Comparison between combination therapy of percutaneous ethanol injection and radiofrequency ablation and radiofrequency ablation alone for patients with hepatocellular carcinoma

Clinical efficacy of CT-guided 125I brachytherapy in patients with local residual or recurrent hepatocellular carcinoma after thermal ablation

OBJECTIVES

Treatment methods of local residual or recurrent hepatocellular carcinoma (HCC) after thermal ablation are limited. Therefore, our study aimed to explore the efficacy and prognostic factors of ¹²⁵I brachytherapy for local residual or recurrent lesion after thermal ablation.

METHODS

A total of 114 patients with 212 local residual or recurrent HCC tumors after thermal ablation underwent ¹²⁵I brachytherapy. Local progression-free survival (LPFS) and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

RESULTS

After a 6-month follow-up, the percentage of patients who achieved complete response (CR), partial response (PR), and stable disease (SD) was 57%, 13.2%, and 5.2%, respectively. The 1-, 2-, and 3-year LPFS rates were 58.7%, 50.0%, and 41.2%, respectively. Portal vein tumor thrombus (PVTT) (p = 0.03), the number of intrahepatic tumors (p = 0.01), and AFP level (p = 0.02) were independent risk factors for local tumor progression (LTP). The median LPFS in patients without PVTT (22 months) was much longer compared to those with PVTT (10 months). The median LPFS in patients with less than three intrahepatic lesions improved from 17 to 24 months. The median LPFS was only 5 months in the high AFP group, but was prolonged with a decrease in AFP level (24 months). No severe complications were recorded. All complications were controllable and treatable.

CONCLUSIONS

CT-guided ¹²⁵I brachytherapy was a safe and effective treatment for patients with local residual or recurrent HCC after thermal ablation to improve local control rate.

Engineering nanotheranostic strategies for liver cancer

The incidence and mortality of hepatocellular carcinoma have continued to increase over the last few years, and the medicine-based outlook of patients is poor. Given great ideas from the development of nanotechnology in medicine, especially the advantages in the treatments of liver cancer. Some engineering nanoparticles with active targeting, ligand modification, and passive targeting capacity achieve efficient drug delivery to tumor cells. In addition, the behavior of drug release is also applied to the drug loading nanosystem based on the tumor microenvironment. Considering clinical use of local treatment of liver cancer, in situ drug delivery of nanogels is also fully studied in orthotopic chemotherapy, radiotherapy, and ablation therapy. Furthermore, novel therapies including gene therapy, phototherapy, and immunotherapy are also applied as combined therapy for liver cancer. Engineering nonviral polymers to function as gene delivery vectors with increased efficiency and specificity, and strategies of co-delivery of therapeutic genes and drugs show great therapeutic effect against liver tumors, including drug-resistant tumors. Phototherapy is also applied in surgical procedures, chemotherapy, and immunotherapy. Combination strategies significantly enhance therapeutic effects and decrease side effects. Overall, the application of nanotechnology could bring a revolutionary change to the current treatment of liver cancer.

In Vitro Bovine Liver Experiment of Cisplatin-Infused and Normal Saline-Infused Radiofrequency Ablation with an Internally Cooled Perfusion Electrode

PURPOSE

To evaluate the efficacy of cisplatin-infused and normal saline-infused radiofrequency ablation (RFA) with internally cooled perfusion (ICP) electrode.

MATERIALS AND METHODS

Using a 200 W generator, thirty ablation zones were created and divided into three groups of 10 each as follows: group A, RFA alone with 16 gauge monopolar internally cooled (IC) electrode; group B, cisplatin-infused RFA with 16 gauge ICP electrode; and group C, normal saline-infused RFA with 16 gauge ICP electrode. Radiofrequency was applied to the explanted bovine liver for 12 min. During RFA, cisplatin and normal saline were injected into tissue at a rate of 0.5 mL/min through the ICP electrode by injection pump. Dimensions of the ablation zone and technical parameters were compared between the three groups.

RESULT

In the cisplatin-infused RFA group, the ablation zone size was significantly larger than that of the RFA-alone group but significantly smaller than normal saline-infused RFA group. The width of longitudinal section and volume were 3.39 ± 0.22 cm² and 26.55 ± 4.62 cm³ in RFA-alone group, 3.88 ± 0.32 cm² and 36.45 ± 5.46 cm³ in cisplatin-infused RFA group, and 4.52 ± 0.50 cm² and 49.44 ± 7.55 cm³ in normal saline-infused RFA group, respectively (p < 0.05 between any two groups). The mean impedance in group A, B, and C were 60.0 ± 7.2, 50.3 ± 2.5, and 40.3 ± 4.0 Ω, respectively (p < 0.05 between any two groups).

CONCLUSION

Cisplatin-infused RFA with ICP electrode created the larger size of ablation zone than that of monopolar RFA with an IC electrode, but created the smaller size of ablation zone than that of normal saline-infused RFA.

Comparison of radiofrequency ablation alone & in combination with percutaneous ethanol injection for management of hepatocellular carcinoma

Background & objective:

It has been shown that the combined use of alcohol before radiofrequency ablation (RFA) helps to augment the therapeutic advantage of RFA. The present study was conducted to compare the outcome of treatment with RFA alone and RFA with alcohol as ablative technique in patients with small hepatocellular carcinomas (HCCs), who were not candidates for surgery.

Methods:

Fifty patients with chronic liver disease and concurrent HCC were enrolled in this prospective study. The patients were treated with either RFA alone (n=25) or RFA combined with alcohol (n=25). Patient outcome was evaluated, and the tumour recurrence and survival of the patients were assessed in the two groups.

Results:

The survival rates at six months in patients who completed at least six months of follow up were 84 and 80 per cent in patients treated with RFA alone and combination therapy, respectively. During the follow up period, 11 and four patients treated with RFA alone showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at one to 18 months of the follow up period. The distant recurrences occurred at 6-36 months of the follow up period. During the follow up period, eight and six patients treated with combination therapy showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at 1.5-15 months during the follow up period. The distant intrahepatic recurrences occurred at 6-72 months during the follow up period.

Interpretation & conclusions:

No significant difference was seen between the survival time of the patients treated with RFA alone and RFA with alcohol as well as in the local recurrences and distant intrahepatic recurrences in RFA compared to RFA and alcohol group patients. Combined use of RFA and alcohol did not improve the local tumour control and survival in patients with HCC compared to RFA alone.

Innovative Techniques for Image-Guided Ablation of Benign Thyroid Nodules: Combined Ethanol and Radiofrequency Ablation

In the treatment of benign thyroid nodules, ethanol ablation (EA), and radiofrequency ablation (RFA) have been suggested for cystic and solid thyroid nodules, respectively. Although combining these ablation techniques may be effective, no guidelines for or reviews of the combination have been published. Currently, there are three ways of combining EA and RFA: additional RFA is effective for treatment of incompletely resolved symptoms and solid residual portions of a thyroid nodule after EA. Additional EA can be performed for the residual unablated solid portion of a nodule after RFA if it is adjacent to critical structures (e.g., trachea, esophagus, and recurrent laryngeal nerve). In the concomitant procedure, ethanol is injected to control venous oozing after aspiration of cystic fluid prior to RFA of the remaining solid nodule.

Hepatocellular carcinoma ≤ 4 cm treated with radiofrequency ablation with or without percutaneous ethanol injection

BACKGROUND

To compare the survival of Chinese cirrhotic patients with hepatocellular carcinoma (HCC) ≤ 4 cm who underwent radiofrequency ablation (RFA) alone or a combination of RFA with percutaneous ethanol injection (PEI).

MATERIAL AND METHODS

Retrospective analysis was performed for 681 cases with HCC ≤ 4 cm who were treated with RFA alone or RFA combined with PEI (RFA + PEI) between 2004 and 2011.

RESULTS

As a result, 180 patients in each group were selected after propensity score matching (PSM). Higher overall survival (OS) and recurrence-free survival (RFS) rates were achieved by RFA + PEI compared with RFA alone (P = 0.019 and 0.009, respectively). The 1-, 3-, and 5-year cumulative OS rates were 78.0, 44.4, and 30.1% for patients in RFA group and 88.2, 58.0, and 41.1% for patients in RFA + PEI group, respectively. Besides, the 1-, 3-, and 5-year cumulative RFS rates were 77.0, 43.8, and 29.2% in RFA group, and 87.9, 57.6, and 38.4% in RFA + PEI group, respectively. The local recurrence, complete ablation and five-year mortality showed no distinct differences between RFA and RFA + PEI groups in three subgroups classified with tumor size. Moreover, Cox regression multivariate analysis results showed that sex and treatment approach were significantly related to OS, whereas sex, status of HBsAg, local recurrence, and number of tumor nodule were related to RFS.

CONCLUSION

Therefore, the combination of RFA and PEI yielded better OS and RFS rates than RFA alone for Chinese patients with HCC ≤ 4 cm.

Treatment of liver cancer of middle and advanced stages using ultrasound-guided percutaneous ethanol injection combined with radiofrequency ablation: A clinical analysis

Liver cancer is a malignancy of the digestive system and has a high morbidity and mortality rate. Local intervention has become a viable option in identifying liver treatment. The aim of the present study was to analyze the clinical effects of treating liver cancer in middle and advanced stages using ultrasound-guided percutaneous ethanol injection (PEI) in tumors combined with radiofrequency ablation (RFA). A total of 100 patients with stage III-IV liver cancers were selected to participate in the study. Patients were divided into groups. In group A, treatment was initiated with PEI and after 1-2 weeks RFA was applied while in group B treatment was initiated with RFA and after 1-2 weeks PEI was applied. Patients in group C received PEI and RFA simultaneously. The clinical effects in the 3 groups were compared after 6-month follow ups. The volume of tumor ablation necrosis in group A was significantly greater than that in the groups B and C, while the size was significantly smaller compared to groups B and C after ablation. For group A, the complete ablation rate was significantly higher than that in groups B and C, and the differences were statistically significant (P<0.05). Liver damage indices, including raising levels of glutamic-pyruvic transaminase and total bilirubin, were significantly decreased in group A (P<0.05). The survival rate in group A was also significantly higher than in groups B and C (P<0.05). In conclusion, for patients with liver cancer in middle and advanced stages, the treatment method using PEI followed by RFA was more beneficial in terms of improving the tumor ablation rate, alleviating liver damages and increasing survival rates.

Liver Ablation: Best Practice

Tumor ablation in the liver has evolved to become a well-accepted tool in the management of increasing complex oncologic patients. At present, percutaneous ablation is considered first-line therapy for very early and early hepatocellular carcinoma and second-line therapy for colorectal carcinoma liver metastasis. Because thermal ablation is a treatment option for other primary and secondary liver tumors, an understanding of the underlying tumor biology is important when weighing the potential benefits of ablation. This article reviews ablation modalities, indications, patient selection, and imaging surveillance, and emphasizes technique-specific considerations for the performance of percutaneous ablation.

Evaluation of in vivo efficacy of radiofrequency ablation with D-sorbitol in animal liver

Percutaneous radiofrequency ablation (RFA) enables cauterization of liver cancer in a limited number of sessions without major complications. In contrast to the efficacy of this technique, the size of coagulation necrosis is limited due to increased impedance. D-sorbitol has been used as an irrigating fluid during transurethral resection of the prostate, since it is considered to be a dielectric fluid. In order to determine whether D-sorbitol enhances the effect of RFA, RFA was performed by slowly injecting 3% D-sorbitol near the tip of the RFA needle. The maximum of the total injected volume of D-sorbitol was 20 ml and RFA was terminated if the threshold of impedance was exceeded. RFA and D-sorbitol RFA were performed in 5 different parts of pig livers and dog livers in vivo. The total volumes of coagulation necrosis in the D-sorbitol RFA group were significantly higher compared with those in the RFA group. The total delivered energy in the D-sorbitol RFA group was also higher compared with that in the RFA group, due to the suppression of impedance elevation. No significant complications, such as bleeding or damage, were observed during the D-sorbitol RFA procedure in the in vivo model. In conclusion, RFA combined with D-sorbitol increases the total volume of coagulation necrosis through controlling impedance in the ablated liver and, therefore, D-sorbitol may be useful for the treatment of liver cancers.

Radiofrequency ablation-combined multimodel therapies for hepatocellular carcinoma: Current status

Radiofrequency ablation (RFA) is widely accepted as a first-line interventional oncology approach for hepatocellular carcinoma (HCC) and has the advantages of high treatment efficacy and low complication risk. Local control rates equivalent to hepatic resection can be reached by RFA alone when treating small HCCs (<2 cm) in favorable locations. However, local tumor progression and recurrence rates with RFA monotherapy increase sharply when treating larger lesions (>3 cm). To address this clinical problem, recent efforts have focused on multimodel management of HCC by combining RFA with different techniques, including percutaneous ethanol injection, transarterial chemo-embolization, targeted molecular therapy, nanoparticle-mediated therapy, and immunotherapy. The combination strategy indeed leads to better outcomes in comparison to RFA alone. In this article, we review the current status of RFA-combined multimodal therapies in the management of HCC.

Systematic evaluation of percutaneous radiofrequency ablation versus percutaneous ethanol injection for the treatment of small hepatocellular carcinoma: a meta-analysis

BACKGROUND

Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) have been used for patients with hepatocellular carcinoma (HCC). However, which therapy is superior remains to be further elucidated. We aimed to conduct a systematic review to assess survival and local tumor recurrence rate with RFA compared with PEI therapy for HCC.

METHODS

We conducted systematic review and meta-analysis of randomized controlled trials (RCTs) published up to 2014 in PubMed, MEDLINE, EMBASE, EBSCO, Springer, Ovid and the Cochrane library. Only RCTs that evaluated survival rate and occurrence of HCC between RFA and PEI therapy were included. The OR (odds ratio) with a 95% confidence interval (CI) was calculated by the Revman 5.0 software.

RESULTS

A total of six studies including 983 HCC patients were eligible for this analysis. The survival rate showed a significant benefit under RFA therapy over PEI at 1-year (P = 0.02, OR = 1.88, 95% CI: 1.09 to 3.22), 2-years (P = 0.0003, OR = 2.06, 95% CI: 1.39 to 3.05) and 3-years (P = 0.0007, OR = 1.68, 95% CI: 1.25 to 2.27). Likewise, RFA achieved significantly lower rates of local tumor recurrence over PEI at 1-year (P = 0.002, OR = 0.43, 95% CI: 0.26 to 0.73), 2-year (P = 0.03, OR = 0.33, 95% CI: 0.12 to 0.88) and 3-year (P = 0.003, OR = 0.61, 95% CI: 0.43 to 0.84).

CONCLUSIONS

The current evidence suggests that RFA is superior to PEI in better survival and local disease control for small HCCs <5 cm in diameter and that RFA is worthy of promotion in clinical applications.

Radiofrequency (thermal) ablation versus no intervention or other interventions for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the fifth most common cancer worldwide. Percutaneous interventional therapies, such as radiofrequency (thermal) ablation (RFA), have been developed for early hepatocellular carcinoma. RFA competes with other interventional techniques such as percutaneous ethanol injection, surgical resection, and liver transplantation. The potential benefits and harms of RFA compared with placebo, no intervention, chemotherapy, hepatic resection, liver transplantation, or other interventions are unclear.

OBJECTIVES

To assess the beneficial and harmful effects of RFA versus placebo, no intervention, or any other therapeutic approach in patients with hepatocellular carcinoma.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ISI Web of Science to September 2012. We handsearched meeting abstracts from ASCO, ESMO, AASLD, EASL, APASL, and references of articles. We also contacted researchers in the field (last search September 2012).

SELECTION CRITERIA

We considered for inclusion randomised clinical trials investigating the effects of RFA versus placebo, no intervention, or any other therapeutic approach on hepatocellular carcinoma patients regardless of blinding, language, and publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the selection of trials, assessment of risk of bias, and data extraction. We contacted principal investigators for missing information. We analysed hazard ratios (HR) as relevant effect measures for overall survival, two-year survival, event-free survival, and local recurrences with 95% confidence intervals (CI). In addition, we analysed dichotomous survival outcomes using risk ratios (RR). We used trial sequential analysis to control the risk of random errors ('play of chance').

MAIN RESULTS

We identified no trials comparing RFA versus placebo, no intervention, or liver transplantation. We identified and included 11 randomised clinical trials with 1819 participants that included four comparisons: RFA versus hepatic resection (three trials, 578 participants); RFA versus percutaneous ethanol injection (six trials, 1088 participants) including one three-armed trial that also investigated RFA versus acetic acid injection; RFA versus microwave ablation (one trial, 72 participants); and RFA versus laser ablation (one trial, 81 participants). Ten of the eleven included trials reported on the primary outcome of this review, overall survival. Rates of major complications or procedure-related deaths were reported in 10 trials. The overall risk of bias was considered low in five trials and high in six trials. For a subgroup analysis, we included only low risk of bias trials. Regarding the comparison RFA versus hepatic resection, there was moderate-quality evidence from two low risk of bias trials that hepatic resection seems more effective than RFA regarding overall survival (HR 0.56; 95% CI 0.40 to 0.78) and two-year survival (HR 0.38; 95% CI 0.17 to 0.84). However, if we included a third trial with high risk of bias, the difference became insignificant (overall survival: HR 0.71; 95% CI 0.44 to 1.15). With regards to the outcomes event-free survival and local progression, hepatic resection also yielded better results than RFA. However, the number of complications was higher in surgically treated participants (odds ratio (OR) 8.24; 95% CI 2.12 to 31.95). RFA seemed superior to percutaneous ethanol or acetic acid injection regarding overall survival (HR 1.64; 95% CI 1.31 to 2.07). The RR for mortality was also in favour of RFA, but did not reach statistical significance (150/490 (30.6%) people in the percutaneous ethanol or acetic acid group versus 119/496 (24.0%) people in the RFA group; RR 1.76; 95% CI 0.97 to 3.22). The proportion of adverse events did not differ significantly between RFA and percutaneous ethanol or acetic acid injection (HR 0.70; 95% CI 0.33 to 1.48). Trial sequential analyses revealed that the number of participants in the included trials was insufficient and that more trials are needed to assess the effects of RFA versus other interventions.

AUTHORS' CONCLUSIONS

The effects of RFA versus no intervention, chemotherapeutic treatment, or liver transplantation are unknown. We found moderate-quality evidence that hepatic resection is superior to RFA regarding survival. However, RFA might be associated with fewer complications and a shorter hospital stay than hepatic resection. We found moderate-quality evidence showing that RFA seems superior to percutaneous ethanol injection regarding survival. There were too sparse data to recommend or refute ablation achieved by techniques other than RFA. More randomised clinical trials with low risk of bias and low risks of random errors assessing the effect of RFA are needed.

Recent advances in radiofrequency ablation for the management of hepatocellular carcinoma

CONTEXTS: Hepatocellular carcinoma (HCC) is one of the most common malignant diseases in the world. Because less than 20% of patients with HCC are resectable, various types of non-surgical treatment have been developed.

EVIDENCE ACQUISITION

At present, radiofrequency ablation (RFA) is accepted as the standard local treatment for patients with HCC because of its superior local control and overall survival compared to other local treatments.

RESULTS

New devices for RFA and combination treatments of RFA with other procedures have been developed to improve anti-tumoral effects.

CONCLUSIONS

This review mainly focuses on the status of RFA in the management of HCC and recent advances in RFA treatment technology.

Percutaneous radiofrequency ablation using internally cooled wet electrodes for the treatment of hepatocellular carcinoma

OBJECTIVE

The objective of our study was to evaluate the efficacy and safety of percutaneous radiofrequency ablation (RFA) using internally cooled wet electrodes in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From March 2008 to October 2010, 122 patients with 129 HCCs (mean size, 2.2 ± 0.6 [SD] cm; range, 0.7-4 cm) were treated with RFA using internally cooled wet electrodes. Primary technical effectiveness, the frequency of major complications, and local tumor progression rates were evaluated.

RESULTS

Two patients (2%) had major complications (liver abscess, significant pleural effusion) after RFA. When evaluated 1 month after RFA, the primary technical effectiveness rate was 99%. The 1- and 2-year local tumor progression rates were 8% and 12%, respectively. Additionally, there was no difference in effectiveness and complication rates between patients with subcapsular HCC and those with nonsubcapsular HCC.

CONCLUSION

Percutaneous RFA using internally cooled wet electrodes is safe and provides successful local tumor control in patients with HCC. The safety and effectiveness of RFA using internally cooled wet electrodes are comparable to those reported in the literature using conventional RFA electrodes and are similar for nonsubcapsular and subcapsular tumors.

Radiofrequency ablation combined with percutaneous ethanol injection in patients with hepatocellular carcinoma

BACKGROUND AND STUDY AIMS

Hepatocellular carcinoma (HCC) is a major burden on health-care systems worldwide. Although radiofrequency ablation (RFA) is currently considered the best technique for coagulative necrosis, the superiority of concomitant use of RFA and percutaneous ethanol injection (PEI) needs to be determined. The study was designed to compare efficacy, safety and rate of survival of patients with HCC assigned to receive combined PEI-RFA versus RFA alone and versus PEI alone.

PATIENTS AND METHODS

This 3-year study enrolled 90 cirrhotic patients with HCC (Child's class A or B, but not class C). They were randomly assigned for either PEI-RFA (group I), RFA alone (group II) or PEI alone (group III). The primary end point was ablation of the tumour. The secondary end point was rate of survival and recurrence.

RESULTS

After the first session, complete ablation was significantly higher in the combination group (87.9%) compared with the RFA group (54.54%). After the second session, complete ablation was achieved in 97.0% of the combination group and in 84.8% of the RFA group. Regarding the PEI group, 75% had complete ablation, whereas 25% had partial ablation after multiple sessions. The survival rate, 1.5 years later, was significantly higher in group I (86.7%) compared with group III (63.3%). The overall incidence of serious adverse events was nil.

CONCLUSION

Combined treatment is superior to RFA alone and to PEI alone, in safety and efficacy in patients with HCC.

Ferucarbotran expands area treated by radiofrequency ablation in rabbit livers

BACKGROUND AND AIM

Several studies have examined the factors involved with expansion of the coagulation volume following radiofrequency ablation (RFA). Ferucarbotran contains superparamagnetic iron oxide that generates heat in a radiofrequency electric field and may have an effect on the area affected by RFA. We attempted to determine whether ferucarbotran administration expands radiofrequency-ablated volume using a rabbit model.

METHODS

A total of 15 male Japanese white rabbits (16 weeks old) were used and divided into three groups of five each. A 1-mL saline solution was given intravenously into a dorsal ear vein in the control group, whereas 1 mL ferucarbotran solution (0.016 mL/kg bodyweight) was given to the common-dose group and 1 mL of a twofold concentrated ferucarbotran solution (0.032 mL/kg bodyweight) was given to the high-dose group. RFA was performed with a cool-tip electrode 4 h after the administration and immediately thereafter the rabbits were killed, and the volume of the ablated area measured using magnetic resonance imaging (MRI). Following the MRI analysis, the rabbit's livers were resected, and the maximum short axis diameter of the ablated area in each was measured.

RESULTS

None of the rabbits died during the RFA procedure. The volume of the ablated area estimated on MR images in the ferucarbotran-administered groups was larger than that in the control group. Further, our macroscopic assessment showed that the maximum short axis diameter had a tendency to increase with ferucarbotran administration.

CONCLUSION

Ferucarbotran may expand the area treated by RFA.

A combination therapy of ethanol injection and radiofrequency ablation under general anesthesia for the treatment of hepatocellular carcinoma

AIM: To summarize the effects of laparoscopic ethanol injection and radiofrequency ablation (L-EI-RFA), thoracoscopic (T-EI-RFA) and open-surgery assisted EI-RFA (O-EI-RFA) under general anesthesia for the treatment of hepatocellular carcinoma (HCC).

METHODS: Time-lag performance of RFA after ethanol injection (Time-lag PEI-RFA) was performed in all cases. The volume of coagulated necrosis and the applied energy for total and per unit volume coagulated necrosis were examined in the groups treated under general (group G) or local anesthesia (group L).

RESULTS: The results showed that the total applied energy and the applied energy per unit volume of whole and marginal, coagulated necrosis were significantly larger in group G than those in the group L, resulting in a larger volume of coagulated necrosis in the group G. The rate of local tumor recurrence within one year was extremely low in group G.

CONCLUSION: These results suggest that EI-RFA, under general anesthesia, may be effective for the treatment of HCC because a larger quantity of ethanol and energy could be applied during treatment under pain-free condition for the patients.

Successful treatment of hypovascular advanced hepatocellular carcinoma with lipiodol-targetting intervention radiology

We report a case of hypovascular advanced hepa-tocellular carcinoma (HCC) successfully treated with a novel combination therapy of percutaneous ethanol-lipiodol injection (PELI) and intervention radiology (IVR), lipiodol-targetting IVR (Lipi-IVR). The present case had a hypovascular HCC (3 cm in diameter) located in the S6 region of the liver. Although the tumor was not detectable at all by both of early and late phase of helical dynamic computed tomography (CT), it could be detected by ultrasonography (US) as a low echoic space occupying lesion (SOL) beside the gallbladder and right kidney. Serum levels of alpha fetoprotein (AFP) and AFP-L3 were extremely high. Combination therapy of PELI, firstly reported in our department, and IVR (PELI and IVR, lipiodol-targetting IVR) was performed twice for the treatment. PELI could effectively visualize the location of the tumor for IVR treatment and show the presence of a thin blood vessel branching from the right hepatic artery flowing into the lipiodol deposit. After treatment, the serum levels of AFP and AFP-L3 were rapidly decreased to normal and maintained for more than eight months. Thus, this case expressing the tremendous effect might give us insight into the effectiveness of the novel combination therapy of PELI and IVR for the treatment of hypovascular HCC.

Bipolar Radiofrequency Ablation Using Internally Cooled Electrodes in Ex Vivo Bovine Liver

OBJECTIVE

We sought to evaluate the relationship between parameters of bipolar radiofrequency (RF) ablation using internally cooled electrodes.

MATERIALS AND METHODS

Bipolar RF ablations (n = 24) were performed in ex vivo bovine liver using an internally cooled applicator with 2 electrodes located on the same shaft. The power-output was systematically varied (20-75 W). On the basis of our experimental data, mathematical functions were fitted and the goodness-of-fit was assessed by the parameter R.

RESULTS

The duration to induce an increase of tissue resistance and the amount of applied energy increased with a decreased power-output. The maximum short-axis was 4.5 cm (20 W) and required an application of 64 kilojoules (kJ). The volume of coagulation can be determined as a function of the duration of energy application (R = 0.954) and the amount of applied energy (R = 0.945).

CONCLUSION

The amount of applied energy and the duration of energy application can predict the volume of induced coagulation and may be useful to control internally cooled bipolar RF ablation.

Combined ethanol injection therapy and radiofrequency ablation therapy in percutaneous treatment of hepatocellular carcinoma larger than 4 cm

BACKGROUND

Optimal treatment of large-sized hepatocellular carcinoma (HCC) is still debated, because percutaneous ablation therapies alone do not always achieve complete necrosis.

OBJECTIVE

To report our experience in the treatment of patients with HCC larger than 4 cm in diameter by combined percutaneous ethanol injection and radiofrequency thermal ablation.

METHODS

In a 5-year period there were 40 consecutive patients meeting the inclusion criteria (24 men and 16 women; age range 41-72 years, mean 58 years). These subjects had a single HCC larger than 4 cm. Twelve subjects also had one or two additional nodules smaller than 4 cm (mean 1.2 nodules per patient). Patients were submitted to one to three sessions consisting of ethanol injection at two opposite tumor poles (mean 12 ml) and then of radiofrequency application through one or two electrodes placed at the tumor center (mean treatment duration 30 min).

RESULTS

Complete necrosis was obtained in all cases with one to three sessions (mean 1.3 sessions per patient). All patients experienced pain and fever but one only subject had a major complication requiring treatment (abscess development and fistulization). Overall follow-up was 7-69 months. Two patients showed local recurrence and 9 developed new etherotopic HCC nodules. Seven subjects died during follow-up while 33 were free from recurrence 8-69 months after treatment.

CONCLUSION

A combination of ethanol injection and radiofrequency ablation is effective in the treatment of large HCC.

Combination of repeated single-session percutaneous ethanol injection and transarterial chemoembolisation compared to repeated single-session percutaneous ethanol injection in patients with non-resectable hepatocellular carcinoma

AIM: To evaluate the treatment effect of percutaneous ethanol injection (PEI) for patients with advanced, non-resectable HCC compared with combination of transarterial chemoembolisation (TACE) and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care.

METHODS: All patients who received PEI treatment during the study period were included and stratified to one of the following treatment modalities according to physical status and tumor extent: combination of TACE and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care. Prognostic value of clinical parameters including Okuda-classification, presence of portal vein thrombosis, presence of ascites, number of tumors, maximum tumor diameter, and serum cholinesterase (CHE), as well as Child-Pugh stage, α-fetoprotein (AFP), fever, incidence of complications were assessed and compared between the groups. Survival was determined using Kaplan-Meier and multivariate regression analyses.

RESULTS: The 1- and 3-year survival of all patients was 73% and 47%. In the subgroup analyses, the combination of TACE and PEI (1) was associated with a longer survival (1-, 3-, 5-year survival: 90%, 52%, and 43%) compared to PEI treatment alone (2) (1-, 3-, 5-year survival: 65%, 50%, and 37%). Secondary PEI after initial stratification to TACE (3) yielded comparable results (1-, 3-, 5-year survival: 91%, 40%, and 30%) while PEI after stratification to best supportive care (4) was associated with decreased survival (1-, 3-, 5-year survival: 50%, 23%, 12%). Apart from the chosen treatment modalities, predictors for better survival were tumor number (n < 5), tumor size (< 5 cm), no ascites before PEI, and stable serum cholinesterase after PEI (P < 0.05). The mortality within 2 wk after PEI was 2.8% (n = 3). There were 24 (8.9%) major complications after PEI including segmental liver infarction, focal liver necrosis, and liver abscess. All complications could be managed non-surgically.

CONCLUSION: Repeated single-session PEI is effective in patients with advanced HCC at an acceptable and manageable complication rate. Patients stratified to a combination of TACE and PEI can expect longer survival than those stratified to repeated PEI alone. Furthermore, patients with large or multiple tumors in good clinical status may also profit from a combination of TACE and reconsideration for secondary PEI.

Effects of Vascular Perfusion on Coagulation Size in Radiofrequency Ablation of Ex Vivo Perfused Bovine Livers

OBJECTIVES

A standardized perfused ex vivo bovine liver model was used to evaluate the effect of organ perfusion on coagulation size and energy deposition during radiofrequency ablation (RFA) procedures.

MATERIALS AND METHODS

Bovine livers were perfused in a tank after rinsing the prepared liver vessels with anticoagulants. Tyrode's solution, oxygenated and heated to 36.5 degrees C, was used as perfusion medium. A flow and pressure controlled pump regulated Portal vein circulation; a dialysis machine provided pulsatile arterial circulation. Impedance-guided radiofrequency ablations were performed with 4-cm LeVeen electrodes with and without underlying liver perfusion. Two-dimensional diameters (Dv, Dh) of each ablation area were measured after dissecting the livers.

RESULTS

In 4 bovine livers weighing 8.85 +/- 0.83 kg per organ (min, 7.7 kg; max, 9.7 kg) altogether 40 RF ablations were performed. A total of 20 ablations were generated with underlying liver perfusion (group 1) and 20 ablations with no liver perfusion (group 2). In group 1, Dv was 28.4 +/- 5.3 mm, Dh 38.6 +/- 7.8 mm, and energy deposition 36.9 +/- 18.0 kJ. The 20 ablation areas generated without liver perfusion displayed statistically significant differences, with Dv being 35.7 +/- 6.5 mm (P = 0.001), Dh 49.5 +/- 9.4 mm (P = 0.001), and energy deposition 25.5 +/- 13.0 kJ (P = 0.018).

CONCLUSION

The model reproduced the cooling effect of perfused tissue during RFA. The ablation areas produced under perfusion conditions had smaller diameters despite longer exposure times and higher energy deposition.

Successful treatment of advanced hepatocellular carcinoma by combined administration of 5-fluorouracil and pegylated interferon-α

We report a case of hepatocellular carcinoma (HCC) treated successfully by transarterial chemoembolization (TACE) followed by combination therapy of 5-fluorouracil (5-FU) and pegylated interferon-α (PEG-IFN-α). In the present case, the patient had massive and advanced HCC with a diameter of over 8 cm located in segment 7 (S7) of the liver. Furthermore, the tumor invaded into the major branch of the portal vein (Vp3). After TACE, combined administration of 5-FU and PEG-IFN-α was performed for 5 mo. HCC was totally eradicated and the serum levels of tumor markers were markedly decreased by the treatment. Although it has been reported that the combined use of conventional IFN-α and 5-FU showed striking effects on HCC in some cases, this case may suggest the more promising effect of PEG-IFN-α with a long-lasting effect, in the combined use with 5-FU for the treatment of massive advanced HCC.