61) and higher 1-, 2- and 3-year PFS rates than TACE monotherapy. The pooled odds ratio (OR) for the LTC was also in favor of TACE combination therapy (OR, 0.36, 95% CI, 0.24-0.53). No significant difference was found between the two groups regarding the major complication rate (OR, 1.26, 95% CI, 0.74-2.16). These results were consistent across subgroups of TACE + RFA versus TACE and TACE + MWA versus TACE.

CONCLUSION

TACE combined with RFA or MWA can provide significantly better OS, PFS and LTC than TACE monotherapy for patients with intermediate-stage HCC, without increasing the risk of major complications.

Combined treatments in hepatocellular carcinoma: Time to put them in the guidelines?

The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma (HCC) we do have a far-reaching arsenal. Moreover, because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options. The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies, discussing their advantages and flaws in comparison to the current standard of care. One particular combination therapy seems to be in the forefront: Transarterial chemoembolization plus ablation for medium-size non-resectable HCC (3-5 cm), which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B. Not only does it improve the outcome in contrast to each individual therapy, but it also seems to have similar results to surgery. Also, the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC. Although the path of combination therapies in HCC is still filled with uncertainty and caveats, in the following years the hepatology and oncology fields could witness an HCC guideline revolution.

Hyperthermia ablation combined with transarterial chemoembolization versus monotherapy for hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND AIMS

The existing evidence has indicated that hyperthermia ablation (HA) and HA combined with transarterial chemoembolization (HATACE) are the optimal alternative to surgical resection for patients with hepatocellular carcinoma (HCC) in the COVID-19 crisis. However, the evidence for decision-making is lacking in terms of comparison between HA and HATACE. Herein, a comprehensive evaluation was performed to compare the efficacy and safety of HATACE with monotherapy.

MATERIALS AND METHODS

Worldwide studies were collected to evaluate the HATACE regimen for HCC due to the practical need for global extrapolation of applicative population. Meta-analyses were performed using the RevMan 5.3 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Thirty-six studies involving a large sample of 5036 patients were included finally. Compared with HA alone, HATACE produced the advantage of 5-year overall survival (OS) rate (OR:1.90; 95%CI:1.46,2.46; p < 0.05) without increasing toxicity (p ≥ 0.05). Compared with TACE alone, HATACE was associated with superior 5-year OS rate (OR:3.54; 95%CI:1.96,6.37; p < 0.05) and significantly reduced the incidences of severe liver damage (OR:0.32; 95%CI:0.11,0.96; p < 0.05) and ascites (OR:0.42; 95%CI:0.20,0.88; p < 0.05). Subgroup analysis results of small (≤3 cm) HCC revealed that there were no significant differences between the HATACE group and HA monotherapy group in regard to the OS rates (p ≥ 0.05).

CONCLUSIONS

Compared with TACE alone, HATACE was more effective and safe for HCC. Compared with HA alone, HATACE was more effective for non-small-sized (>3 cm) HCC with comparable safety. However, the survival benefit of adjuvant TACE in HATACE regimen was not found for the patients with small (≤3 cm) HCC.

Fusion imaging-guided radiofrequency ablation for residual hepatocellular carcinoma invisible on ultrasound after transcatheter arterial chemoembolization

PURPOSE

This study aimed to investigate the technical efficiency and therapeutic response of fusion imaging (considered as virtual navigation) between contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography/magnetic resonance imaging (CECT/CEMRI) for the guidance of radiofrequency ablation (RFA) in patients with residual hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE).

METHODS

For this prospective study, 98 patients with residual HCC lesions after TACE treatment were enrolled between June 2017 and December 2020. All the lesions were invisible on conventional ultrasound scans. Percutaneous RFA was performed using either CEUS (CEUS group, 52 lesions) or virtual navigation (VN group, 46 lesions) guidance. The lesion display rate, disease-free survival rate, local recurrence rate, overall survival rate and complication incidence were calculated and compared.

RESULTS

Fusion imaging had a significant impact on the RFA outcomes (hazard ratio, 2.629; 95% confidence interval, 1.256-5.505; p = .01). The median disease-free survival time of the VN group was significantly higher than that of the CEUS group (10.9 vs. 8.8 months; p = .007). The local recurrence rates after 3, 6 and 12 months in the VN group were significantly lower than those in the CEUS group (p = .014, .002 and .011). The minor complication rate was not significantly different between the two groups.

CONCLUSIONS

CEUS-CECT/CEMRI fusion imaging for guiding RFA enables an efficient and useful therapy of inconspicuous HCC lesions after TACE. The novel solution prolongs the disease-free survival time and reduces the long-term local recurrence of residual lesions treated when using virtual-navigation (VN)-guided RFA.

Current Strategies to Identify Patients That Will Benefit from TACE Treatment and Future Directions a Practical Step-by-Step Guide

Treatment of hepatocellular carcinoma (HCC) depends on the stage of disease. In the Western Hemisphere, the Barcelona Clinic Liver Cancer classification (BCLC) is the preferred staging system. Approximately one-third of patients initially present with intermediate-stage disease. For these patients, transarterial chemoembolization (TACE) is the treatment of choice. However, the intermediate-stage comprises a heterogeneous subgroup of patients with considerable differences in tumor burden and liver function. In addition, differences in individual factors that are not captured by the BCLC framework, such as the tumor growth pattern, degree of hypervascularity, and vascular supply, complicate further evaluation of these patients. Due to these differences, not all patients benefit equally from TACE. Several tools and scoring systems have been devised to provide decision-making support. All of these have shown promising initial results but failed external evaluation and have not been translated to the clinic. Nevertheless, criteria for objectifying treatment decisions in daily clinical practice are needed in all stages of disease. Therefore, this review provides a concise practical step-by-step guide on current strategies for patient selection and decision-making, with a focus on TACE, to critically evaluate the existing decision-support tools and provide a summary of the latest updates in the field.

A systematic review and meta-analysis of radio frequency ablation and routine resection in the treatment of small hepatocellular carcinoma

Background

This study sought to conduct a meta-analysis of the relevant literature on radiofrequency ablation (RFA) and routine resection in the treatment of small hepatocellular carcinoma (SHCC) in recent years, and to examine the clinical efficacy and safety of different schemes.

Methods

PubMed, The Cochrane Library, Embase, CNKI, Chinese biomedical literature, VIP Chinese journal and the Wanfang Database were used to comprehensively search for relevant papers on clinical control studies of RFA and the routine resection SHCC published between January 2008 and December 2019. The clinical efficacy and safety of different schemes in the treatment of SHCC were compared, including the overall survival rate within 1, 3, and 5 years, and the incidence of complications during treatment. A meta-analysis was undertaken using methods provided by the Cochrane Collaboration and RevMan 5.3 software.

Results

A total of 13 publications of studies were retrieved in which 2,384 patients participated. Of these patients, 1,256 (52.68%) were allocated to the RFA group and 1,128 patients (47.32%) to the conventional resection group. The effect size of the 1-year overall survival rate for the two groups was odds ratio (OR): 0.78 [95% confidence interval (CI), 0.43-1.38]; Z test: P=0.32. The effect size of the overall survival rate within 3 years was OR: 0.71 (95% CI, 0.48-1.05); Z test: P=0.07. The difference was not statistically significant. The 5-year overall survival rate of the RFA group and conventional resection group was OR: 0.55 (95% CI, 0.40-0.72). The OR value fell within the CI, excluding 1; Z test: P<0.0001. The difference was statistically significant. The incidence of complications in the RFA group during treatment was lower than that in the conventional resection group (OR: 0.45; 95% CI, 0.32-0.69). The OR value was within the CI, excluding 1; Z test: P=0.0002. The difference was statistically significant.

Conclusions

The short-term effect of RFA in the treatment of SHCC is basically the same as that of routine resection; however, the long-term effect is significantly lower than that of routine resection. RFA has a lower incidence of complications during treatment, and thus better clinical safety.

Association of Addition of Ablative Therapy Following Transarterial Chemoembolization With Survival Rates in Patients With Hepatocellular Carcinoma

IMPORTANCE

Hepatocellular carcinoma (HCC) is a heterogeneous disease with many available treatment modalities. Transarterial chemoembolization (TACE) is a valuable treatment modality for HCC lesions. This article seeks to evaluate the utility of additional ablative therapy in the management of patients with HCC who received an initial TACE procedure.

OBJECTIVE

To compare the overall survival (OS) and freedom from local progression (FFLP) outcomes after TACE alone with TACE that is followed by an ablative treatment regimen using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation for patients with HCC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 289 adults at a single urban medical center examined survival outcomes for patients with nonmetastatic, unresectable HCC who received ablative therapies following TACE or TACE alone from January 2010 through December 2018. The Lee, Wei, Amato common baseline hazard model was applied for within-patient correlation with robust variance and Cox regression analysis was used to assess the association between treatment group (TACE vs TACE and ablative therapy) and failure time events (FFLP per individual lesion and OS per patient), respectively. In both analyses, the treatment indication was modeled as a time-varying covariate. Landmark analysis was used as a further sensitivity test for bias by treatment indication.

EXPOSURES

TACE alone vs TACE followed by ablative therapy.

MAIN OUTCOMES AND MEASURES

Freedom from local progression and overall survival. Hypotheses were generated before data collection.

RESULTS

Of the 289 patients identified, 176 (60.9%) received TACE only and 113 (39.1%) received TACE plus ablative therapy. Ablative therapy included 45 patients receiving stereotactic body radiation therapy, 39 receiving microwave ablation, 20 receiving radiofrequency ablation, and 9 receiving a combination of these following TACE. With a median (interquartile range) follow-up of 17.4 (9.5-29.5) months, 242 of 512 (47.3%) lesions progressed, 211 in the group with TACE alone and 31 in the group with TACE plus ablative therapy (P < .001). Over 3 years, FFLP was 28.1% for TACE alone vs 67.4% for TACE with ablative therapy (P < .001). The 1-year and 3-year OS was 87.5% and 47.1% for patients with lesions treated with TACE alone vs 98.7% and 85.3% for patients where any lesion received TACE plus ablative therapy, respectively (P = .01), and this benefit remained robust on landmark analyses at 6 and 12 months. The addition of ablative therapy was independently associated with OS on multivariable analysis for all patients (hazard ratio, 0.26; 95% CI, 0.13-0.49; P < .001) and for patients with Barcelona clinic liver cancer stage B or C disease (hazard ratio, 0.31; 95% CI, 0.14-0.69; P = .004).

CONCLUSIONS AND RELEVANCE

Adding ablative therapy following TACE improved FFLP and OS among patients with hepatocellular carcinoma. This study aims to guide the treatment paradigm for HCC patients until results from randomized clinical trials become available.

High-intensity focused ultrasound ablation combined with transcatheter arterial chemoembolization improves long-term efficacy and prognosis of primary liver cancer

Background

To investigate the clinical efficacy of high‐intensity focused ultrasound (HIFU) combined with transcatheter arterial chemoembolization (TACE) in the treatment of primary liver cancer (PLC) and its effect on the prognosis of patients.

Methods

A total of 132 patients with PLC admitted to our hospital were selected for the study, among whom 68 patients received TACE combined with HIUF and were assigned to the observation group (OG), whereas the remaining 54 patients were treated with TACE alone and were assigned to the control group (CG). The factors influencing the patients’ prognosis were also evaluated by multivariate analysis.

Results

The total effective rate of the OG was 83.82%, which was significantly higher than that of 55.56% of the CG (P < .05). No significant difference was found in incidence of adverse reactions between the two groups (P > .05). After treatment, the increases of CD3+, CD4+, CD4+/CD8+, and NK cells in the OG were more significant than those in the CG (P < .05). However, the decrease of CD8+ cells was more significant in the OG than that in the CG (P < .05). The 3‐year survival rate of patients in the OG was 61.76%, which was significantly higher than that of 40.74% in the CG (P < .05).

Conclusion

The application of TACE combined with HIFU is effective in treating PLC, which can prolong the life expectancy and improve the prognosis of patients with PLC without increasing the incidence of adverse reactions.

The Prognostic Value of Inflammation Factors in Hepatocellular Carcinoma Patients with Hepatic Artery Interventional Treatments: A Retrospective Study

Background

Hepatic artery interventional therapy has been recognized as the first choice for advanced liver cancer. However, reliable prognostic markers are still lacking. In the present study, we aimed to evaluate the prognostic value of inflammation factors including neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and monocyte to lymphocyte ratio (MLR) in hepatocellular carcinoma (HCC) patients with hepatic artery interventional treatments.

Methods

Patients undergoing hepatic artery interventional therapy after being diagnosed with HCC between 2007 and 2014 were enrolled. Pre-treatment NLR, PLR and MLR were calculated, and all factors including gender, age, TNM stage, BCLC staging, inflammation factors, LDH, ALP, CEA, AFP, hepatitis, liver cirrhosis, portal vein involvement, surgical history and hepatic artery interventional treatment on overall survival (OS) were evaluated by the univariate and multivariate Cox proportional hazards analyses.

Results

Overall, 407 patients were included. The optimal cutoff values determined by receiver operating characteristic (ROC) curve analyses for NLR, PLR and MLR were 3.82, 140.00 and 0.27, respectively. High NLR was associated with worse OS (median survival time: high NLR group 9 vs low NLR group 19 months, HR 1.842, 95% CI: 1.457–2.329, P<0.001). Elevated PLR was negatively correlated with OS (8 vs 18 months, HR 1.677, 95% CI: 1.302–2.161, P<0.001). Patients in high MLR group had a worse OS (10 vs 21 months, HR 1.626, 95% CI: 1.291–2.048, P<0.001). In multivariate analysis, NLR, LDH, ALP and portal vein involvement were independent prognostic factors for OS of HCC patients after hepatic artery interventional therapy. In addition, for patients in BCLC stage A and B, higher NLR, PLR and MLR were all significantly negatively correlated to median survival time (NLR: 17 vs 26 months, HR: 1.739 (95% CI: 1.279–2.365), P<0.001; PLR: 18 vs 26 months, HR: 1.681 (95% CI: 1.245–2.271), P=0.001; MLR: 20 vs 26 months, HR: 1.589 (95% CI: 1.185–2.129), P=0.002).

Conclusion

Elevated pre-treatment NLR, PLR and MLR were associated with worse survival time in HCC patients after hepatic artery interventional therapy. Among them, NLR was an independent prognostic factor for OS.

Multiple imaging modality-guided radiofrequency ablation combined with transarterial chemoembolization for hepatocellular carcinoma in special locations

PURPOSE

We aimed to evaluate the safety and effectiveness of radiofrequency ablation (RFA) combined with transarterial chemoembolization (TACE) guided by multiple imaging modalities for hepatocellular carcinomas (HCCs) in special (i.e., high-risk or unfavorable) locations compared with those in conventional locations.

METHODS

A total of 122 HCC patients were enrolled, including 85 patients (69.7%) with HCC in conventional locations and 37 (30.3%) with HCC in special locations. The clinical data, overall survival (OS), progression-free survival (PFS), and procedure-related adverse events were analyzed.

RESULTS

RFA combined with TACE was successfully performed in all patients. Three complications (2.5%) occurred, with no significant difference between the conventional (n=1, 1.2%) and special (n=2, 5.4%) locations (P = 0.218). Complete tumor necrosis rate was not significantly different between the conventional (n=73, 85.9%) and special (n=34, 91.9%) locations at one-month imaging (P = 0.353). After a follow-up of 3-48 months, the PFS was 17 months for patients with HCC in conventional locations and 14 months for patients with HCC in special locations; one-year PFS rate was 68.1% in the conventional location group, not significantly (P = 0.741) different from 59.1% in the special location group. The OS was 28 months in the conventional location group while 32 months in the special location group. The cumulative one- and two-year OS rates were 89.9% and 63.3%, respectively, in the conventional location group, not significantly different from 96.3% and 65% in the special location group (P = 0.273). Age (P = 0.043) and tumor size (P < 0.001) were significant prognostic factors for OS, and tumor size (P < 0.001) was the only significant prognostic factor for PFS.

CONCLUSION

RFA guided by multiple imaging modalities combined with TACE may be safe and effective for treating HCCs in special locations.

Treatment of Intermediate-Stage Hepatocellular Carcinoma in Japan: Position of Curative Therapies

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is the standard therapy for intermediate-stage (IM) hepatocellular carcinoma (HCC). However, IM-HCC includes various clinical conditions, and various therapies were conducted in practice. In this study, we retrospectively analyzed the actually conducted treatments for IM-HCC and their efficacies to elucidate the treatment strategies suitable for IM-HCC.

METHODS

This study included 627 IM-HCC of 5,260 HCC from 9 hospitals. We examined the treatment strategies of these patients and analyzed the efficacy of each therapy with the Cox proportional hazard model and propensity score-matched analysis.

RESULTS

Liver resection, radiofrequency ablation (RFA), and TACE were performed in 165, 108, and 351 patients, respectively. Liver resection and RFA were preferably selected in cases of Barcelona Clinic Liver Cancer (BCLC)-B1/B2, and patient survival was significantly longer than in those treated with TACE (p< 0.0001). However, no beneficial effect of these active therapies was observed in cases of BCLC-B3/B4. Multivariate analysis revealed that surgical resection (hazard ratio = 0.384) and RFA (hazard ratio = 0.597) were negative risk factors for survival. Propensity score-matching analysis revealed that -survival of RFA-treated patients was longer than that of TACE-treated patients (p = 0.036).

CONCLUSION

RFA and surgical resection were effective for IM-HCC, particularly in BCLC-B1/B2 cases.

A new substage classification strategy for Barcelona Clinic Liver Cancer stage B patients with hepatocellular carcinoma

BACKGROUND AND AIM

Patients with Barcelona Clinic Liver Cancer stage B hepatocellular carcinoma are a heterogeneous population, and the classifications available could not predict the prognosis accurately. Herein, we proposed a new substage classification method, Scoring Method for Intermediate Stage, for precise classification and clinical guidance in hepatocellular carcinoma patients within Barcelona Clinic Liver Cancer stage B.

METHODS

A total of 1026 stage B patients of hepatocellular carcinoma who underwent transcatheter arterial chemoembolization as a first-line treatment in Liver Cancer Institute, Zhongshan Hospital, Fudan University were retrospectively enrolled. The prognostic evaluation ability of the new substage classification criteria was analyzed, in comparison with the existing substage classification criteria.

RESULTS

Using Scoring Method for Intermediate Stage, 1026 stage B patients were subclassified into three subgroups, based on Child-Pugh score and up-to-7 grade, as B1 (scoring 2), B2 (scoring 3 or 4), and B3 (scoring 5 or 6). The median survival time of the three substages was 29 (95% confidence interval [CI]: 25-36), 19 (95% CI: 16-21), and 10 (95% CI: 8-12) months, respectively. More favorable discrimination efficacy was identified by the new criteria in comparison with the existing substage classification criteria, including Bolondi, Kinki, MICAN, and Kim's criteria. Moreover, multivariate analyses indicated that the novel classification was highly associated with prognosis (Hazard ratio(s) = 1.63, 95% CI: 1.43-1.86, P < 0.001).

CONCLUSIONS

Scoring Method for Intermediate Stage demonstrates satisfying capacity in classifying patients with stage B hepatocellular carcinoma and predicting prognosis.

Improved clinical outcome using transarterial chemoembolization combined with radiofrequency ablation for patients in Barcelona clinic liver cancer stage A or B hepatocellular carcinoma regardless of tumor size: results of a single-center retrospective case control study

Background

To determine the safety and efficacy of transarterial chemoembolization (TACE) combined with radiofrequency ablation (hereafter, TACE-RFA) in treating Barcelona Clinic Liver Cancer (BCLC) Stage A or B (hereafter, BCLC A/B) hepatocellular carcinoma (HCC) patients, and to explore the range of tumor sizes suitable for combination therapy.

Methods

This retrospective study assessed the consecutive medical records of HCC patients with BCLC A/B who received TACE-RFA or TACE from September 2009 to September 2018. Progression-free survival (PFS), overall survival (OS), therapeutic response, and complications were compared between the two groups.

Results

Among 2447 patients who received TACE-RFA or TACE, 399 eligible patients were enrolled in our study, including 128 patients in the TACE-RFA group and 271 patients in the TACE group. Compared with the TACE group, the PFS and OS rates of 1,3,5,8 years in the TACE-RFA group were significantly better, with higher objective tumor regression rate and better disease control rate. RFA treatment did not increase the risk of death in patients with HCC, and both liver subcapsular hematoma and bile duct injury were improved by symptomatic treatment. Serum α-fetoprotein level and treatment method were important independent prognostic factors for OS, whereas albumin, hepatitis B and treatment method were important independent prognostic factors for PFS. Subgroup analysis showed that patients in the TACE-RFA group always showed better OS and PFS.

Conclusions

TACE-RFA had an advantage over TACE alone in prolonging PFS and improving OS in HCC patients with BCLC A/B, and can benefit patients regardless of tumor size.

Prediction of Prognosis of Intermediate-Stage HCC Patients: Validation of the Tumor Marker Score in a Nationwide Database in Japan

BACKGROUND/AIM

Adequate assessment of transcatheter arterial chemoembolization (TACE)-refractory status has become more important for switching treatment in intermediate-stage (BCLC-B) hepatocellular carcinoma (HCC) patients treated with TACE. The usefulness of a previously proposed tumor marker score for predicting prognosis of BCLC-B HCC patients treated with TACE was investigated.

METHODS

Using a nationwide database, we examined the records of 1,306 naïve BCLC-B HCC with Child-Pugh A who were treated from 2001 to 2007, after excluding those with missing data (hepatic function or tumor markers) or cases with a single large tumor. Alpha-fetoprotein (AFP) ≥100 ng/mL, fucosylated AFP (AFP-L3) ≥10%, and des-gamma-carboxy prothrombin ≥100 mAU/mL were markers used to define positive cases. The number of positive tumor markers was used as a prognostic score, and its predictive value was evaluated in a retrospective manner.

RESULTS

Median survival time became shorter along with increased score (0, 1, ≥2 = 4.8, 3.8, 3.2 years, respectively; p < 0.01). Tumor marker score (≥2; hazard ratio [HR] 1.675, 95% confidence interval [CI] 1.372-2.044, p < 0.001), serum levels of albumin (≥3.5 g/dL; HR 0.726, 95% CI 0.528-0.997, p = 0.048), and up-to-7 criteria (HR 1.673, 95% CI 1.400-2.000, p < 0.001) were significant prognostic factors for death in the Cox hazard multivariate analysis.

CONCLUSION

Tumor marker score had a useful predictive prognostic value in BCLC-B HCC treated with TACE. Especially in patients with a tumor marker score of 2 or greater, a poor therapeutic response should be expected, and appropriate judgement of TACE-refractory status is necessary.

Prognostic impact of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation in patients with unresectable hepatocellular carcinoma: Comparison with TACE alone using decision-tree analysis after propensity score matching

AIMS

The prognosis of hepatocellular carcinoma (HCC) patients treated with transcatheter arterial chemoembolization (TACE) is still poor. We aimed to evaluate the impact of TACE combined with radiofrequency ablation (TACE+RFA) on the prognosis of HCC patients using decision-tree analysis after propensity score matching.

METHODS

This was a retrospective study. We enrolled 420 patients with HCC treated with TACE alone (n = 311) or TACE+RFA (n = 109) between 1998 and 2016 (median age, 72 years; male / female, 272/148; Barcelona Clinic Liver Cancer (BCLC) stage A / B, 215/205). The prognosis of patients who underwent TACE+RFA was compared to patients who underwent TACE alone after propensity score matching. Decision-tree analysis was used to investigate the profile for prognosis of the patients.

RESULTS

After propensity score matching, there was no significant difference in age, sex, BCLC stage, or albumin-bilirubin (ALBI) score between both groups. The survival rate of the TACE+RFA group was significantly higher than the TACE alone group (median survival time [MST] 57.9 months vs. 33.1 months, P < 0.001). In a stratification analysis according to BCLC stage, the overall survival rate of the TACE+RFA group was significantly higher than the TACE alone group in BCLC stage A and B (MST 57.9 and 50.7 months vs. 39.8 and 24.5 months [P = 0.007 and 0.001], respectively). Decision-tree analysis showed that TACE+RFA was the third distinguishable factor for survival in patients with α-fetoprotein level >7 ng/mL and ALBI <-2.08.

CONCLUSION

Decision-tree analysis after propensity score matching showed that TACE+RFA could prolong the survival of HCC patients compared to TACE alone.

Comparison of clinical outcomes of laparoscopic versus open surgery for recurrent hepatocellular carcinoma: a meta-analysis

BACKGROUND

The purpose of this study is to compare the clinical outcomes of laparoscopic liver resection versus open liver resection for recurrent hepatocellular carcinoma (RHCC).

METHODS

Published studies which investigated laparoscopic versus open liver resection for RHCC were identified, and meta-analysis was used for statistical analysis.

RESULTS

Six studies were analyzed by meta-analysis method, and cumulative 335 cases were included in this study. Laparoscopic liver resection was performed in 145 cases, and open liver resection was performed in 190 cases. Meta-analysis showed that there was no difference in operative time and 90-day mortality between the laparoscopic group and the open group (p = 0.06 and p = 0.06 respectively); Nevertheless, compared with the open group, the laparoscopic group resulted in significantly lower rate of in-hospital complication (p < 0.0001), much less blood loss (p < 0.0001) and shorter postoperative hospital stay (p = 0.002).

CONCLUSION

Laparoscopic liver resection for RHCC offers a benefit of lower in-hospital complication rate, less blood loss, shorter postoperative hospital stay, while similar operative time and 90-day mortality as the open liver resection. Laparoscopic liver resection is feasible with satisfactory postoperative outcomes and can be a safe alternative treatment strategy to open procedure for RHCC.

Interventional oncology treatments for unresectable early stage HCC in patients with a high risk for intraprocedural bleeding: Is a single-step combined therapy safe and feasible?

PURPOSE

This study was designed to assess the feasibility and safety of a single-step combined therapy using radiofrequency ablation and transarterial chemoembolization (RFA + TACE) in patients with hepatocellular carcinoma (HCC) and uncontrolled coagulopathy. The study also aimed to compare the effectiveness of this approach with TACE alone, performed in a control group.

MATERIAL AND METHODS

One hundred and forty-three consecutive cirrhotic patients having a single HCC < 8 cm were enrolled in this observational prospective single-center study from January 2010 to June 2017 and were divided, according to coagulation tests, into three groups (A: low risk; B: intermediate risk and C: high risk of bleeding). The feasibility and safety of a single-step combined treatment (RFA followed by TACE) were evaluated in terms of technical success rate, periprocedural complications, and laboratory values variations. Tumor response obtained at 1-month CT follow-up for group C was compared with that of control group, composed by 16 matched patients with severe coagulopathy and single HCC < 8 cm, who underwent only TACE in a previous period, performed by the same operator.

RESULTS

Technical success was achieved in all patients, without any major complications. Minor complications rate was significantly higher in group C after RFA; however, the patients were successfully treated with subsequent TACE therapy, without any differences between pre- and post-procedural laboratory values. One-month complete response rates were similar in all the three groups; however, the response rates of group C were significantly higher as compared to that of the control TACE Group (p < .001).

CONCLUSION

The single-step RFA plus TACE therapy allows expansion of the indication for percutaneous thermal ablation, allowing to also include cases previously contraindicated due to the procedural high-risk of complications associated with bleeding, thus improving short-term patient outcome.

Efficacy of combination therapy with transcatheter arterial chemoembolization and radiofrequency ablation for intermediate-stage hepatocellular carcinoma

OBJECTIVES

Transcatheter arterial chemoembolization (TACE) is the standard therapy for patients with intermediate-stage hepatocellular carcinoma (HCC). This study aimed to determine whether combination therapy with radiofrequency ablation (RFA) and TACE was superior to TACE monotherapy for intermediate-stage HCC and identify cases in which this technique was the most effective.

MATERIALS AND METHODS

We selected patients with intermediate HCC who met the following eligibility criteria: (1) ≥ 20 years of age, (2) receiving initial therapy, (3) ≤7 tumors, and (4) maximum tumor diameter <5 cm. We performed propensity score matching (PSM) using potential confounding factors. We retrospectively compared the cumulative overall survival rate and recurrence-free survival rate between the TACE + RFA and TACE groups. Additionally, a sub-group analysis was performed for preoperative factors.

RESULTS

Among the 103 patients, 92 were selected using PSM. The cumulative overall survival rates at 1, 3, and 5 years for the TACE + RFA group were 97.4%, 70.4%, and 60.4%, respectively, which were significantly higher than those for the TACE group (92.7%, 55.7%, and 22.8%, respectively, p = .045). The recurrence-free survival rates at 0.5, 1, and 2 years for the TACE + RFA group were 80.0%, 58.6%, and 33.3%, respectively, which were significantly higher than those for the TACE group (34.5%, 8.8%, and 2.9%, respectively, p < .01). For the sub-group with α-fetoprotein (AFP) <100 ng/mL, the TACE + RFA group demonstrated a significantly improved prognosis than the TACE group (p = .036).

CONCLUSIONS

The addition of RFA to TACE improved cumulative overall and recurrence-free survival in patients with intermediate-stage HCC, especially in patients with AFP <100.

Long-term follow-up of unresectable medium-large hepatocellular carcinoma nodules treated with radiofrequency ablation using a multiple-electrode switching system

OBJECTIVE

The purpose of this study was to prospectively evaluate the safety and effectiveness of radiofrequency ablation (RFA) by using a multiple-electrode switching system to treat unresectable medium-large (3.1-6.0 cm) HCC nodules.

METHODS

RFA using a multiple-electrode switching system was performed for HCC nodules with size > 3.0 < 6.0 cm in nonsurgical candidates. Two electrodes were consecutively placed for 3.1-4.0 cm tumours, and three electrodes for 4.1-5.9 cm tumours, with a 2.0-2.5 cm spacing. The power was switched from one electrode to the next automatically when the impedance reached 30 Ω above the baseline level. 25 patients (M/F = 9/16; median age 76 years, range 61-84) with liver cirrhosis (20 HCV-positive) in Child's Class A (22 cases) and B (3 cases) and 26 HCC nodules (median diameter 4.0 cm; range 3.2-5.5 cm) underwent treatment in 25 sessions from 2013 and 2018. Therapeutic effectiveness was assessed through CT or MRI exam at 30-40 days post-ablation.

RESULTS

No procedure-related death or major complications occurred. Complete ablation was obtained in all nodules (100%). At a median follow up of 30 months, local tumor progression occurred in five out of 26 nodules (19.2%). Overall survival at 4 years was 49%.

CONCLUSION

RFA with a multiple-electrode switching system may be a safe, quick and effective therapeutic option for treatment of 3.1-6.0 cm unresectable HCC tumours.

ADVANCES IN KNOWLEDGE

RFA with multiple electrodes provides favourable clinical results in patients with medium-large HCC nodules who are not suitable for surgery.