Comparison of transcatheter arterial chemoembolization, laparoscopic radiofrequency ablation, and conservative treatment for decompensated cirrhotic patients with hepatocellular carcinoma

A Comparison of Adverse Events Among Radiofrequency Ablation, Conventional Transarterial Chemoembolization (TACE) and Drug-Eluting Bead TACE in Treating Hepatocellular Carcinoma Patients

Background

There has been very limited investigation regarding the comparison of adverse events (AEs) among radiofrequency ablation (RFA), conventional transarterial chemoembolization (cTACE), and drug-eluting bead TACE (DEB-TACE) in treating HCC patients; therefore, the present study aimed to resolve this issue.

Methods

Two-hundred and forty-six HCC patients (with a total of 267 procedures [treatment times]) treated with RFA (73 patients with 79 procedures), cTACE (86 patients with 94 procedures), or DEB-TACE (87 patients with 94 procedures) were included. Demographic and clinical data were collected. The information on AEs was also retrieved and analyzed.

Results

Total AEs incidence was notably different among the RFA group, cTACE group, and DEB-TACE group and was the highest in cTACE group (86.2%), then in DEB-TACE group (76.6%), and the lowest in RFA group (63.3%). Regarding specific AEs incidence, the incidences of fever, fatigue, and nausea were distinctive among the three groups, while no distinctiveness was found in incidence of other AEs. Furthermore, multivariate logistic regression revealed that cTACE (versus RFA) was independently correlated with increased risk of total AEs, fatigue, and nausea/vomiting; however, the interventional therapies were not independently correlated with the risk of pain, fever or constipation. Other independent predictive factors for total AEs risk were male gender, bronchial asthma, and disease duration.

Conclusion

cTACE resulted in the highest AEs incidence compared with RFA and DEB-TACE in treating HCC patients.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

Ten-year survival of hepatocellular carcinoma patients undergoing radiofrequency ablation as a first-line treatment

AIM: To investigate the long-term survival and prognostic factors in hepatocellular carcinoma (HCC) patients undergoing radiofrequency ablation (RFA) as a first-line treatment.

METHODS: From 2000 to 2013, 316 consecutive patients with 404 HCC (1.0-5.0 cm; mean: 3.2 ± 1.1 cm) underwent ultrasonography-guided percutaneous RFA as a first-line treatment. There were 250 males and 66 females with an average age of 60.1 ± 10.8 years (24-87 years). Patients were followed for 1 year to > 10 years after RFA (234, 181, 136, and 71 for 3, 5, 7, and 10 years, respectively). Overall local response rates and long-term survival rates were assessed. Survival results were generated using Kaplan-Meier estimates, and multivariate analysis was performed using the Cox regression model.

RESULTS: In total, 548 RFA sessions were performed and major complications occurred in 10 sessions (1.8%). Local tumor progression and/or new tumor development were observed in 43.3% (132/305) of the patients during the follow-up period. Overall 5- and 10-year survival rates were 49.7% and 28.4%, respectively. Based on multivariate analysis, three factors were identified as independent prognostic factors for overall survival: Child-Pugh classification (HR = 4.054, P < 0.001), portal vein hypertension (HR = 2.743, P = 0.002), and tumor number (HR = 2.693, P = 0.003). The local progression-free 5- and 10-year survival rates were 42.7% and 19.5%. In addition to the Child-Pugh classification and the number of tumors, the number of RFA sessions (HR = 1.550, P = 0.002) was associated with local progression-free survival.

CONCLUSION: RFA can achieve acceptable outcomes for HCC patients as a first-line treatment, especially for patients with Child-Pugh class A, patients with a single tumor and patients without portal vein hypertension.

Efficacy and safety of radiofrequency ablation and transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: A meta-analysis

AIM

To investigate the efficacy and safety of radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) for treatment of patients with hepatocellular carcinoma (HCC).

METHODS

All eligible studies were collected from PubMed, the Cochrane Libraries and Embase. The evaluation indices included overall survival (OS) rate, recurrence-free survival rate, local tumor progression rate and major complications. All statistical analysis was performed by RevMan version 5.2 software.

RESULTS

There were 21 studies with 3073 patients included in this meta-analysis. The RFA monotherapy was associated with higher 3- and 5-year OS rates (OR3-year  = 2.33, 95% confidence interval [CI] = 1.34-4.05; OR5-year  = 2.05, 95% CI = 1.48-2.85) compared with TACE alone. The combination of RFA and TACE was associated with higher 1-, 3- and 5-year OS rates (OR1-year  = 1.94, 95% CI = 1.28-2.96; OR3-year  = 1.56, 95% CI = 1.19-2.04; OR5-year  = 1.53, 95% CI = 1.13-2.07) compared with RFA alone.

CONCLUSION

The combination of TACE with RFA could obviously improve the short- and long-term survival rates and significantly provide a better prognosis for patients with intermediate-size HCC. RFA was associated with a higher long-term OS rate than that of TACE-treated patients with HCC.

Laparoscopic microwave ablation in patients with hepatocellular carcinoma: a prospective cohort study

OBJECTIVES

There are no prospective studies of laparoscopic microwave (MW) ablation in patients with hepatocellular carcinoma (HCC). The aim of this study was to demonstrate the safety and efficacy of laparoscopic MW ablation.

METHODS

A prospective study group of consecutive HCC patients considered ineligible for liver resection and/or percutaneous ablation was conducted from December 2009 to December 2010. Short-term (3-month) outcomes included a centralized revision of radiological response, mortality and morbidity. Mid-term (24-month) outcomes included time to recurrence in the study group compared with that in a cohort of consecutive patients treated with laparoscopic radiofrequency (RF) ablation using propensity score analysis.

RESULTS

A total of 42 patients were enrolled. Their median age was 64 years; 67% were positive for hepatitis C virus; 33% were of Child-Pugh class B status; the median tumour diameter was 2.5 cm, and 48% of patients had multinodular HCC. In 47 of 50 (94%) nodules treated with MW ablation, a complete radiological response was observed at 3 months. There was no perioperative mortality. The overall morbidity rate was 24%. The 2-year survival rate was 79% and the 2-year recurrence rate was 55%. Using propensity score analysis (in 28 MW ablation patients and 28 RF ablation controls), 2-year recurrence rates were 55% in the MW ablation group and 77% in the control group (P = 0.03).

CONCLUSIONS

Laparoscopic MW ablation is a safe and effective therapeutic option for selected HCC patients who are ineligible for liver resection and/or percutaneous ablation.

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

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

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence

BACKGROUND

Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence.

METHODS

One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed.

RESULTS

There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05).

CONCLUSIONS

RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.

Arterial chemoembolization/embolization and early complications after hepatocellular carcinoma treatment: a safe standardized protocol in selected patients with Child class A and B cirrhosis

PURPOSE

To assess the safety of transarterial treatments of hepatocellular carcinoma (HCC), and the statistical correlation of various patient factors with the frequency of complications, in selected patients with cirrhosis when adhering to well-standardized protocols.

MATERIALS AND METHODS

Three hundred twenty consecutive patients with unresectable HCC were treated with transarterial chemoembolization, oil chemoembolization, and embolization. A total of 712 treatments were performed, with an average of 2.3 treatments for each patient. The epirubicin dose was adjusted according to defined laboratory criteria. An early complication was defined as one that occurred within 4 weeks of treatment. Complications were classified as minor and major and assessed by using clinical and laboratory data.

RESULTS

Of the 712 procedures, 21 complications (2.9%) occurred in 17 of the 320 patients (5.3%). Major complications included acute liver failure (n = 1, 0.1%), variceal bleeding (n = 2, 0.3%), moderate-to-severe ascites (n = 4, 0.6%), sepsis (n = 3, 0.4%), cholecystitis (n = 1, 0.1%), and diverticulitis (n = 1, 0.1%). Minor complications were hepatic artery damage, including spontaneously resolved dissection (n = 3, 0.4%), mild encephalopathy (n = 1, 0.1%), and aspartate aminotransferase/alanine aminotransferase levels greater than 500 U/L (n = 5, 0.7%). The 30-day mortality rate was 0.003% (n = 1). Constitutional syndrome (P = .0001), Child-Pugh score (P = .0001), ascites (P = .037), and the Model for End-Stage Liver Disease score (P = .02) were found to have a statistically significant correlation with complications after univariate analysis. Child-Pugh score (P = .012) and constitutional syndrome (P = .003) were found to have a statistically significant correlation with complications after logistic regression analysis.

CONCLUSIONS

Transarterial treatments can be considered safe in patients with Child class A and B cirrhosis when an adjusted dose of epirubicin is used according to body surface, severity of liver disease, and white blood cell count. Accurate patient selection and procedure-related factors may reduce the frequency of complications and help preserve liver function.

Laparoscopic radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Although the percutaneous approach is less invasive and is considered the first choice, RFA with laparoscopic guidance is highly recommended for patients with a relative contraindication for percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct and heart. Recent advances in laparoscopic ultrasound have widened the indication for laparoscopic ablation. In the present paper, we review the indications, advantages, prognosis and safety of laparoscopic RFA for hepatocellular carcinoma.

Transarterial therapy for hepatocellular carcinoma: which technique is more effective? A systematic review of cohort and randomized studies

BACKGROUND

Chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, or whether embolization (TAE) alone gives the same survival advantage, is not known.

PURPOSE

To evaluate whether specific patient characteristics and/or radiological transarterial techniques result in better outcomes.

METHOD

A PubMed search was carried out for cohort and randomized trials (n = 175) testing transarterial therapies; meta-analysis was performed where appropriate.

RESULTS

Anticancer drugs were used as sole agent in 75% of cases (double 15% and triple 6%): doxorubicin (36%), cisplatin (31%), epirubicin (12%), mitoxantrone (8%), mitomycin (8%), and SMANCS (5%). Embolizing agents used were: gelatin sponge particles (71%), polyvinyl alcohol (PVA) particles (8%), degradable starch microspheres (DSM) (4%), and embospheres (4%). Sessions per patient were 2.5 +/- 1.5 (interval: 2 months). Objective response was 40 +/- 20%; survival rates at 1, 2, 3, and 5 years were: 62 +/- 20%, 42 +/- 17%, 30 +/- 15%, and 19 +/- 16%, respectively, and survival time was 18 +/- 9.5 months. The post-TACE complications were: acute liver failure, 7.5% (range 0-49%); acute renal failure, 1.8% (0-13%); encephalopathy, 1.8% (0-16%); ascites, 8.3% (0-52%); upper gastrointestinal bleeding; 3% (0-22%); and hepatic or splenic abscess, 1.3% (0-2.5%). Treatment-related mortality was 2.4% (0-9.5%), mainly due to acute liver failure. Our meta-analysis of nine randomized controlled trials (RCTs) confirmed that TACE improves survival; but a meta-analysis of TACE versus TAE alone (3 RCTs, 412 patients) demonstrated no survival difference.

CONCLUSIONS

No chemotherapeutic agent appears better than any other. There is no evidence for benefit with lipiodol. Gelatin sponge is the most used embolic agent, but PVA particles may be better. TAE appears as effective as TACE. New strategies to reduce the risk of post-TACE complications are required.

Radiofrequency ablation for hepatocellular carcinoma and metastatic liver tumors: a comparative study

BACKGROUND

This study compared the effectiveness of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) and liver metastases.

METHODS

We compared the outcomes of 240 patients with HCC and 44 patients with liver metastases treated with RFA. Data were prospectively collected and retrospectively analyzed. Effects of different variables on recurrences were studied.

RESULTS

A total of 406 tumor nodules were treated. The median size of the largest ablated tumor was 2.5 cm, and the median tumor number was 1. Complete tumor ablation was achieved in 91.2%. Local recurrence rate was 15.4% after a median follow-up of 24.5 months. There was no significant impact of tumor pathology on local recurrence. However, patients with liver metastasis had higher extrahepatic recurrence rate (P = 0.019) and shorter disease-free survival (P = 0.007). Patients with multiple tumors had higher local (P = 0.047) and extrahepatic (P = 0.019) recurrence rates than those with a solitary tumor. Tumor size had an impact on local recurrence rate only in patients with liver metastasis with a higher rate in those with tumor > 2.5 cm in diameter (P = 0.028).

CONCLUSIONS

Tumor pathology does not appear to have a significant impact on local recurrence rates. RFA is effective in local tumor control for both HCC and liver metastasis.

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND

Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial.

AIM

To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE.

METHOD

PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate.

RESULTS

A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate.

CONCLUSIONS

A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.

Treatment and outcomes of treating of hepatocellular carcinoma among Medicare recipients in the United States: a population-based study

BACKGROUND/AIMS

There are several treatment alternatives available for patients diagnosed with hepatocellular carcinoma (HCC). Yet, neither the extent to which potentially curative or palliative therapy is used to treat HCC, nor the determinants of using such therapies are known. Further, it is unclear how effective different modalities are for treating HCC.

METHODS

We used the linked SEER-Medicare dataset to identify patients diagnosed with HCC between 1992 and 1999. We identified 2963 patients with continuous Medicare enrollment who were not enrolled in a Medicare-HMO. HCC treatments were categorized as potentially curative therapy (resection, transplant, local ablation), or palliative (trans-arterial chemoembolization (TACE), chemotherapy), and no therapy. Demographic (age, sex, race, geographic region), clinical (comorbidity, risk factors and severity of liver disease) and tumor factors (tumor size, extent of disease) were examined as potential determinants of therapy, as well as survival in univariate and multivariable analyses. Survival curves were also generated and compared among the different treatment modalities.

RESULTS

The median age at diagnosis was 74 years (range: 32-105), and most patients (91%) were older than 65 years. Approximately 68% were White, 10% Black, 4% Hispanic, 8% Asian, and 9% were of other race. Thirteen percent of the patients received potentially curative therapy (transplant 0.9%, resection 8.2%, local ablation 4.1%), 4% received TACE, 57% received other palliative therapy, and 26% received no specific therapy. Only 34% of 513 patients with single lesions, and 34% of 143 patients with lesions <3.0 cm received potentially curative therapy. However, 19.2% of patients with unfavorable tumor features (lesion >10.0 cm) received such therapy. Among patients who received potentially curative therapy (n=392), resection was the most common procedure (n=243, 62%) followed by local ablation (n=122, 31%) and finally transplantation (n=27, 7%). In regression analyses, geographic variations in the extent and type of curative therapy persisted after adjusting for demographic, clinical, and tumor features. Median overall survival was 104 days following HCC diagnosis with the longest survival in the transplant group (852 days) and the shortest survival in the group with no treatment (58 days). In the survival analysis, transplantation led to the longest survival, followed by resection. Neither ablation nor TACE yielded prolonged survival (3 year survival was less than 10%).

CONCLUSIONS

In this predominantly 65 years and older Medicare population, there are marked geographic variations in the management of HCC that seem to be at least as important as clinical and tumor-related features in determining the extent and type of HCC therapy. There is underutilization of potentially curative therapy, even among those with favorable tumor features.

Retrospective Clinicopathologic Correlation of Gross Tumor Size of Hepatocellular Carcinoma

PURPOSE

To determine the degree of correlation between radiographic size and true gross pathologic size for subjects with primary hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

This analysis included 18 patients with 27 tumors who underwent either partial hepatectomy or orthotopic liver transplantation for HCC at the University of Colorado Hospital between 1997 and 2002. Preoperative imaging was performed using computed tomography (CT) or magnetic resonance imaging (MRI). After surgical resection the size of each tumor on gross pathologic examination was recorded. The maximal measurement in one dimension on axial imaging and pathologic examination was extracted for statistical analysis. The clinical and pathologic sizes were compared using a percent size difference (%Deltasize) as an end point for each patient. A regression analysis was applied to study the association between pathologic and clinical size.

RESULTS

The median radiographic size was 2.90 cm (range 1.2-4.9). The median pathologic size was 2.50 cm (range 1-4.8). The radiographic size was larger than or equal to the pathologic size in 22/27 tumors (81%) and smaller in 5/27 (19%) tumors. The median %Deltasize was 17.5% (range -20-144%). Overall, the radiographic and pathologic sizes were positively correlated (r = 0.8). This correlation was not affected by choice of imaging modality (CT versus MRI, P = 0.71) or time of preoperative imaging (0-4 weeks versus 4-8 weeks before surgery, P = 0.61).

CONCLUSIONS

Our study shows that in most instances (81%), imaging by CT or MRI overestimates true gross pathologic size of HCC. Nineteen percent of tumors appeared smaller on preoperative imaging than on the final pathologic specimen. Radiation therapy utilizing a 0.5 or 1.0 cm margin around the radiographic tumor would have encompassed the gross pathologic tumor in 93% and 100% of cases, respectively.

Radiofrequency ablation for malignant liver tumor

Radiofrequency ablation (RFA) has been widely practiced to treat unresectable malignant liver tumors. It has the merits of localized tumor ablation and preservation of maximal normal liver parenchyma. In recent years, there has been a tremendous expansion in the application of RFA for patients with malignant liver tumors. However, the therapeutic effect of this local ablation treatment needs to be balanced against its risks and possible local failure. This review focuses on the current status of RFA for malignant liver tumors, with special attention to the indication, approaches, complications, survival benefits, combination therapies, and comparison with other treatment modalities. Although the results of most clinical studies of RFA seem favorable, the associated risks and tumor recurrence should not be underestimated. Careful patient selection, meticulous RFA techniques, and prompt treatment of residual and recurrent tumors are necessary to ensure a better outcome after RFA. Until recently, there has been no strong evidence showing that RFA can replace any other treatment modalities in the management of liver tumors. Nonetheless, more convincing evidence by randomized trials is required for the establishment of a treatment protocol of RFA for patients with malignant liver tumors.

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

Orthotopic liver transplantation (OLT) can be a definitive treatment for patients with hepatocellular carcinoma (HCC). Prolonged waiting times for cadaveric livers, however, may lead to dropout from the waiting list or worsened post-OLT prognosis as a result of interval tumor progression. Percutaneous radiofrequency ablation (RFA) is widely used for local control of small unresectable HCC, but its pretransplant role remains unclear. We studied the outcome of 52 consecutive patients accepted for OLT bearing 87 HCC nodules and treated with percutaneous RFA. On initial staging, the tumor burden exceeded the Milan criteria in 10 patients. Complete tumor coagulation was observed in 74 of 87 (85.1%) nodules based on postablation imaging. After a mean of 12.7 months (range: 0.3-43.5) on the waiting list, 3 of 52 patients (5.8%) had dropped out due to tumor progression. Forty-one patients had undergone transplantation, with 1- and 3-year post-OLT survival rates of 85% and 76%, respectively. No patient developed HCC recurrence. There were three major complications in 76 RFA procedures (hepatic arterial hemorrhage, small bowel perforation, and liver decompensation salvaged by OLT), without resultant death or dropout. In conclusion, percutaneous RFA is an effective bridge to OLT for patients with compensated liver function and safely accessible tumors. Tumor-related dropout rate and post-OLT outcome compared favorably with published controls of patients with early-stage disease. This can be attributed to the efficacy of RFA in producing local cure or curbing tumor progression during the waiting period.

Radio frequency ablation for primary liver cancer: an evidence-based analysis

OBJECTIVE

The Medical Advisory Secretariat undertook a review of the evidence on the safety, clinical effectiveness, and cost-effectiveness of radio frequency ablation (RFA) compared with other treatments for unresectable hepatocellular carcinoma (HCC) in Ontario.

BACKGROUND

Liver cancer is the fifth most common type of cancer globally, although it is most prevalent in Asia and Africa. The incidence of liver cancer has been increasing in the Western world, primarily because of an increased prevalence of hepatitis B and C. Data from Cancer Care Ontario from 1998 to 2002 suggest that the age-adjusted incidence of liver cancer in men rose slightly from 4.5 cases to 5.4 cases per 100,000 men. For women, the rates declined slightly, from 1.8 cases to 1.4 cases per 100,000 women during the same period. Most people who present with symptoms of liver cancer have a progressive form of the disease. The rates of survival in untreated patients in the early stage of the disease range from 50% to 82% at 1 year and 26% to 32% at 2 years. Patients with more advanced stages have survival rates ranging from 0% to 36% at 3 years. Surgical resection and transplantation are the procedures that have the best prognoses; however, only 15% to 20% of patients presenting with liver cancer are eligible for surgery. Resection is associated with a 50% survival rate at 5 years.

THE TECHNOLOGY

RADIO FREQUENCY ABLATION RFA is a relatively new technique for the treatment of small liver cancers that cannot be treated with surgery. This technique applies alternating high-frequency electrical currents to the cancerous tissue. The intense heat leads to thermal coagulation that can kill the tumour. RFA is done under general or local anesthesia and can be done percutaneously (through the skin with a small needle), laparoscopically (microinvasively, using a small video camera), or intraoperatively. Percutaneous RFA is usually a day procedure.

METHODS

The leading international organizations for health technology assessments, including the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) and the International Network of Agencies for Health Technology Assessment (INAHTA), were scanned for previous systematic reviews on RFA. The Cochrane Library Database was also scanned. The most recent systematic review examined the literature up to October 2003. Five previous health technology assessments were found. To update the international systematic reviews, the Medical Advisory Secretariat systematically reviewed the literature from January 1, 2003 to the third week of April 2004. Peer-reviewed literature from EMBASE, MEDLINE (including in-process and other nonindexed citations) and the Cochrane Library Database were searched for the following search terms: Catheter ablationRadiofrequency or radio-frequency or radio frequency or RFA or RFTALiver neoplasms or liver cancer or hepatocellular or hepatocellular or hepaticCancerThe inclusion criteria were as follows:

POPULATION

patients with primary hepatocellular carcinoma

PROCEDURE

RFA used as the only treatment (not as an adjunct)LANGUAGE: publication in EnglishPublished health technology assessments, guidelines, and peer-reviewed literature (abstracts and in-progress manuscripts)

OUTCOMES

therapeutic response (% complete ablation), mortality, survival, and tumour recurrenceGrey literature, where relevant, was also reviewed.

SUMMARY OF FINDINGS

The Medical Advisory Secretariat included 5 previous health technology assessments from 2002 to 2004 and 9 peer-reviewed studies from January 2003 to April 2004 in its review. The health technology assessments suggested that RFA is as safe and effective for treating up to 3 or 4 small (< 4 to 5 cm), unresectable liver tumours in the short term (2 years). One small randomized controlled trial (RCT) that compared RFA with percutaneous ethanol injection (PEI), another ablative technique, suggested that RFA is at least as safe and effective for small unresectable primary liver tumours compared to PEI. However, the patient populations and comparison technologies in the peer-reviewed literature and the previous health technology assessments were heterogeneous; therefore, meta-analyses could not be performed. RFA has also been used to treat colorectal and neuroendocrine liver metastases and kidney, lung, breast, and bone cancer. Although this report did not focus on these indications because of a paucity of published evidence of effectiveness, some individual patients with the above indications may benefit from RFA; therefore, RFA may quickly diffuse into these areas. Various clinical trials focussing on these indications are underway.

CONCLUSIONS

Level 2 evidence suggests RFA is as safe and perhaps more effective than percutaneous ethanol injection to treat HCC.RFA and percutaneous ethanol injection are more effective and more cost-effective than transcatheter arterial chemoembolization.RFA is marginally more expensive, yet more cost-effective than percutaneous ethanol injection.Complications are few, but experienced interventional radiologists should do RFA.RFA may benefit some patients with liver metastases or other primary cancers, although published evidence of effectiveness has not yet been established.

Effects of metastasis-suppressor gene KAI1 on tumorigenicity and metastasis of hepatocellular carcinoma MHCC97-H cells with high metastatic potential in nude mice

AIM: To explore the effects of metastasis-suppressor gene KAI1 on tumorigenicity and metastasis of hepatocellular carcinoma cells MHCC97-H with high metastatic potential in nude mice.

METHODS: The MHCC97-H hepatocellular carcinoma cells with high metastatic potential transfected with sense or antisense KAI1 expression plasmid in our previous experiments were inoculated subcutaneously into nude mice. The growth of subcutaneous tumor was observed, then the subcutaneous tumor tissues were harvested and implanted orthotopicly into nude mice liver. The tumor metastasis in lung was carefully examined under microscope. MHCC97-H and the cells transfected with vector pCI-neo, but without KAI1 gene were used as control.

RESULTS: The different cells inoculated subcutaneously all had tumorigenicity. There were no significant differences in the speed of tumor growth among different groups, but the antisense group showed stronger invasion ability than others. The spontaneous metastasis to lung occurred in latency period of six wk via orthotopic implantation of tumor tissue. Immunostaining showed strongly positive for AFP in lung metastatic lesions, which indicated those were lung metastatic lesions from hepatocellular carcinoma. The number of lung metastatic lesions increased dramaticly in antisense group (P = 0.00 158), decreased significantly in sense group (P = 0.00 465) and no significant difference in vector pCI-neo group (P = 0.15 166), as compared with their paternal MHCC97-H group.

CONCLUSION: The metastasis-suppressor gene KAI1 has no significant effects on tumorigenicity and growth of MHCC97-H hepatocellular carcinoma cells, but enhanced KAI1 expression can decrease the invasion ability and inhibit the metastasis, which offers an important clue to investigate the anti-metastasis treatment for hepatocellular carcinoma.