Current status of radiofrequency ablation of hepatocellular carcinoma

Proton beam radiotherapy versus transarterial chemoembolization for hepatocellular carcinoma: Results of a randomized clinical trial

BACKGROUND

This study compares survival rates, recurrence patterns, toxicity, and treatment cost in patients with hepatocellular carcinoma (HCC) treated with either transarterial chemoembolization (TACE) or proton beam radiotherapy (PBT).

METHODS

Subjects with untreated HCC meeting Milan or San Francisco transplant criteria were recruited. Subjects were randomized to receive PBT (n = 36) or TACE (n = 40). Proton therapy was administered in 15 fractions over 3 weeks to a total dose of 70.2 Gy. TACE was repeated until complete or maximal response. The primary outcome measure was overall survival (OS). Secondary end points were progression-free survival (PFS), local control (LC), toxicity, and cost.

RESULTS

Of the 76 randomized patients, 74 were assessed for outcome measures. The 2-year OS for PBT versus TACE was similar at 68%, 95% confidence interval (CI), 0.54-0.86, and 65%, 95% CI, 0.52-0.83 (p = .80), however, median PFS was improved for PBT versus TACE (not reached vs. 12 months, p = .002). LC was improved with PBT versus TACE (hazard ratio, 5.64; 95% CI, 1.78-17.9, p = .003). Days of posttreatment hospitalization were 24 for PBT and 166 for TACE (p < .001). Total mean cost per patient for treatment and posttreatment care revealed a 28% cost savings for PBT.

CONCLUSIONS

PBT and TACE yielded similar OS for treatment of HCC, but PFS and LC were improved with PBT compared to TACE. Patients treated with PBT required fewer courses of treatment, fewer posttreatment hospitalization days, and reduced cost of treatment compared to TACE. These data support the use of PBT as a viable treatment alternative to TACE for patients with HCC within transplant criteria.

One-Step Method in Creation of Artificial Ascites

Background

The study aims to improve the success rate and the rapidity in creating artificial ascites before starting the treatment for subcapsular hepatocellular carcinomas.

Methods

Two hundred and forty-six consecutive hepatocellular carcinoma patients who required the instillation of artificial ascites for better visualization or prevention from organ injury were recruited between November 2011 and September 2017. Initially, 95 patients were using the Seldinger technique, while the remaining 151 patients were using the one-step method. The proportions of patients who had undergone surgery, transarterial chemoembolization, or radiofrequency ablation therapy before performing artificial ascites infusion were 11.6% (11/95), 3% (3/95), and 37% (35/95) in the Seldinger group, and 15.9% (24/151), 15.2% (23/151), and 52.3% (79/151), respectively, in the one-step group.

Results

The complete success rate, partial success rate, and failure rate in creating artificial ascites using the Seldinger technique and the one-step method were 76.8% (73/95), 11.6% (11/95), 11.6% (11/95) and 88.1% (133/151), 7.9% (12/151), 4% (6/151), respectively. The complete success rate was significantly higher in the one-step method group (P < 0.05) than that of the Seldinger group. The mean time required from starting the procedure to successful intraperitoneal instillation of glucose water was 145.79 ± 133.37 s in the one-step method, which was statistically shorter than that of 238.68 ± 95.58 s in the Seldinger group (P < 0.05).

Conclusion

The one-step method has a higher success rate than the Seldinger method in creating artificial ascites and is faster, especially in treatment-experienced patients.

Effectiveness of combined therapy radiofrequency ablation/transarterial chemoembolization versus transarterial chemoembolization/radiofrequency ablation on management of hepatocellular carcinoma

BACKGROUND

One of the most widespread cancer-associated death worldwide is Hepatocellular carcinoma. Concerning hepatic malignant tumor staging system known as Barcelona clinic of liver cancer, a superior curative response could be carried out by combined techniques [radiofrequency ablation (RFA) and transarterial chemoembolization (TACE)] for stage B comparing with TACE alone as palliative monotherapy.

OBJECTIVES

To discuss the merging effect of RFA followed by TACE and vice versa on objective response, overall survival, local recurrence and tumor-free survival.

PATIENTS AND METHODS

Sixty-eight cases included with hepatic tumor on top of chronic liver disease post-viral infection and divided into two groups according to different combined treatment modality; first cohort included 34 patients treated with TACE followed by RFA, while the second one included 34 patients treated with RFA followed by TACE for two lesions or single medium-sized lesion stage.

RESULTS

Complete response and objective response rates were 91% and 82% after TACE/RFA and 100% and 91% after RFA/TACE, respectively. Regarding Milan criteria, there was significant downstaging after RFA/TACE (P < 0.05). First and second overall survival rates were 85% and 65% after TACE/RFA versus 100% and 74%, respectively, after RFA/TACE (P > 0.05). Kaplan-Meier curve as regards disease-free survival rate, median time were 17.1 months [95% confidence interval (CI) 12.2-22.0] in TACE/RFA and 23.2 (95% CI 18.1-28.2) months in RFA/TACE (P > 0.05).

CONCLUSION

RFA/TACE showed effective complete response, downstaging, disease-free survival and overall survival for the treatment of hepatic malignant tumors.

The Optimal Management for Sub-Centimeter Hepatocellular Carcinoma: Curative Treatments or Follow-Up?

Background

The optimal strategy for dealing with sub-centimeter hepatic nodules has not yet been established. This study aimed to assess whether there was a need to provide curative treatments for sub-centimeter hepatocellular carcinomas (HCCs) to patients at risk for high false positives.

Material/Methods

We identified patients with primary pathologically diagnosed HCC ≤2 cm from 2004 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database. They were divided according to the interventions they received: local ablation, surgical resection, or liver transplantation. In each group, overall survival and cancer-specific survival were used as endpoints to compare the prognoses between patients with sub-centimeter HCC and patients with HCC measuring 1 to 2 cm by Kaplan-Meier. Propensity score matching was performed to reduce bias. We also compared the survival of patients with a primary solitary HCC based on interventions, in the different tumor size groups. Bootstrapping was performed to validate the findings.

Results

Overall, 10.4% of patients (197 out of 1894) had HCCs <1 cm, and 89.6% of patients (1697 out of 1894) had HCCs in the 1 to 2 cm range. There was no significant difference in overall and cancer-specific survival between patients with HCCs <1 cm and those with HCCs in the 1 to 2 cm range, in all treatment groups. After adjusting confounding factors, no significant correlation was found between tumor size and survival time. In patients with HCCs measuring ≤2 cm, overall survival and cancer-specific survival were superior in liver transplantation compared with surgical resection and local ablation. Surgical resection provided better survival than local ablation.

Conclusions

Compared to patients with HCCs measuring 1 to 2 cm, the survival rates of patients with sub-centimeter HCCs was not improved through curative treatments, risking high false positives.

Improved therapeutic outcomes of thermal ablation on rat orthotopic liver allograft sarcoma models by radioiodinated hypericin induced necrosis targeted radiotherapy

Residual tumor resulting in tumor recurrence after various anticancer therapies is an unmet challenge in current clinical oncology. This study aimed to investigate the hypothesis that radioiodinated hypericin (131I-Hyp) may inhibit residual tumor recurrence after microwave ablation (MWA) on rat orthotopic liver allograft sarcoma models.Thirty Sprague-Dawley (SD) rats with hepatic tumors were divided into three groups: Group A received laparotomy MWA and sequential intravenous injection (i.v.) of 131I labelled hypericin (131I-Hyp) in a time interval of 24 h; Group B received only laparotomy MWA; Group C was a blank control. Tumor inhibitory effects were monitored with in vivo magnetic resonance imaging (MRI) and these findings were compared to histopathology data before (baseline, day 0) and 1, 4, and 8 days after MWA. In addition, biodistribution of 131I-Hyp was assessed with in vivo single-photon emission computed tomography-computed tomography (SPECT-CT) imaging, in vitro autoradiography, fluorescent microscopy, and gamma counting.A fast clearance of 131I-Hyp and increasing deposit in necrotic tumors appeared over time, with a significantly higher radioactivity than other organs (0.9169 ± 1.1138 % ID/g, P < 0.01) on day 9. Tumor growth was significantly slowed down in group A compared to group B and C according to MRI images and corresponding tumor doubling time (12.13 ± 1.99, 4.09 ± 0.97, 3.36 ± 0.72 days respectively). The crescent tagerability of 131I-Hyp to necrosis was visualized consistently by autoradiography and fluorescence microscopy.In conclusion, 131I-Hyp induced necrosis targeted radiotherapy improved therapeutic outcomes of MWA on rat orthotopic liver allograft sarcoma models.

Comparison of repeated surgical resection and radiofrequency ablation for small recurrent hepatocellular carcinoma after primary resection

There is controversy concerning whether radiofrequency ablation (RFA) or surgical resection (SR) is a better treatment option for recurrent HCC after resection. In Kaohsiung Veteran General Hospital, from January 2002 to September 2014, a total of 100 consecutive patients who developed recurrent HCCs with a tumor size ≦ 3 cm and tumor numbers ≦ 3 after surgical resection were enrolled. Among these patients, 57 patients received RFA and 43 patients underwent repeated SR. Baseline characteristics at the time of recurrence after hepatic resection and clinical outcomes following treatment of recurrent HCC were compared between the two groups. The baseline data of initial HCC and the first recurrence of HCC were comparable in both groups. The 1-, 3-, 5-year overall survival rates following treatment of the first recurrence of HCC were 97.6%, 82.7%, 56.4% in the repeated SR group and 98.2%, 77.2%, 52.6% in the RFA group (p = 0.69). The 1-, 3-, 5-year disease-free survival rates were 57.0%, 32.1%, 28.6% in the repeated SR group and 60.8%, 26.6%, 16.6% in the RFA group ((p = 0.89). There was a trend whereby patients who underwent repeated SR had more procedure-related morbidity than patients who underwent RFA (16% vs. 7%, p = 0.14). The median total hospital days were longer in the repeated SR group than that in the RFA group (13 vs. 5 days, p < 0.05). In the small recurrent HCCs after SR, RFA achieved similar overall survival and disease-free survival than those with repeated SR as well as having a shorter hospital stay.

Effect of treatment support on preventing local recurrence of hepatocellular carcinoma directly adjacent to the diaphragm

Treatment support is anticipated to improve the results of radiofrequency ablation (RFA) treatment in cases in which visualization of tumors using the conventional B-mode is unclear. In the present study, the effectiveness of treatment support for RFA reducing the local recurrence rate of hepatocellular carcinoma (HCC) that are located directly adjacent to the diaphragm, and which are difficult to visualize with B-mode ultrasound imaging, was investigated. A total of 103 HCC tumors measuring <5 cm, which were located abutting the diaphragm, and which were difficult to visualize using the B-mode, were treated using RFA. Thirty-three of those HCC tumors were treated using RFA without treatment support, whereas the remaining 70 HCC tumors were treated using RFA with treatment support, including artificial pleural effusion, contrast-enhanced ultrasonography (CEUS) with the contrasting agent, Sonazoid™, and fusion imaging, either alone or in combination to improve the visualization of the tumors. The rate of local recurrence, and factors affecting local recurrence, were analyzed. Local recurrences were confirmed in 17 of the 103 nodules (16.50%). The overall rate of local recurrence was 13.1% at 6 months, and 20.2% at 12 months. The rate of local recurrence using RFA with artificial pleural effusion was significantly lower compared with those cases of HCC tumors treated without artificial pleural effusion (P=0.008). Similarly, the rate of local recurrence for CEUS RFA with Sonazoid™ was significantly lower compared with those cases of HCC tumors treated without Sonazoid™ (P=0.00081). In a multivariate analysis, CEUS RFA with Sonazoid™ and artificial pleural effusion contributed to the decrease in the rate of local recurrence (hazard ratios, 0.075 and 0.143, respectively). Based on these results, it is possible to conclude that CEUS with Sonazoid™ as a treatment support was the most effective method for reducing the rate of local recurrences abutting the diaphragm that are difficult to visualize using B-mode ultrasonography.

Hepatic Resection Improved the Long-Term Survival of Patients with BCLC Stage B Hepatocellular Carcinoma in Asia: a Systematic Review and Meta-Analysis

OBJECTIVE

Hepatic resection has been increasingly performed in patients with Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC), but the current evidence supporting its efficacy remains controversial. The aim of this systematic review was to investigate the long-term survival and safety of hepatic resection compared to transarterial chemoembolization (TACE) alone for BCLC stage B HCC.

METHODS

Eligible trials that compared hepatic resection with TACE alone for intermediate HCC were identified from the Embase, PubMed, Web of Science, and Cochrane databases. The study outcomes included overall survival (OS) rate and treatment-related complication rate. Hazard ratios (HRs) with a 95% confidence interval were used to measure the pooled effect according to a random-effects or fixed-effects model, depending on the heterogeneity among the included studies. The heterogeneity among these trials statistically was evaluated using the χ(2) and I (2) tests. Sensitivity analyses were also performed.

RESULTS

A total of 9 studies containing 4958 patients were included. The comparison between hepatic resection and TACE revealed a pooled HR for 3-year OS of 0.403 (95% CI 0.364-0.446, p = 0.000; I (2) = 0 %, p = 0.643) and a pooled HR for 5-year OS of 0.433 (95% CI 0.394-0.475, p = 0.000; I (2) = 0%, p = 0.468). An AFP level >400 ng/ml and being HBV-positive were factors significantly correlated with overall survival. For treatment-related complications, the overall odds ratio (OR) for hepatic resection versus TACE was 0.990 (95% CI 0.934-1.049; p = 0.728; I (2) = 64.5%, p = 0.060).

CONCLUSION

Hepatic resection likely improved overall survival compared with TACE alone in BCLC stage B HCC patients, but did not increase the incidence of treatment-related complications. An AFP level >400 ng/ml and HBV positivity were significantly correlated with poor OS.

Hep88 mAb-initiated paraptosis-like PCD pathway in hepatocellular carcinoma cell line through the binding of mortalin (HSPA9) and alpha-enolase

Background

Hepatocellular carcinoma (HCC) is the most prevalent hepatic cancer worldwide. Currently, a targeted therapy via monoclonal antibodies (mAbs) specific to tumor-associated antigen is undergoing continual development in HCC treatment.

Methods

In this regard, after establishing and consequently exploring Hep88 mAb’s tumoricidal effect on hepatocellular carcinoma cell line (HepG2 cell line), the Hep88 mAb’s specific antigens from both membrane and cytoplasmic fractions of HepG2 cell line were identified by 2-D gel electrophoresis and western blot analysis. After in-gel digestion and subsequent analysis by liquid chromatography-mass spectrometry (LC-MS), mortalin (HSPA9) and alpha-enolase were identified. The recombinant proteins specific to Hep88 mAb were cloned and expressed in E. coli BL21(DE3). Moreover, alteration of HepG2 and Chang liver cell line after being induced by Hep88 mAb for 1–3 days was investigated using a transmission electron microscope.

Results

The result demonstrated that Hep88 mAb can bind to the recombinant mortalin (HSPA9) and alpha-enolase. In addition, the gradual appearing of mitochondria vacuolization and endoplasmic reticulum dilatation were observed. Those characteristics might be explained by the paraptosis-like program cell death (PCD), which is induced by the binding of Hep88 mAb to mortalin (HSPA9). Mortalin depletion resulting from the formation of Hep88 mAb-mortalin (HSPA9) complex might initiate transcription-independence of p53-mediated apoptosis. Additionally, Hep88mAb-alpha-enolase complex might initiate HepG2 cells energy exhaustion by glycolysis pathway obstruction.

Conclusion

These fascinating results imply that Hep88 mAb might be a promising tool for the development of an effective treatment of HCC in the next decade.

Efficacy and safety of percutaneous radiofrequency ablation versus surgical resection for small hepatocellular carcinoma: a meta-analysis of 23 studies

PURPOSE

The aim of our meta-analysis was to compare the efficacy and safety of radiofrequency ablation (RFA) versus surgical resection for patients with small hepatocellular carcinoma (SHCC).

METHODS

Randomized controlled trials (RCTs) or retrospective studies comparing the RFA with surgical resection for patients with SHCC published from 2004 to 2014 were selected from database of PubMed, EMBASE and Cochrane library. The outcomes including overall survival rate, recurrence-free survival rate, recurrence rate and complications (mortality rate and morbidity rate) were abstracted. Individual and pooled odds ratio with 95% confidence interval of each outcome was analyzed.

RESULTS

Three RCTs and twenty retrospective studies were included with a total of 15,482 patients. The 1-, 3- and 5-year overall survival rate and recurrence-free survival rate of surgical resection were significantly higher than RFA. The 2- and 3-year but not 1-year recurrence rate of RFA was significantly higher than surgical resection. The morbidity rate of complication in surgical resection group was higher than it in RFA group, but the mortality was not different between the two groups.

CONCLUSION

Surgical resection led to a higher overall survival and recurrence-free survival rate in treating SHCC. However, RFA led to a lower morbidity rate of complication than surgical resection.

Percutaneous radiofrequency ablation versus surgical radiofrequency ablation for malignant liver tumours: the long-term results

BACKGROUND

Radiofrequency ablation (RFA) has been used to treat hepatocellular carcinoma (HCC) and liver metastases for more than 10 years with promising early outcomes. Preliminary results comparing percutaneous and surgical approaches have shown no difference in short-term outcomes. In this study, the longer-term outcomes were presented.

METHODS

Patients with liver malignancies treated by RFA were prospectively studied from 2003 to 2011. Post-ablation assessment by computed tomography (CT) scan and serum biochemistry was performed at regular intervals. Recurrence rates and long-term survival were analysed.

RESULTS

A total of 233 patients with liver malignancies (75.5% HCC and 24.5% liver metastases) were analysed. Three RFA approaches were used (percutaneous 58.4%, laparoscopic 9.4% and open 32.2%). The median follow-up time was 29 months. Complete ablation was achieved in 83.7%, with no difference between the two approaches. More wound and chest complications were observed in the surgical group. Intra-hepatic recurrences were observed in 69.5%; extra-hepatic recurrences were detected in 22.3%, with no difference between the two groups. There was no statistical difference between the two approaches in overall 1-, 3- and 5-year survival.

CONCLUSION

An extended period of follow-up in patients with liver malignancies showed that RFA is an effective treatment. No difference was demonstrated between the percutaneous and surgical approach, in terms of recurrence and survival.

Comparison of long-term survival of patients with BCLC stage B hepatocellular carcinoma after liver resection or transarterial chemoembolization

BACKGROUND AND AIMS

Treatment of patients with Barcelona Clinic Liver Cancer Stage B hepatocellular carcinoma (BCLC-B HCC) is controversial. This study compared the long-term survival of patients with BCLC-B HCC who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

A total of 257 and 135 BCLC-B HCC patients undergoing LR and TACE, respectively, were retrospectively evaluated. Kaplan-Meier method was used for long-term survival analysis. Independent prognostic predictors were determined by the Cox proportional hazards model.

RESULTS

The hospital mortality rate was similar between groups (3.1% vs. 3.7%; P = 0.76). However, the LR group showed a significantly higher postoperative complication rate than the TACE group (28 vs. 18.5%; P = 0.04). At the same time, the LR group showed significantly higher overall survival rates (1 year, 84 vs. 69%; 3 years, 59 vs. 29%; 5 years, 37 vs. 14%; P<0.001). Moreover, similar results were observed in the propensity score model. Three independent prognostic factors were associated with worse overall survival: serum AFP level (≥400 ng/ml), serum ALT level, and TACE.

CONCLUSIONS

LR appears to be as safe as TACE for patients with BCLC-B HCC, and it provides better long-term overall survival. However, prospective studies are needed to disclose if LR may be regarded as the preferred treatment for these patients as long as liver function is preserved.

Comparison of long-term survival of patients with BCLC stage B hepatocellular carcinoma after liver resection or transarterial chemoembolization

BACKGROUND AND AIMS

Treatment of patients with Barcelona Clinic Liver Cancer Stage B hepatocellular carcinoma (BCLC-B HCC) is controversial. This study compared the long-term survival of patients with BCLC-B HCC who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

A total of 257 and 135 BCLC-B HCC patients undergoing LR and TACE, respectively, were retrospectively evaluated. Kaplan-Meier method was used for long-term survival analysis. Independent prognostic predictors were determined by the Cox proportional hazards model.

RESULTS

The hospital mortality rate was similar between groups (3.1% vs. 3.7%; P = 0.76). However, the LR group showed a significantly higher postoperative complication rate than the TACE group (28 vs. 18.5%; P = 0.04). At the same time, the LR group showed significantly higher overall survival rates (1 year, 84 vs. 69%; 3 years, 59 vs. 29%; 5 years, 37 vs. 14%; P<0.001). Moreover, similar results were observed in the propensity score model. Three independent prognostic factors were associated with worse overall survival: serum AFP level (≥400 ng/ml), serum ALT level, and TACE.

CONCLUSIONS

LR appears to be as safe as TACE for patients with BCLC-B HCC, and it provides better long-term overall survival. However, prospective studies are needed to disclose if LR may be regarded as the preferred treatment for these patients as long as liver function is preserved.

Radiofrequency ablation during continuous saline infusion can extend ablation margins

AIM: To determine whether fluid injection during radiofrequency ablation (RFA) can increase the coagulation area.

METHODS: Bovine liver (1-2 kg) was placed on an aluminum tray with a return electrode affixed to the base, and the liver was punctured by an expandable electrode. During RFA, 5% glucose; 50% glucose; or saline fluid was infused continuously at a rate of 1.0 mL/min through the infusion line connected to the infusion port. The area and volume of the thermocoagulated region of bovine liver were determined after RFA. The Joule heat generated was determined from the temporal change in output during the RFA experiment.

RESULTS: No liquid infusion was 17.3 ± 1.6 mL, similar to the volume of a 3-cm diameter sphere (14.1 mL). Mean thermocoagulated volume was significantly larger with continuous infusion of saline (29.3 ± 3.3 mL) than with 5% glucose (21.4 ± 2.2 mL), 50% glucose (16.5 ± 0.9 mL) or no liquid infusion (17.3 ± 1.6 mL). The ablated volume for RFA with saline was approximately 1.7-times greater than for RFA with no liquid infusion, representing a significant difference between these two conditions. Total Joule heat generated during RFA was highest with saline, and lowest with 50% glucose.

CONCLUSION: RFA with continuous saline infusion achieves a large ablation zone, and may help inhibit local recurrence by obtaining sufficient ablation margins. RFA during continuous saline infusion can extend ablation margins, and may be prevent local recurrence.

Small hepatocellular carcinomas and thrombocytopenia

BACKGROUND

Clinical phenotypes of small and large hepatocellular carcinomas (HCCs) are not well characterized.

AIM

To evaluate the characteristics of small HCCs diagnosed by screening.

METHOD

A cohort of 430 small HCCs that were diagnosed through screening, were dichotomized according to a size of ≤ 3 cm or >3 cm maximum tumor diameter and compared for radiological and blood-test parameters.

RESULTS

There were 330 males and 100 females. A higher percent of females had smaller tumors. The majority of patients had single tumors, but 15% of those with larger tumors had portal vein thrombosis (PVT) compared to 5% of those with smaller tumors. Significant differences between the tumor-size groups included alpha-fetoprotein (AFP) values and platelet counts, with thrombocytopenia and elevated bilirubin levels being associated with smaller tumors. In comparing PVT-positive and PVT-negative patients, AFP levels and platelet counts were also significantly different between the 2 groups. A mean multinomial multiple logistic regression model was developed for maximum tumor diameter plus PVT.

CONCLUSIONS

The finding of larger tumors being associated with normal platelets and bilirubin levels in comparison to smaller tumors having thrombocytopenia reveals 2 different patterns of HCC presentation.

Ki-67 is a prognostic biomarker of survival after radiofrequency ablation of liver malignancies

PURPOSE

To assess the predictive value of examinations of tissue adherent to multitined electrodes on local tumor progression-free survival (LPFS) and overall survival (OS) after liver tumor radiofrequency ablation (RFA).

METHODS

An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant review identified 68 liver tumors treated with RFA in 63 patients with at least 3 years' follow-up. Tissue adherent to the electrode after liver tumor RFA was evaluated with proliferation (Ki-67) and apoptotic (caspase-3) markers. LPFS and OS were evaluated by Kaplan-Meier methodology and the log-rank test. Multivariate analysis assessed the effect of tumor size, pathology, and post-RFA tissue characteristics on LPFS and OS.

RESULTS

Post-RFA tissue examination classified 55 of the 68 tumors as completely ablated with coagulation necrosis, with cells positive for caspase-3 and negative for Ki-67 (CN). Thirteen had viable Ki-67-positive tumor cells. Mean liver tumor size was larger in the viable (V) group versus the CN group (3.4 vs. 2.5 cm, respectively; P = .017). For the V and CN groups, respectively, local tumor progression occurred in 12 (92 %) of 13 and 23 (42 %) of 55 specimens. One, 3-, and 5-year LPFS was 8 %, 8 %, and 8 %, and 79 %, 47 %, and 47 % (P < .001) for the V and CN groups, respectively. During a 63-month median follow-up, 92 % of patients in the V group and 58 % in the CN group died, resulting in 1-, 3-, and 5-year OS of 92 %, 25 %, and 8 % vs. 92 %, 59 %, and 33 % (P = .032), respectively.

CONCLUSIONS

Ki-67-positive tumor cells on the electrode after liver tumor RFA is an independent predictor of LPFS and OS. Size, initially thought to be an independent risk factor for local tumor progression in tumors 3-5 cm, does not hold its significance at long follow-up.

Multidisciplinary management of hepatocellular carcinoma

Hepatocellular carcinoma is a leading cause of death in patients with cirrhosis. Management algorithms continually are increasing in sophistication and involve application of single and multimodality treatments, including liver transplantation, hepatic resection, ablation, transarterial chemoembolization, radioembolization, and systemic chemotherapy. These treatments have been shown to increase survival times. As many as 75% of patients with limited-stage disease who are given curative therapies survive 5 years, whereas less than 20% of untreated patients survive 1 year. Treatment can be optimized based on the patient's tumor stage, hepatic reserve, and functional status. However, because of the heterogeneity in presentation among patients, a multidisciplinary approach is required to treat hepatocellular carcinoma, involving hepatologists, surgeons, interventional radiologists, and oncologists. We present each specialist's viewpoint on controversies and advances in the management of hepatocellular carcinoma.

Lyso-thermosensitive liposomal doxorubicin: an adjuvant to increase the cure rate of radiofrequency ablation in liver cancer

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer death worldwide. No more than 30% of HCC patients are considered suitable for curative treatment because of tumor size and severity of liver impairment, among other factors. Radiofrequency ablation (RFA) monotherapy can cure small (<3 cm) HCC tumors. An adjuvant that interacts synergistically with RFA might enable curative therapy for many HCC patients with lesions >3 cm. Lyso-thermosensitive liposomal doxorubicin (LTLD) consists of the heat-enhanced cytotoxic doxorubicin within a heat-activated liposome. LTLD is infused intravenously prior to RFA. When heated to >39.5°C, LTLD releases doxorubicin in high concentrations into the tumor and the tumor margins. The RFA plus LTLD combination has shown a statistically significant dose-response effect for time to treatment failure in a Phase I trial in which most subjects (62.5%) had tumors >3 cm. RFA plus LTLD is currently being evaluated in a 600-patient randomized, double-blind, dummy-controlled trial.