MWA combined with TACE as a combined therapy for unresectable large-sized hepotocellular carcinoma

Locoregional therapies for hepatocellular carcinoma: The current status and future perspectives

Hepatocellular carcinoma (HCC) is one of the most common cancers and a leading cause of cancer-related mortality. Locoregional therapies (LRTs) play a crucial role in HCC management and are selectively adopted in real-world practice across various stages. Choosing the best form of LRTs depends on technical aspects, patient clinical status and tumour characteristics. Previous studies have consistently highlighted the efficacy of combining LRTs with molecular targeted agents in HCC treatment. Recent studies propose that integrating LRTs with immune checkpoint inhibitors and molecular targeted agents could provide substantial therapeutic benefits, a notion underpinned by both basic and clinical evidence. This review summarised the current landscape of LRTs in HCC and discussed the anticipated outcomes of combinations with immunotherapy regimens.

Outcome of transarterial radioembolization in patients with hepatocellular carcinoma as a first-line interventional therapy and after a previous transarterial chemoembolization

Purpose

Due to a lack of data, there is an ongoing debate regarding the optimal frontline interventional therapy for unresectable hepatocellular carcinoma (HCC). The aim of the study is to compare the results of transarterial radioembolization (TARE) as the first-line therapy and as a subsequent therapy following prior transarterial chemoembolization (TACE) in these patients.

Methods

A total of 83 patients were evaluated, with 38 patients having undergone at least one TACE session prior to TARE [27 male; mean age 67.2 years; 68.4% stage Barcelona clinic liver cancer (BCLC) B, 31.6% BCLC C]; 45 patients underwent primary TARE (33 male; mean age 69.9 years; 40% BCLC B, 58% BCLC C). Clinical [age, gender, BCLC stage, activity in gigabecquerel (GBq), Child-Pugh status, portal vein thrombosis, tumor volume] and procedural [overall survival (OS), local tumor control (LTC), and progression-free survival (PFS)] data were compared. A regression analysis was performed to evaluate OS, LTC, and PFS.

Results

No differences were found in OS (95% CI: 1.12, P = 0.289), LTC (95% CI: 0.003, P = 0.95), and PFS (95% CI: 0.4, P = 0.525). The regression analysis revealed a relationship between Child-Pugh score (P = 0.005), size of HCC lesions (>10 cm) (P = 0.022), and OS; neither prior TACE (Child-Pugh B patients; 95% CI: 0.120, P = 0.729) nor number of lesions (>10; 95% CI: 2.930, P = 0.087) correlated with OS.

Conclusion

Prior TACE does not affect the outcome of TARE in unresectable HCC.

CT-guided 125I brachytherapy for hepatocellular carcinoma in high-risk locations after transarterial chemoembolization combined with microwave ablation: a propensity score-matched study

BACKGROUND

This study aimed to evaluate the safety and efficacy of ¹²⁵I brachytherapy combined with transarterial chemoembolization (TACE) and microwave ablation (MWA) for unresectable hepatocellular carcinoma (HCC) in high-risk locations.

PATIENTS AND METHODS

After 1:2 propensity score matching (PSM), this retrospectively study analyzed 49 patients who underwent TACE +MWA+¹²⁵I brachytherapy (group A) and 98 patients who only received TACE +MWA (group B). The evaluated outcomes were progression-free survival (PFS), overall survival (OS), and treatment complications. Cox proportional hazards regression analysis survival was used to compare the two groups.

RESULTS

The patients in group A showed a longer PFS than group B (7.9 vs. 3.3 months, P = 0.007). No significant differences were observed in median OS between the two groups (P = 0.928). The objective response rate (ORR), disease control rate of tumors in high-risk locations, and the ORR of intrahepatic tumors were 67.3%, 93.9%, and 51.0%, respectively, in group A, and 38.8%, 79.6% and 29.6%, respectively, in group B (P < 0.001, P = 0.025 and P = 0.011, respectively). TACE-MWA-¹²⁵I (HR = 0.479, P < 0.001) was a significant favorable prognostic factor that affected PFS. The present of portal vein tumor thrombosis was an independent prognostic factor for PFS (HR = 1.625, P = 0.040). The Barcelona clinic liver cancer (BCLC) stage (BCLC C vs. B) was an independent factor affecting OS (HR = 1.941, P = 0.038). The incidence of complications was similar between the two groups, except that the incidence of abdominal pain was reduced in the group A (P = 0.007).

CONCLUSIONS

TACE-MWA-¹²⁵I resulted in longer PFS and better tumor control than did TACE-MWA in patients with unresectable hepatocellular carcinoma in high-risk locations.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

LAG3 blockade coordinates with microwave ablation to promote CD8+ T cell-mediated anti-tumor immunity

Background

The immune checkpoint inhibitors (ICIs) combined with other therapeutic strategies have shown exciting results in various malignancies, and ICIs have now become the gold standard for current cancer treatment. In several preclinical and clinical investigations, ablation coupled with immunotherapy has proved to be quite effective. Our previous studies have shown that ablation coupled with ICI is a potential anti-cancer regimen for colorectal cancer liver metastases (CRLM). Furthermore, we have reported that following microwave ablation (MWA), the expression of LAG3 is up-regulated in tumor microenvironment (TME), indicating that LAG3 is implicated in the regulation of immunosuppressive immune response, and combination therapy of MWA and LAG3 blockade can serve as a promising therapeutic strategy against cancer.

Methods

The expression of LAG3 was investigated in this study utilizing a preclinical mouse model treated with MWA. Moreover, we monitored the tumor development and survival in mice to assess the anti-cancer effects of MWA alone or in combination with LAG3 blockade. Flow cytometry was also used to phenotype the tumor-infiltrating lymphocytes (TILs) and CD8⁺ T cell effector molecules. We finally analyzed the single-cell RNA sequencing (scRNA-seq) data of infiltrating CD45⁺ immune cells in the tumors from the MWA alone and MWA combined with LAG3 blockade groups.

Results

After MWA, the expression of LAG3 was up-regulated on sub-populations of TILs, and introducing LAG3 blockade to MWA postponed tumor development and extended survival in the MC38 tumor model. Flow cytometry and scRNA-seq revealed that LAG3 blockade in combination with MWA markedly boosted the proliferation and the function of CD8⁺ TILs, leading to altered myeloid cells in the TME.

Conclusion

Combination therapy of LAG3 blockade and MWA was a unique therapeutic regimen for some solid tumors, and such combination therapy might reprogram the TME to an anti-tumor manner.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03646-7.

Comparison of combined transarterial chemoembolization and ablations in patients with hepatocellular carcinoma: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compares the efficacy of three combination therapies, including transarterial chemoembolization (TACE) with radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CRA) for the treatment of patients with hepatocellular carcinoma (HCC).

METHODS

Online databases, including Scopus, Web of Science, PubMed, Embase, CNKI, Google Scholar, and Cochrane Library were searched.

RESULTS

Forty-two studies with 5468 pooled patients (TACE + RFA: 21 studies with 3398 patients, TACE + MWA:14 studies with 1477 patients, and TACE + CRA: 7 studies with 593 patients) reported combination therapy versus TACE alone. The TACE + MWA subcohort had the best odds of long-term overall survival (OR 4.81, 95% CI 1.44, 16.08, P = 0.011) and objective response rate (OR 3.93, 95% CI 2.34, 6.61, P < 0.001) compared with the other two combination subcohorts. The TACE + RFA and TACE + MWA subcohorts had approximately similar odds of 1-year recurrence-free survival (OR 5.21, 95% CI 2.13, 12.75, P < 0.001 and OR 4.61, 95% CI 1.70, 12.51, P = 0.003, respectively). The disease control rate was similar between the TACE + MWA and TACE + CRA subcohorts (OR 4.01, 95% CI 2.66, 6.04, P < 0.001 and OR 4.05, 95% CI 1.68, 9.74, P = 0.002) but greater than the TACE + RFA subcohort (OR 3.23, 95% CI 2.14, 4.86, P < 0.001).

CONCLUSION

Overall, the TACE + MWA subcohort had the best efficacy and outcomes, especially for younger patients (less than 60-year-old) with tumor size of ≤ 3 cm, compared with the TACE + RFA or TACE + CRA subcohorts.

Combined Transarterial Chemoembolization with Microwave Ablation versus Microwave Alone for Treatment of Medium Sized Hepatocellular Carcinoma

Background & Aims:

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related deaths. The only definitive treatment for both HCC and cirrhosis is liver transplantation, but long wait times in some regions and a relatively fixed number of donor organs negatively impact access to liver transplantation. The aim of the work was to evaluate and compare the short outcome of patients with medium-sized HCC who will undergo percutaneous microwave ablation (MWA) alone and in combination with TACE.

Methods:

This prospective study included 40 patients with medium-sized HCC lesions who were classified into two groups; Group A that included twenty patients treated by TACE followed by percutaneous MWA after 2 weeks and group B that included twenty patients treated by 2 sessions of percutaneous MWA with 2 weeks interval. Full history taking, clinical examination, laboratory investigation, abdominal ultrasonography and abdominal tri-phasic computed tomography (CT) with contrast were obtained from the two groups. Laboratory and radiological follow up of the cases were done at 1 and 3 months after the treatment.

Results:

There was no statistically significant difference in the sociodemographic criteria, laboratory measurement and clinical criteria between the cases in the two study groups before initiation of treatment. The response was slightly better in the combined treatment group, but it did not show a statistically significant difference. The incidence of complications was higher in the MWA group.

Conclusion::

Hepatocellular carcinoma is a common complication of HCV related cirrhosis. Association of TACE-MWA led to better response rates than MWA with fewer complications.

New approach for hepatocellular carcinoma treatment

Hepatocellular carcinoma (HCC) is the fifth most common cancer, with an increasing incidence in recent years. The prognosis is unfavorable, representing the third most frequent cause of cancer-related death worldwide. This is because it generally develops in patients with pre-existing liver pathology, thus limiting therapeutic options. The role of ablative therapies is well-established in nodules smaller than 3 cm, but for nodules from 3 to 5 cm, the best therapeutic management is not well defined. Recent studies reported that combining minimally invasive procedures like transarterial chemoembolization (TACE) with microwave ablation (MWA) or radiofrequency ablation is superior to each alone. However, there is no consensus regarding the timing and the order in which each procedure should be performed. We report a case of an 86 years old male with HCV-related compensated hepatic cirrhosis and multiple cardiac comorbidities diagnosed with a 47/50 mm HCC. Pre-surgical evaluation of the associated pathologies determined that the risk for the surgical approach outweighs the benefits, so the committee decided to treat it in a less invasive manner. We performed MWA and TACE in a single session with technical success according to the modified Response Evaluation Criteria in Solid Tumors (m-RECIST). This case illustrates the first case of simultaneous MWA and TACE performed in our center. This new approach of hepatocellular carcinoma appears to be a good alternative to more invasive methods, with good results even in older people that are unfit for surgery.

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.

Transcatheter Arterial Chemoembolization Combined with Simultaneous Cone-beam Computed Tomography-guided Microwave Ablation in the Treatment of Small Hepatocellular Carcinoma: Clinical Experiences From 50 Procedures

RATIONALE AND OBJECTIVES

To investigate the technical success, safety and outcomes of transcatheter arterial chemoembolization (TACE) combined with simultaneous cone-beam computed tomography (CBCT)-guided microwave ablation (MWA) in small hepatocellular carcinoma (SHCC).

MATERIALS AND METHODS

Retrospective analysis of 66 lesions in 50 patients (38 men, 12 women) who underwent TACE combined with simultaneous CBCT-guided MWA for SHCC. After 1 month of treatment, the tumor responses were assessed using the mRECIST criteria, along with interventional-related complications and changes in hepatic and renal function. Moreover, progression-free survival (PFS) and overall survival (OS) were calculated.

RESULTS

All patients achieved technical success. The mean target tumor size was 3.4 ± 0.7 (range, 2.2-4.9) cm. The mean energy, ablation duration per tumor, and the mean safety margin were 51.3  ±  8.4  kJ, 6.7  ±  0.8  minutes and 1.4 ± 0.6 cm, respectively. The 1-, 3-, and 5-year PFS rates were 90.0%, 65.4%, and 35.7%, respectively, with a mean PFS of 43.46 months; and the 1-, 3-, and 5-year OS rates were 98.0%, 89.8%, and 74.3%, respectively, with a mean OS of 54.90 months. Multivariate Cox regression analysis further illustrated that TACE combined with MWA in the treatment of a single tumor with a diameter of less than 3 cm was an independent protective factor for PFS and OS (p < 0.001). The patients had no major complications. Among the exceptions, one patient (2%) had an asymptomatic perihepatic effusion that resolved spontaneously, two patients (4%) developed massive right pleural effusion, requiring thoracic drainage, and another patient (2%) developed a hepatic subcapsular hemorrhage required interventional embolization.

CONCLUSION

CBCT-guided TACE combined with simultaneous MWA was a safe and successful treatment of SHCC with a high technical efficacy.

MoS2-based nanocomposites for cancer diagnosis and therapy

Molybdenum is a trace dietary element necessary for the survival of humans. Some molybdenum-bearing enzymes are involved in key metabolic activities in the human body (such as xanthine oxidase, aldehyde oxidase and sulfite oxidase). Many molybdenum-based compounds have been widely used in biomedical research. Especially, MoS2-nanomaterials have attracted more attention in cancer diagnosis and treatment recently because of their unique physical and chemical properties. MoS2 can adsorb various biomolecules and drug molecules via covalent or non-covalent interactions because it is easy to modify and possess a high specific surface area, improving its tumor targeting and colloidal stability, as well as accuracy and sensitivity for detecting specific biomarkers. At the same time, in the near-infrared (NIR) window, MoS2 has excellent optical absorption and prominent photothermal conversion efficiency, which can achieve NIR-based phototherapy and NIR-responsive controlled drug-release. Significantly, the modified MoS2-nanocomposite can specifically respond to the tumor microenvironment, leading to drug accumulation in the tumor site increased, reducing its side effects on non-cancerous tissues, and improved therapeutic effect. In this review, we introduced the latest developments of MoS2-nanocomposites in cancer diagnosis and therapy, mainly focusing on biosensors, bioimaging, chemotherapy, phototherapy, microwave hyperthermia, and combination therapy. Furthermore, we also discuss the current challenges and prospects of MoS2-nanocomposites in cancer treatment.

Predicting the prognosis of hepatocellular carcinoma with the treatment of transcatheter arterial chemoembolization combined with microwave ablation using pretreatment MR imaging texture features

OBJECTIVE

To investigate the prognostic value of baseline magnetic resonance imaging (MRI) texture analysis of hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) and microwave ablation (MWA).

METHODS

MRI was performed on 102 patients with HCC before receiving TACE combined with MWA in this retrospective study. The best 10 texture features were screened as a feature group for each MRI sequence by MaZda software using mutual information coefficient (MI), nonlinear discriminant analysis (NDA) and other methods. The optimal feature group with the lowest misdiagnosis rate was achieved on one MRI sequence between two groups dichotomized by 3-year survival, which was used to optimize the significant texture features with the optimal cutoff values. The Cox proportional hazards model was generated for the significant texture features and clinical variables to determine the independent predictors of overall survival (OS). The predictive performance of the model was further evaluated by the area under the ROC curve (AUC). Kaplan-Meier and log-rank tests were performed for disease-free survival (DFS) and Local recurrence-free survival (LRFS).

RESULTS

The optimal feature group with the lowest misdiagnosis rate of 8.82% was obtained on T2WI using MI combined with NDA feature analysis. For Cox proportional hazards regression models, the independent prognostic factors associated with OS were albumin (P = 0.047), BCLC stage (P = 0.001), Correlat_{(1,- 1)T2} (P = 0.01) and SumEntrp_(3,0)T2 (P = 0.015), and the prediction efficiency of multivariate model is AUC = 0.876, 95%CI = 0.803-0.949. Kaplan-Meier analyses further demonstrated that BCLC (P < 0.001), Correlat_{(1,- 1)T2} (P = 0.023) and SumEntrp_(3,0)T2 (P < 0.001) were associated with DFS, and BCLC (P = 0.007) related to LRFS.

CONCLUSIONS

MR imaging texture features may be used to predict the prognosis of HCC treated with TACE combined with MWA.

Combined trans-arterial embolisation and microwave ablation for the treatment of large unresectable hepatic metastases (>3 cm in maximal diameter)

PURPOSE

To assess the safety and efficacy of a two-step single-session procedure, combining transarterial embolization (TAE) and percutaneous microwave ablation (MWA), in the treatment of > 3 cm unresectable liver metastases. We also compared the final volume obtained by the two techniques (V_E-T) and the expected ablation volume of the stand-alone MWA (V_T).

METHODS

From January 2015 to December 2017, 22 consecutive patients, with a total of 24 unresectable hepatic metastases >3 cm in diameter underwent a two-step single-session combined treatment of TAE and MWA. Follow-up computed tomography scans were performed at 1-, 3-, 6-, 12, and 24 months post-procedure. V_E-T as final ablation volume induced by the combined treatment (TAE-MWA), V_N as initial nodule volume, V_T as expected ablation volume of MWA treatment alone were evaluated and compared.

RESULTS

Tumor dimensions ranged from 32 to 73 mm. Technical success was achieved in all treated tumors with no local tumor recurrence. Final ablation volumes ranged from 50 to 450 cm³ and the short-axis diameter of the ablation zone ranged from 12 to 48 mm. The mean ΔV increment in the final ablation volume with respect to the stand-alone MWA was 196% (ranging from 25 cm³ - 210 cm³) (p < 0.05). The V_E-T mean was four times the V_N mean, while the V_T mean was about twice the V_N mean. No recurrence and only one case of post-embolization bleeding were observed.

CONCLUSIONS

This study demonstrated the safety and efficacy of a combined two-step single-session TAE-MWA treatment of unresectable hepatic metastases > 3 cm in diameter.

High-intensity focused ultrasound alone or combined with transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma with unsuitable indications for hepatectomy and radiofrequency ablation: a phase II clinical trial

OBJECTIVES

This study aims to evaluate the efficacy and safety of high-intensity focused ultrasound (HIFU) alone or combined with transcatheter arterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) but were contraindicated for hepatectomy and radiofrequency ablation (RFA).

METHODS

Patients between 20 and 80 years of age with 1-3 foci of HCC were selected. Included patients have had primary or recurrent liver lesions with no evidence of extra-hepatic metastasis prior to the study. Patients were treated with ultrasound-guided HIFU alone or HIFU combined with TACE (treated with TACE once within 4 weeks prior to receiving HIFU).

RESULTS

Thirty-seven patients were enrolled, for a total of 45 lesions. The 2-year local control (LC) rate was 73.0% and the median LC time was 22 months. The 2-year progression-free survival (PFS) was 29.7% and the median PFS time was 9 months. Finally, the 2-year overall survival (OS) was 70.3%, and the median OS time was 24 months. The most common adverse events (AEs) were elevated liver enzymes, followed by fatigue, and pain, no grade 4 AEs or death occurred. Multivariate analysis showed that age, Child-Pugh class, and the number of tumors were independent prognostic factors for PFS and that the AFP levels and the number of tumors were significantly correlated with the OS.

CONCLUSIONS

This study indicates that the HIFU/HIFU combined with TACE treatment is safe, and is capable of achieving both a good LC rate and a considerably good prognosis. The procedure should be considered for patients who were deemed unsuitable for other local treatments.

Combined therapy with conventional trans-arterial chemoembolization (cTACE) and microwave ablation (MWA) for hepatocellular carcinoma >3-<5 cm

PURPOSE

To compare safety and efficacy of combined therapy with conventional transarterial chemoembolization (cTACE)+microwave ablation (MWA) versus only TACE or MWA for treatment of hepatocellular carcinoma (HCC) >3-<5 cm.

METHODS

This randomized controlled trial (NCT04721470) screened 278 patients with HCC >3-<5 cm. Patients were randomized into three groups: 90 underwent TACE (Group 1); 95 underwent MWA (Group 2); and 93 underwent combined therapy (Group 3). Patients were followed-up with contrast-enhanced CT or MRI. Images were evaluated and compared for treatment response and adverse events based on modified response evaluation criteria in solid tumor. Serum alpha-fetoprotein (AFP) concentration was measured at baseline and during every follow-up visit.

RESULTS

Final analysis included 265 patients (154 men, 111 women; mean age = 54.5 ± 11.8 years; range = 38-76 years). Complete response was achieved by 86.5% of patients who received combined therapy compared with 54.8% with only TACE and 56.5% with only MWA (p = 0.0002). The recurrence rate after 12 months was significantly lower in Group 3 (22.47%) than Groups 1 (60.7%) and 2 (51.1%) (p = 0.0001). The overall survival rate (three years after therapy) was significantly higher in Group 3 (69.6%) than Groups 1 (54.7%) and 2 (54.3%) (p = 0.02). The mean progression-free survival was significantly higher in Group 3 than groups 1 and 2 (p < 0.001). A decrease in AFP concentration was seen in 75%, 63%, and 48% patients of Group 3, 2, and 1, respectively.

CONCLUSIONS

Combined therapy with cTACE + MWA is safe, well-tolerated, and more effective than TACE or MWA alone for treatment of HCC >3-<5 cm.

Microwave ablation versus sorafenib for intermediate-Stage Hepatocellular carcinoma with transcatheter arterial chemoembolization refractoriness: a propensity score matching analysis

Purpose: To compared the benefits of sorafenib with microwave ablation (MWA) in intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after Transcatheter Arterial Chemoembolization (TACE) failure.Methods: A retrospective, single-center study was conducted using a one-to-one propensity score matching (PSM) analysis and involved 52 intermediate-stage HCC patients with absence of evidence of intrahepatic vascular invasion and extrahepatic metastasis after TACE failure and underwent treatment with MWA or sorafenib between 2007 and 2019. The overall survival (OS) and progression-free survival (PFS) were evaluated by the Kaplan-Meier method. The factors with OS and PFS were determined by Cox regression.Results: Of the 52 patients included in our study, 30 (57.7%) underwent MWA and 22 (42.3%) received sorafenib. After PSM, 22 pairs were enrolled into different groups for further analysis. Patients in the MWA-group had a significantly longer median PFS than patients in the sorafenib-group on both before (median, 9.3 vs. 2.8 months, p = .001) and after PSM (median, 9.0 vs. 2.8 months, p = .006). They also had a significantly longer median OS than patients in the sorafenib-group on before (median, 48.8 vs. 16.6 months, p = .001) and after PSM (median, Not reached vs. 16.6 months, p = .001). Besides, Cox regression analysis showed that the treatment and age were the independent prognostic factors of OS and PFS (p＜0.05).Conclusions: MWA was superior to sorafenib in improving survival for intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after TACE failure.Key PointsCompared with sorafenib, microwave ablation may be a more reasonable alternative treatment for intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after TACE refractoriness.The treatment (MWA vs sorafenib) and the age of patients were the independent prognostic factors of OS and PFS.

Balloon-Occluded MWA (b-MWA) Followed by Balloon-Occluded TACE (b-TACE): Technical Note on a New Combined Single-Step Therapy for Single Large HCC

Purpose To evaluate the feasibility, safety and efficacy of a combined single-step therapy in patients with unresectable single large (> 5 cm) hepatocellular carcinoma (HCC), with balloon-occluded microwave ablation (b-MWA) plus transcatheter arterial balloon-occluded chemoembolization (b-TACE).

MATERIALS & METHODS

Five consecutive Child A patients (mean age: 71.4 ± 3.2 yo; range 68-76 yo) with an unresectable single large HCC (> 5 cm) (mean size: 5.7 ± 0.6 cm; range 5.1-6.5 cm) were enrolled in our pilot study. The schedule consisted of percutaneous microwave ablation of the lesion during balloon occlusion of the hepatic artery supplying the tumor (b-MWA), followed by TACE under the occlusion of feeding arteries by a microballoon catheter (b-TACE). Adverse events and intra- and peri-procedural complications were clinically assessed. Early local efficacy was evaluated on 1- and 6-month follow-up multiphasic computed tomography (CT) on the basis of m-RECIST criteria.

RESULTS

Technical success was obtained in all procedures. No major complications occurred. A mean necrotic area of 6.8 ± 0.47 cm (range 6.3-7.4 cm) was obtained, with a complete response at 1-month follow-up obtained in 4 out of 5 lesions, with 1 partial response (less than 30% of residual tumor), successfully treated with a single TACE treatment. No residual tumor or local recurrence was registered at 6-month CT follow-up.

CONCLUSIONS

Our preliminary experience seems to demonstrate that b-MWA plus b-TACE could be a safe and effective combined therapy for unresectable large HCC lesions, allowing a high rate of local response also in lesion exceeding 5 cm in size.

Microwave ablation of liver cancer: An updated review

The treatment methods for early liver cancer include surgical resection, liver transplantation, and local ablation. Among them, microwave ablation (MWA) is widely used in clinical practice because of its outstanding advantages, such as minimal invasiveness, radical curative effect, short treatment time, few complications, and no heat-sink effect, especially for the treatment of tumors adjacent to major vessels and hepatic metastases. However, MWA also has limitations such as unpredictable size and shape of the ablation area. This review systematically illustrates the effectiveness and safety of MWA in the treatment of liver cancer. Meanwhile, the relative superiority of the new generation of MWA is discussed, with an aim to provide reference for MWA of liver cancer.

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.

Enhancement Effect of Microbubble-Enhanced Ultrasound in Microwave Ablation in Rabbit VX2 Liver Tumors

Objectives

One reason for the high recurrence and metastatic rates of tumors such as hepatocellular carcinoma (HCC) treated by microwave ablation (MWA) is the presence of residual foci in the tumor due to heat sink effect. Microbubble-enhanced ultrasound (MEUS) can noninvasively disrupt and block the tumor blood perfusion and has the potential to overcome the heat sink effect and enhance the therapeutic effect of MWA. The study aimed at evaluating the potential additional benefit of microbubble-enhanced ultrasound (MEUS) in hepatocellular carcinoma (HCC) treated by microwave ablation (MWA).

Methods

In this study, a new strategy of combining MWA with MEUS for treating HCC was proposed. Twenty-four rabbits with VX2 tumors in livers were randomly divided into MEUS + MWA, MEUS alone, MWA alone, and blank control groups, respectively (n = 6). In the MEUS group, the tumors were directly exposed to therapeutic ultrasound for 5 min with a concurrent intravenous injection of microbubbles (0.1 ml/kg diluted into 5 ml saline). In the MWA group, the tumors were treated by MWA for 1 min. In the MEUS + MWA group, tumors were ablated by MWA for 1 min after ultrasound cavitation enhanced by microbubbles as in the MEUS group. In the blank control group, the tumors received probe sham and intravenous saline. Contrast-enhanced ultrasound (CEUS) was performed before treatment and immediately after treatment to display the size, shape, and contour of the tumors. Throughout the treatment process, the local temperature of the treatment area was detected by a temperature needle punctured into the tumor. The blood samples of animals were obtained after treatment for evaluating the liver function. Tumor cell necrosis and apoptotic rates were observed after treatment by histological examination.

Results

CEUS showed that although perfusion defects appeared in all the treatment groups, especially in the MEUS + MWA group, there was no significant difference between the two groups on the volumes of perfusion defects, which were 1.78 ± 0.31 (cm³) in the MWA group and 1.84 ± 0.20 (cm³) in the combined group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (

Conclusions

These results suggested MEUS treatment alone may significantly reduce tumor blood perfusion and led to a sharp rise in the local temperature of the treatment area to a higher PT using MEUS + MWA with higher rates of necrosis and apoptosis of cancer cells without severe liver function damage, which might be a safe strategy for treating HCC.

A review of conventional and newer generation microwave ablation systems for hepatocellular carcinoma

Although microwave ablation (MWA) exhibits a high thermal efficiency, the major limitation of conventional MWA systems is the lack of predictability of the ablation zone size and shape. Therefore, a specific newer generation MWA system, The Emprint™ Ablation System with Thermosphere™ Technology, was designed to create predictable large spherical zones of ablation that are not impacted by varying tissue environments. The time required for ablation with MWA systems is short, and the shape of the necrosis is elliptical with the older systems and spherical with the new system. In addition, because MWA has no heat-sink effect, it can be used to ablate tumors adjacent to major vessels. Although these factors yield a large ablation volume and result in good local control, excessive ablation of liver tissue and unexpected ablation of surrounding organs are possible. Therefore, MWA should be carefully performed. This review highlights the efficacy and complications of MWA performed with conventional systems and the newer generation system in patients with hepatocellular carcinoma (HCC). MWA with the newer generation system seems to be a promising treatment option for large HCCs and secondary hepatic malignancies, with several advantages over other available ablation techniques, including conventional MWA. However, further randomized controlled trials are necessary to fully clarify the benefits and pitfalls of this new system.

3D visualization ablation planning system assisted microwave ablation for hepatocellular carcinoma (Diameter >3): a precise clinical application

Background

The aim of this retrospective study was to compare the feasibility and efficiency of ultrasound-guided percutaneous microwave ablation (US-PMWA) assisted by three-dimensional visualization ablation planning system (3DVAPS) and conventional 2D planning for hepatocellular carcinoma (HCC) (diameter > 3 cm).

Methods

One hundred thirty patients with 223 HCC nodules (5.0 ± 1.5 cm in diameter, [3.0–10.0 cm]) who met the eligibility criteria divided into 3D and 2D planning group were reviewed from April 2015 to August 2018. Ablation parameters and oncological outcomes were compared, including overall survival (OS), recurrence-free survival (RFS), and local tumor progression (LTP). Multivariate analysis was performed on clinicopathological variables to identify the risk factors for OS and LTP.

Results

The median follow-up period was 21 months (range 3–44). Insertion number (5.4 ± 1.2 VS. 4.5 ± 0.9, P = 0.034), ablation time (1249.2 ± 654.2 s VS. 1082.4 ± 584.7 s, P = 0.048), ablation energy (57,000 ± 11,892 J VS. 42,600 ± 10,271 J, P = 0.038) and success rate of first ablation (95.0% VS. 85.7%, P = 0.033) were higher in the 3D planning group compared with those in 2D planning group. There was no statistical difference in OS, and RFS between the two groups (P = 0.995, P = 0.845). LTP rate of 3D planning group was less than that of 2D planning group (16.5% VS 41.2%, P = 0.003). Multivariate analysis showed tumor maximal diameters (P < 0.001), tumor number (P = 0.003) and preoperative TACE (P < 0.001) were predictors for OS and sessions (P = 0.024), a-fetoprotein level (P = 0.004), and preoperative planning (P = 0.002) were predictors for LTP, respectively.

Conclusions

3DVAPS improves precision of US guided ablation resulting in lower LTP and higher 5 mm-AM for patients with HCC lesions larger than 3 cm in diameter.

Locoregional treatments for hepatocellular carcinoma: Current evidence and future directions

Liver cancers are the second most frequent cause of global cancer-related mortality of which 90% are attributable to hepatocellular carcinoma (HCC). Despite the advent of screening programmes for patients with known risk factors, a substantial number of patients are ineligible for curative surgery at presentation with limited outcomes achievable with systemic chemotherapy/external radiotherapy. This has led to the advent of numerous minimally invasive options including but not limited to trans-arterial chemoembolization, radiofrequency/microwave ablation and more recently selective internal radiation therapy many of which are often the first-line treatment for select stages of HCC or serve as a conduit to liver transplant. The authors aim to provide a comprehensive overview of these various image guided minimally invasive therapies with a brief focus on the technical aspects accompanied by a critical analysis of the literature to assess the most up-to-date evidence from comparative systematic reviews and meta-analyses finishing with an assessment of novel combination regimens and future directions of travel.

The Combination Strategy of Transarterial Chemoembolization and Radiofrequency Ablation or Microwave Ablation against Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. Hepatectomy and liver transplantation (LT) are regarded as the radical treatment, but great majority of patients are already in advanced stage on the first diagnosis and lose the surgery opportunity. Multifarious image-guided interventional therapies, termed as locoregional ablations, are recommended by various HCC guidelines for the clinical practice. Transarterial chemoembolization (TACE) is firstly recommended for intermediate-stage (Barcelona Clinic Liver Cancer (BCLC) B class) HCC but has lower necrosis rates. Radiofrequency ablation (RFA) is effective in treating HCCs smaller than 3 cm in size. Microwave ablation (MWA) can ablate larger tumor within a shorter time. Combination of TACE with RFA or MWA is effective and promising in treating larger HCC lesions but needs more clinical data to confirm its long-term outcome. The combination of TACE and RFA or MWA against hepatocellular carcinoma needs more clinical data for a better strategy. The characters and advantages of TACE, RFA, MWA, and TACE combined with RFA or MWA are reviewed to provide physician a better background on decision.

Efficacy of Percutaneous Thermal Ablation Combined With Transarterial Embolization for Recurrent Hepatocellular Carcinoma After Hepatectomy and a Prognostic Nomogram to Predict Survival

AIM

This study aimed to evaluate the efficacy of percutaneous thermal ablation combined with transarterial embolization for recurrent hepatocellular carcinoma after hepatectomy and establish a prognostic nomogram to predict survival.

METHODS

One hundred seventeen patients with recurrent hepatocellular carcinoma receiving ablation from 2009 to 2014 were included in primary cohort to establish a prognostic nomogram. Between 2014 and 2016, 51 patients with recurrent hepatocellular carcinoma treated by ablation were enrolled in the validation cohort to validate the predictive accuracy of the nomogram. All patients underwent locoregional ablation. Overall survival was the primary end point, and progression-free survival was the second end point. The performance of the nomogram was assessed through concordance index and calibration curve and compared with 5 conventional hepatocellular carcinoma staging systems.

RESULTS

The 1-, 3-, and 5-year overall survival rates of primary cohort were 88.4%, 70.7%, and 64.1%, respectively. The 1-, 3-, and 5-year progression-free survival rates of primary cohort were 44%, 14%, and 8.7%, respectively. The results of multivariate analysis showed that tumor size ( P = .0469; hazard ratio, 1.020; 95% confidence interval, 1.0004-1.040), preoperative extrahepatic disease ( P = .0675; hazard ratio, 2.604; 95% confidence interval, 0.933-7.264), and close to hepatic hilum <2 cm ( P = .0053; hazard ratio, 3.691; 95% confidence interval, 1.474-9.240) were predictive factors for overall survival. The study established a nomogram to predict survival (concordance index, 0.752; 95% confidence interval, 0.656-0.849). According to the predicted overall survival, patients with recurrent hepatocellular carcinoma were divided into 3 risk classes ( P < .05): low-risk group (total score <55; predicted 5-year overall survival rate, 82.9%), intermediate-risk group (55 ≤ total score < 99; predicted 5-year overall survival rate, 52.8%), and high-risk group (hazard ratio, total score ≥99; predicted 5-year overall survival rate, not available).

CONCLUSION

Percutaneous thermal ablation appears to be an effective procedure for the treatment of recurrent hepatocellular carcinoma after hepatectomy. The proposed nomogram provides a mechanism to accurately predict survival and could stratify risk among patients with recurrent hepatocellular carcinoma treated by ablation therapy.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Computed tomography-guided percutaneous microwave ablation of hepatocellular carcinoma in challenging locations: safety and efficacy of high-power microwave platforms

OBJECTIVE

To evaluate the clinical efficacy/safety of CT-guided percutaneous microwave ablation for HCC in challenging locations using high-power microwave platforms.

MATERIALS AND METHODS

A retrospective review was conducted in 26 patients with 36 HCC tumours in challenging locations (hepatic dome, subcapsular, close to the heart/diaphragm/hepatic hilum, exophytic) undergoing CT-guided percutaneous microwave ablation in a single centre since January 2011. Two different microwave platforms were used both operating at 2.45 GHz: AMICA and Acculis MWA System. Patient demographics including age, sex, tumour size and location, as well as technical details were recorded. Technical success, treatment response, patients survival and complication rate were evaluated.

RESULTS

Treated tumours were located in the hepatic dome (n = 14), subcapsularly (n = 16), in proximity to the heart (n = 2) or liver hilum (n = 2), while two were exophytic tumours at segment VI (n = 2). Mean tumour diameter was 3.30 cm (range 1.4-5 cm). In 3/26 patients (diameter >4 cm), an additional session of DEB-TACE was performed due to tumour size. Technical success rate was 100%; complete response rate was recorded in 33/36 tumours (91.6%). According to Kaplan-Meier analysis, survival rate was 92.3% and 72.11% at 24- and 60-month follow-up, respectively. There were no major complications; two cases of minor pneumothorax and two cases of small subcapsular haematoma were resolved only with observation requiring no further treatment.

CONCLUSION

CT-guided percutaneous microwave ablation for hepatocellular carcinoma tumours in challenging locations and up to 5 cm in diameter can be performed with high efficacy and safety rates.

Tumor SOCS3 methylation status predicts the treatment response to TACE and prognosis in HCC patients

BACKGROUND

Suppressor of cytokine signaling (SOCS) 1 and 3 methylation have been associated with clinical features and outcomes of cancer patients. However, their roles in determining the treatment response to transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) remain unknown.

RESULTS

We found that presence of SOCS3 methylation is significantly associated with the major clinical features of HCC patients, including tumor stage, lymph node and vascular invasion. Of note, we observed that the presence of SOCS3 methylation is closely related to TACE response. In prognosis analyses, HCC patients with SOCS3 methylation presence have a poorer prognosis indicated by lower 3-, and 5-year survival rates and shorter mean survival period, than those without. Multivariate COX analysis confirms the prognostic role of the presence of SOCS3 methylation in HCC patients receiving TACE treatment.

MATERIALS AND METHODS

A total of 246 HCC patients receiving TACE were enrolled in this study. Tumor samples was obtained from echo-guided fine needle aspiration and genomic DNA from tumor samples was purified. SOCS1 and SOCS3 methylation status were detected using methylation-specific polymerase chain reaction. The treatment responses to TACE of patients were evaluated after procedure and all patients were followed for prognosis analysis.

CONCLUSIONS

This finding suggests that the presence of SOCS3 methylation is a marker to predict treatment response and prognosis in HCC patients receiving TACE therapy.

Safety and effect on ablation size of hydrochloric acid-perfused radiofrequency ablation in animal livers

PURPOSE

Our objective was to determine the safety and ablation size of hydrochloric acid-perfused radiofrequency ablation (HCl-RFA) in liver tissues, prospectively using in vivo rabbit and ex vivo porcine liver models.

MATERIALS AND METHODS

The livers in 30 rabbits were treated in vivo with perfusions of normal saline (controls) and HCl concentrations of 5%, 10%, 15%, and 20%, during RFA at 103 °C and 30 W for 3 min. For each experimental setting, six ablations were created. Safety was assessed by comparing baseline weight and selected laboratory values with those at 2, 7, and 14 days' post-ablation, and by histopathological analysis. The livers in 25 pigs were treated ex vivo with the same five perfusions during RFA at 103 °C, at both 30 W and 60 W, for 30 min. Ablation diameters and volumes were measured by two examiners.

RESULTS

Rabbit weights and selected laboratory values did not differ significantly from baseline to 7 and 14 days' post-ablation, liver tissues outside the ablation zones were normal histologically, and adjacent organs showed no macroscopic damage. The mean ablation volumes in the porcine livers treated with HCl-RFA were all larger than those treated with normal saline perfusion during RFA (NS-RFA), at both 30 W and 60 W (p < 0.001). The largest ablation volume and transverse diameter were observed in the porcine livers during 10% HCl-RFA at 60 W, measuring 179.22 (SD = 24.79) cm³ and 6.84 (SD = 0.36) cm, respectively.

CONCLUSIONS

Based on our experiments, HCl-RFA in the liver appears to be as safe as NS-RFA while also resulting in larger ablation zones.

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

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

Study on the effect of chemoembolization combined with microwave ablation for the treatment of hepatocellular carcinoma in rats

PURPOSE

We aimed to evaluate the combining effects of transarterial chemoembolization (TACE) and open local thermal microwave ablation in a hepatocellular carcinoma animal model.

METHODS

Tumor cubes were implanted into the liver of 30 male inbred ACI rats. Groups of 10 animals were treated at 13 days (TACE or microwave ablation) and 16 days (microwave ablation) postimplantation with combined therapy of TACE (0.1 mg mitomycin C; 0.1 mg iodized oil; 5.0 mg degradable starch microspheres) and microwave ablation (2450 Mhz; 45 s; 35 W) (study group A), TACE alone (control group B), or microwave ablation alone (control group C). At day 12 and day 25 tumor size was measured via magnetic resonance imaging and the relative growth ratio was calculated. Hepatic specimens were immunohistochemically examined for the expression of vascular endothelial growth factor (VEGF).

RESULTS

Mean growth rates were 1.34±0.19 in group A, 3.19±0.13 in group B, and 4.18±0.19 in group C. Compared with control groups B and C, tumor growth rate in group A was significantly inhibited (P < 0.01). The VEGF-antibody reaction in peritumoral tissue (staining intensity at portal triad, percent antibody reaction and staining intensity at central vein) was significantly lower in group A compared with group B (P < 0.01). No significant difference between group A and group C could be observed.

CONCLUSION

This investigation shows improved results of TACE followed by microwave ablation as treatment of hepatocellular carcinoma in a rat model, compared with single therapy regimen regarding the inhibition of growth rate and reduction of VEGF-level in peritumoral tissue.

Microwave ablation combined with attenuated Salmonella typhimurium for treating hepatocellular carcinoma in a rat model

We aim to investigate the safety and efficacy of microwave ablation (MWA) combined with attenuated Salmonella typhimurium strain VNP20009 in treating hepatocellular carcinoma. Portions of tumor tissues were orthotopically implanted in the livers of 40 male rats weighed 150~200 g to establish tumor models. Three weeks later, the rats were randomly divided into four groups: (A) MWA plus VNP20009 group; (B) MWA group; (C) VNP20009 group; and (D) control group. Incomplete MWA was performed (20~30 W, 1~2 min) after the hepatic carcinoma was properly exposed. VNP20009 (about 1×10⁷ cfu) was directly injected into the tumor immediately. MRI scans were performed to assess the tumor responses 7 and 14 days later, respectively. Micro CT was used to observe the lung metastases. After the animals were sacrificed or died, the tumors were cut off for the purpose of pathological and immunohistochemical analyses. The results showed that the mean tumor volumes of MWA plus VNP20009 group on the 7th and 14th day post treatment were obviously smaller than those of other groups (P < 0.05). Lung metastases rates were 20%, 60%, 30% and 100% in MWA plus VNP20009 group, MWA group, VNP20009 group and control group, respectively. The median survival of the rats in MWA plus VNP20009 group was distinctly longer than those in other groups (P < 0.05). In summary, MWA combined with VNP20009 produced better effects than MWA or VNP20009 alone in treating hepatic carcinoma. This strategy might have potential ability to decrease lung metastases and prolong the overall survival.

Microwave ablation for hepatocellular carcinoma associated with Budd-Chiari syndrome after transarterial chemoembolization: an analysis of ten cases

PURPOSE

To evaluate the feasibility, efficacy, and safety of microwave ablation (MWA) in the treatment of hepatocellular carcinoma associated with Budd-Chiari syndrome (BCS) after transarterial chemoembolization (TACE).

METHODS

A total of 10 patients (mean 50.0 ± 7.5 years) with 15 BCS-associated HCC lesions were retrospectively evaluated. All patients received MWA treatment for residual tumors after 1 to 3 sessions of TACE. The diagnosis of residual tumors was confirmed by at least two types of enhanced imaging. CEUS images were performed to confirm the residual lesions and guide the placement of antenna before MWA. Thermal monitoring and artificial pleural effusion or ascites were used to guarantee ablative accuracy and safety for patients with tumors adjacent to vital structures. Technical success, technique efficacy, local tumor progression, survival rate, and the incidence of complications were comprehensively analyzed.

RESULTS

Technical success and technique effectiveness were achieved in all patients. Thirteen lesions achieved complete ablation for the first time, and 2 lesions needed two sessions. Thermal monitoring was used in 2 patients, artificial pleural effusion was used in 1 patient, and artificial ascites in 2 patients. In a median follow-up of 34.5 months (range 21-52 months), no LTP was founded in all patients. Intrahepatic recurrence was found in 5 patients. 1-, 2-, 3-, and 4-year survival rates were 100%, 100%, 74.1%, and 37.0%, respectively. No major or minor complications were observed.

CONCLUSION

Microwave ablation is a feasible and effective way to treat residual tumors after TACE treatment in patients with BCS-associated HCC.

Comparison of single-session transarterial chemoembolization combined with microwave ablation or radiofrequency ablation in the treatment of hepatocellular carcinoma: a randomized-controlled study

BACKGROUND

Globally, hepatocellular carcinoma (HCC) is the third most frequent cause of cancer-related mortality. In recent years, transarterial chemoembolization, radiofrequency ablation, and microwave ablation (MWA) have been accepted as treatment modalities for patients with surgically unresectable HCC.

AIM OF THIS WORK

This study aimed to compare combination treatment with radiofrequency or MWA, followed by transarterial chemoembolization, and performed in a single session.

PATIENTS AND METHODS

This study was carried out on 50 patients with nonresectable single-lesion HCC, who were divided into three groups: group A included 20 patients treated by transcatheter hepatic arterial chemoembolization, group B included 20 patients treated by radiofrequency thermal ablation combined with transcatheter arterial chemoembolization, and group C included 10 patients treated by MWA combined with transcatheter arterial chemoembolization. The combined treatments were performed in a single session, with the ablation performed first.

RESULTS

The total success rate in this study at 6 months following the procedure was 50% in group A, 70% in group B, and 80% in group C. Major complications were recorded in 22% of patients. The number of complications was the highest in group A.

CONCLUSION

Combined ablation with chemoembolization is superior in the treatment of nonresectable single masses larger than 4 cm. Transcatheter arterial chemoembolization and ablation can be performed safely and successfully during a single session, which has not been found to decrease the response rates to treatment. Combined treatment with MWA is more effective in terms of tumor response, and results in the same complication rate as with radiofrequency, but less than chemoembolization alone.

Microwave ablation in primary and secondary liver tumours: technical and clinical approaches

Thermal ablation is increasingly being utilised in the treatment of primary and metastatic liver tumours, both as curative therapy and as a bridge to transplantation. Recent advances in high-powered microwave ablation systems have allowed physicians to realise the theoretical heating advantages of microwave energy compared to other ablation modalities. As a result there is a growing body of literature detailing the effects of microwave energy on tissue heating, as well as its effect on clinical outcomes. This article will discuss the relevant physics, review current clinical outcomes and then describe the current techniques used to optimise patient care when using microwave ablation systems.

Percutaneous microwave ablation combined with synchronous transcatheter arterial chemoembolization for the treatment of colorectal liver metastases: results from a follow-up cohort

BACKGROUND

The purpose of this study was to retrospectively evaluate the therapeutic efficacy and safety of ultrasound-guided percutaneous microwave ablation (MWA) combined with synchronous transcatheter arterial chemoembolization (TACE) in patients with colorectal liver metastases (CRLM).

PATIENTS AND METHODS

A retrospective analysis was performed in 30 patients who were treated with ultrasound-guided percutaneous MWA combined with synchronous TACE for colorectal cancer liver metastases from November 2011 to December 2014 in Zhongshan Hospital, Fudan University. The response of the tumor to treatment was evaluated by follow-up computed tomography and/or magnetic resonance imaging. Local tumor control, procedure-related complications, and long-term survival data were analyzed.

RESULTS

A total of 30 patients with 43 tumors ranging in size from 1.4 cm to 10.0 cm were analyzed. The patients' mean age was 61.6±10.3 years (range, 44.0-78.0 years). The median follow-up time was 26.5±10.4 months (range, 13.3-50.6 months). The complete ablation rate was 81.4% (35/43 lesions) for CRLM. Complete response was achieved in eight cases (26.7%), and partial response was achieved in 17 cases (56.7%) 1 month after the procedure. The objective response rate (complete response + partial response) was 83.4%. Progression-free survival and overall survival were 5.0 months and 11.0 months, respectively. The 12-month and 24-month survival rates were 46.7% and 25.4%, respectively. A total of 22 patients succumbed during follow-up due to tumor progression. No major complications or perioperative mortalities were recorded.

CONCLUSION

Ultrasound-guided percutaneous MWA combined with synchronous TACE therapy is a safe and effective modality for patients with CRLM.

Combination Therapies in the Management of Large (≥ 5 cm) Hepatocellular Carcinoma: Microwave Ablation Immediately Followed by Transarterial Chemoembolization

PURPOSE

To evaluate the safety and efficacy of microwave (MW) ablation combined with transarterial chemoembolization in a single stage for the treatment of large (≥ 5 cm) hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From March 2013 to January 2015, 66 patients (54 men and 12 women; mean age, 54 y; range, 29-83 y) with 72 large HCC lesions were included in this study. Eighteen (27.3%) had Barcelona Clinic Liver Cancer class B disease, and 48 (72.7%) had class C disease. Seventy-nine percent of patients (n = 52) had hepatitis B virus infection. The average tumor size was 9.0 cm ± 3.9, ranging from 5 to 19 cm. MW ablation was performed under ultrasound guidance, immediately followed by chemoembolization. Local tumor response, progression-free survival (PFS), and overall survival (OS) were assessed.

RESULTS

The technique was successfully performed in all patients. Complete response (CR) was achieved in 28 cases (42.4%), and partial response (PR) was achieved in 34 cases (51.5%) at 1 month after the procedure. The objective response rate (ie, CR plus PR) was 93.9%. Median PFS and OS times were 9 months and 21 months, respectively. The 6-, 12-, and 18-month OS rates were 93.9%, 85.3%, and 66.6%, respectively. Hemorrhage was detected in three patients and arteriovenous fistula in two patients after MW ablation; all were promptly treated with embolization. There were no liver abscesses, bile-duct injuries, or other major procedure-related complications.

CONCLUSIONS

MW ablation immediately followed by chemoembolization is safe and effective in the treatment of large HCC lesions.

Microwave ablation for liver tumors

Surveillance programs and widespread use of medical imaging have increased the detection of hepatic tumors. When feasible, surgical resection is widely accepted as the curative treatment of choice, but surgical morbidity and mortality has spurred the development of minimally invasive ablative technologies over the last 2 decades. Microwave ablation has emerged as a promising thermal ablation modality with improving oncologic efficacy due to technical improvements and image guidance strategies. This article provides an overview of microwave application in liver tumors, and we discuss currently available equipment, clinical efficacy, and safety and provide comparisons with other commonly used therapies. This article also introduces advanced ablative techniques and combination therapies that may help achieve precise ablation and further enhance the efficacy of microwave ablation.

Transarterial chemoembolization combination therapy vs monotherapy in unresectable hepatocellular carcinoma: a meta-analysis

PURPOSE

To perform a meta-analysis examining the efficacy of transcatheter arterial chemoembolization (TACE) alone or in combination with radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), or high-intensity focused ultrasound (HIFU) for unresectable hepatocellular carcinoma (HCC).

METHODS

Medline, Embase, the Cochrane Library, and Google Scholar were searched through May 31, 2014, using the following keywords: hepatocellular carcinoma, transarterial chemoembolization, percutaneous ethanol ablation, percutaneous ethanol injection, radiofrequency ablation, and high-intensity focused ultrasound. Randomized controlled trials (RCTs) comparing 1- and 3-year mortality rates in patients with unresectable HCC receiving either TACE alone or TACE in combination with RFA, PEI, or HIFU were included. One- and 3-year survival rates were compared.

RESULTS

Eleven RCTs were included. The total number of patients ranged from 37 to 189, mean age ranged from 52 to 73 years, and percentage male ranged from 54% to 94%. Overall, TACE alone was associated with higher 1-year mortality than TACE combination therapies (pooled odds ratio [OR] 2.47, 95% confidence interval [CI] 1.37 to 4.43, p = 0.003). The 1-year mortality rate between TACE alone vs TACE + PEI was not different, but TACE + PEI was associated with a significantly lower 3-year mortality as compared to TACE alone (pooled OR 6.02, 95% CI 3.03 to 11.93, p&lt;0.001). The RFA alone was associated with higher 1-year mortality compared with TACE + RFA (pooled OR 2.20, 95% CI 1.11 to 4.32, p = 0.023).

CONCLUSIONS

Transcatheter arterial chemoembolization in combination with percutaneous ablation therapies may improve the survival of patients with unresectable HCC.

Transarterial Chemoembolization and (90)Y Radioembolization for Hepatocellular Carcinoma: Review of Current Applications Beyond Intermediate-Stage Disease

OBJECTIVE

The practice guideline of the American Association for the Study of Liver Diseases currently recommends transarterial chemoembolization (TACE) for the treatment of intermediate-stage hepatocellular carcinoma (HCC). The use of transarterial radioembolization (TARE) using (90)Y microspheres is not formally recommended. This article discusses the current clinical applications of TACE and TARE and compares the clinical utility of these techniques for various subpopulations of patients with HCC.

CONCLUSION

For most clinical scenarios, the efficacy and safety of TACE and TARE are probably equivalent. However, TARE appears to have an advantage over TACE in the facilitation of surgical resection by resulting in compensatory hypertrophy of the future liver remnant and possibly in the treatment of patients with portal vein tumor thrombus. On the contrary, TACE is the transarterial treatment of choice for patients with marginal hepatic reserve (i.e., hyperbilirubinemia, ascites) who may be candidates for transplant.

Microwave ablation of hepatocellular carcinoma

Although surgical resection is still the optimal treatment option for early-stage hepatocellular carcinoma (HCC) in patients with well compensated cirrhosis, thermal ablation techniques provide a valid non-surgical treatment alternative, thanks to their minimal invasiveness, excellent tolerability and safety profile, proven efficacy in local disease control, virtually unlimited repeatability and cost-effectiveness. Different energy sources are currently employed in clinics as physical agents for percutaneous or intra-surgical thermal ablation of HCC nodules. Among them, radiofrequency (RF) currents are the most used, while microwave ablations (MWA) are becoming increasingly popular. Starting from the 90s’, RF ablation (RFA) rapidly became the standard of care in ablation, especially in the treatment of small HCC nodules; however, RFA exhibits substantial performance limitations in the treatment of large lesions and/or tumors located near major heat sinks. MWA, first introduced in the Far Eastern clinical practice in the 80s’, showing promising results but also severe limitations in the controllability of the emitted field and in the high amount of power employed for the ablation of large tumors, resulting in a poor coagulative performance and a relatively high complication rate, nowadays shows better results both in terms of treatment controllability and of overall coagulative performance, thanks to the improvement of technology. In this review we provide an extensive and detailed overview of the key physical and technical aspects of MWA and of the currently available systems, and we want to discuss the most relevant published data on MWA treatments of HCC nodules in regard to clinical results and to the type and rate of complications, both in absolute terms and in comparison with RFA.

Prognostic factors for survival after transarterial chemoembolization combined with microwave ablation for hepatocellular carcinoma

AIM: To analyze prognostic factors for survival after transarterial chemoembolization (TACE) combined with microwave ablation (MWA) for hepatocellular carcinoma (HCC).

METHODS: Clinical data of 86 patients who underwent TACE combined with MWA between January 2006 and December 2013 were retrospectively analyzed in this study. Survival curves were detected using log-rank test. Univariate analysis was performed using log-rank test with respect to 13 prognostic factors affecting survival. All statistically significant prognostic factors identified by univariate analysis were entered into a Cox proportion hazards regression model to identify independent predictors of survival. P values were two-sided and P < 0.05 was considered statistically significant.

RESULTS: Median follow-up time was 47.6 mo, and median survival time of enrolled patients was 21.5 mo. The 1-, 2-, 3- and 5-year overall survival rates were 72.1%, 44.1%, 31.4% and 13.9%, respectively. Tumor size(χ² = 14.999, P = 0.000), Barcelona Clinic Liver Cancer (BCLC) stage (χ² = 29.765, P = 0.000), Child-Pugh class (χ² = 51.820, P = 0.000), portal vein tumor thrombus (PVTT) (χ² = 43.086, P = 0.000), arterio-venous fistula (χ² = 29.791, P = 0.000), MWA therapy times (χ² = 12.920, P = 0.002), Eastern Cooperative Oncology Group (ECOG) score (χ² = 28.660, P = 0.000) and targeted drug usage (χ² = 10.901, P = 0.001) were found to be significantly associated with overall survival by univariate analysis. Multivariate analysis identified that tumor size (95%CI: 1.608-4.962, P = 0.000), BCLC stage (95%CI: 1.016-2.208, P = 0.020), PVTT (95%CI: 2.062-9.068, P = 0.000), MWA therapy times (95%CI: 0.402-0.745, P = 0.000), ECOG score (95%CI: 1.012-3.053, P = 0.045) and targeted drug usage (95%CI: 1.335-3.143, P = 0.001) were independent prognostic factors associated with overall survival.

CONCLUSION: Superior performance status, MWA treatment and targeted drug were favorable factors, and large HCC, PVTT and advanced BCLC stage were risk factors for survival after TACE-MWA for HCC.

Microwave ablation of hepatic malignancy

Microwave ablation is an extremely promising heat-based thermal ablation modality that has particular applicability in treating hepatic malignancies. Microwaves can generate very high temperatures in very short time periods, potentially leading to improved treatment efficiency and larger ablation zones. As the available technology continues to improve, microwave ablation is emerging as a valuable alternative to radiofrequency ablation in the treatment of hepatic malignancies. This article reviews the current state of microwave ablation including technical and clinical considerations.

Large primary hepatocellular carcinoma: transarterial chemoembolization monotherapy versus combined transarterial chemoembolization-percutaneous microwave coagulation therapy

BACKGROUND AND AIM

To evaluate the clinical benefits of transarterial chemoembolization (TACE) monotherapy or TACE combined with percutaneous microwave coagulation therapy (PMCT) and the long-term survival rate of patients with large primary hepatocellular carcinoma (HCC) treated with these techniques.

METHODS

This is a retrospective study involving 136 patients with unresectable large HCC (189 tumor nodules, ≥ 5.0 cm in diameter) admitted to Sun Yat-Sen University Memorial Hospital (Guangzhou, China) between January 2004 and December 2011. The median follow-up time was 41 months (range, 6-96 months). Of these patients, 80 patients received TACE monotherapy and 56 patients received TACE combined with PMCT. The median interval between treatments and overall survival (OS) were hierarchically analyzed using log-rank tests.

RESULTS

All patients successfully underwent TACE alone or TACE with PMCT with no serious complications. The median survival time was 13 months (range, 3-84 months) for the TACE group and 25 months (range, 7-96 months) for the TACE-PMCT group. The 1-year, 3-year, and 5-year OS rates were 62.5%, 17.5%, and 5.0% in the TACE group, respectively. In contrast, in the TACE-PMCT group, the 1-year, 3-year, and 5-year OS rates were 87.5%, 50.0%, and 10.0%, respectively. This difference was statistically significant between the groups (P < 0.001).

CONCLUSIONS

TACE combined with PMCT had advantages in prolonging OS with satisfying time to progression and improving liver function in patients with large unresectable HCC. The results suggest that further prospective studies are required to confirm the findings of this study.