We compared surgical resection (SR) and radiofrequency ablation (RFA) as first-line treatment in patients with hepatocellular carcinoma (HCC) based on the risk of microvascular invasion (MVI).
The ...best curative treatment modality between SR and RFA in patients with HCC with MVI remains unclear.
Data from 2 academic cancer center-based cohorts of patients with a single, small (≤3 cm) HCC who underwent SR were used to derive (n = 276) and validate (n = 101) prediction models for MVI using clinical and imaging variables. The MVI prediction model was developed using multivariable logistic regression analysis and externally validated. Early recurrence (<2 years) based on risk stratification between SR (n = 276) and RFA (n = 240) was evaluated via propensity score matching.
In the multivariable analysis, alpha-fetoprotein (≥15 ng/mL), protein induced by vitamin K absence-II (≥48 mAU/mL), arterial peritumoral enhancement, and hepatobiliary peritumoral hypointensity on magnetic resonance imaging were associated with MVI. Incorporating these factors, the area under the receiver operating characteristic curve of the predictive model was 0.87 (95% confidence interval: 0.82-0.92) and 0.82 (95% confidence interval: 0.74-0.90) in the derivation and validation cohorts, respectively. SR was associated with a lower rate of early recurrence than RFA based on the risk of MVI after propensity score matching (P < 0.05).
Our model predicted the risk of MVI in patients with a small (≤ 3 cm) HCC with high accuracy. Patients with MVI who had undergone RFA were more vulnerable to recurrence than those who had undergone SR.
Objectives
The purpose of this study was to evaluate the 10-year overall survival and local tumor progression (LTP) of percutaneous radiofrequency ablation (RFA) for single nodular hepatocellular ...carcinoma (HCC) < 3 cm using a large longitudinal hospital registry and clinical factors associated with overall survival and LTP.
Methods
A total of 467 newly diagnosed patients with single nodular HCC < 3 cm who underwent RFA as first-line therapy between January 2008 to December 2016 were analyzed. Overall survival and LTP were estimated using the Kaplan-Meier method. Cox regression and competing risks Cox regression analysis were performed to identify prognostic factors for overall survival and LTP, respectively.
Results
The 5- and 10-year overall survival rates after RFA were 83.7% and 74.2%, respectively. LTP (hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.19–3.47) was one of the important factors for overall survival after RFA. The 5- and 10-year LTP rates after RFA were 20.4% and 25.1%, respectively. Periportal location (subdistribution HR, 2.29; 95% CI, 1.25–4.21), subphrenic location (2.25, 1.34–3.86), size ≥ 1.5–< 2.0 cm (1.88, 1.05–3.39), and size ≥ 2.0 cm (2.10, 1.14–3.86) were independent factors for LTP.
Conclusion
Ten-year therapeutic outcomes of percutaneous RFA as first-line therapy were excellent for single HCC < 3 cm. LTP was an important prognostic factor for overall survival after RFA. Periportal and subphrenic location of HCCs and tumor size were predictors for the development of LTP after RFA.
Key Points
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Updated 10-year survival outcome of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm was higher than previously reported
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Local tumor progression was an important prognostic factor for overall survival after percutaneous radiofrequency ablation
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Periportal and subphrenic location of hepatocellular carcinomas and tumor size were predictors for the development of local tumor progression after percutaneous radiofrequency ablation
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Image-guided tumor ablation for early stage hepatocellular carcinoma (HCC) is an accepted non-surgical treatment that provides excellent local tumor control and favorable survival benefit. This ...review summarizes the recent advances in tumor ablation for HCC. Diagnostic imaging and molecular biology of HCC has recently undergone marked improvements. Second-generation ultrasonography (US) contrast agents, new computed tomography (CT) techniques, and liver-specific contrast agents for magnetic resonance imaging (MRI) have enabled the early detection of smaller and inconspicuous HCC lesions. Various imaging-guidance tools that incorporate imaging-fusion between real-time US and CT/MRI, that are now common for percutaneous tumor ablation, have increased operator confidence in the accurate targeting of technically difficult tumors. In addition to radiofrequency ablation (RFA), various therapeutic modalities including microwave ablation, irreversible electroporation, and high-intensity focused ultrasound ablation have attracted attention as alternative energy sources for effective locoregional treatment of HCC. In addition, combined treatment with RFA and chemoembolization or molecular agents may be able to overcome the limitation of advanced or large tumors. Finally, understanding of the biological mechanisms and advances in therapy associated with tumor ablation will be important for successful tumor control. All these advances in tumor ablation for HCC will result in significant improvement in the prognosis of HCC patients. In this review, we primarily focus on recent advances in molecular tumor biology, diagnosis, imaging-guidance tools, and therapeutic modalities, and refer to the current status and future perspectives for tumor ablation for HCC.
Background and Aim: Surgery is the standard treatment option for hepatocellular carcinoma (HCC) meeting the Milan criteria, defined as single HCC ≤ 5 cm in maximum diameter or up to three nodules ≤ ...3 cm. However, favorable survival outcomes have also been reported for these HCCs following radiofrequency ablation (RFA).
Methods: We performed a systematic review to compare the results of hepatic resection and percutaneous RFA as a primary treatment option of HCC meeting the Milan criteria. Studies were identified by searching MEDLINE on PubMed, the Cochrane Library database and CANCERLIT using appropriate key words.
Results: In all six identified observational studies, there were no statistically significant differences in overall survival rates between the two treatment modalities. The results of two randomized trials are controversial, while the power of these randomized trials is too limited to reach a reliable conclusion. In practice, the choice of treatment between surgery and RFA largely depends on the relationship between the local recurrence and perioperative mortality rates of HCC patients. Following RFA, local recurrence rates are low when a minimal safety margin ≥ 4–5 mm is achieved. A previous simulation study of overall survival for very early stage HCC, defined as an asymptomatic solitary small HCC ≤ 2 cm, showed that primary RFA with a 9% local recurrence rate is comparable to surgical resection with a 3% operative mortality rate.
Conclusion: Acquisition of a sufficient safety margin seems to be a critical factor before recommending wider application of RFA as primary treatment for HCCs that meet the Milan criteria.
The aim of this study was to elucidate the minimal ablative margin for percutaneous radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) (> 2 and < 5 cm) needed to prevent local tumor ...progression using CT image fusion and a 3D quantitative method.
From April 2005 to March 2007, we performed percutaneous RFA for the treatment of 382 HCCs larger than 2 cm and smaller than 5 cm. A total of 110 tumors in 103 patients (77 men and 26 women; mean age, 59.7 years) that were previously untreated and were monitored for at least 1 year were retrospectively enrolled. A 5-mm safety margin was attempted in all cases, and a CT finding of complete replacement of the index tumor by RFA zone was defined as technical success. We constructed fusion images of CT images obtained before and after RFA and performed radial multiplanar reformation with the rotation axis at the center of the tumor to analyze the ablative margin quantitatively. Risk factors for local tumor progression (the thinnest ablative margin, tumor size, and the effect of hepatic vessels) were assessed by multivariate analysis.
Patients underwent follow-up for 12.9-46.6 months (median, 28.1 months). The tumors were 2.1-4.8 cm (mean +/- SD, 2.7 +/- 0.6 cm) in diameter. The thinnest ablative margins ranged from 0 to 6 mm (1.0 +/- 1.4 mm). A 5-mm safety margin was achieved in only 2.7% (3/110) of cases. In 47.3% (52/110) of cases, vessel-induced indentation of the ablation zone contributed to the thinnest ablative margins. Local tumor progression was detected in 27.3% (30/110) of cases. Concordance between local tumor progression and the thinnest margin was observed in 83.3% (25/30) of cases. The incidence of concordant local tumor progression was 22.7% (25/110), 18.9% (10/53), 5.9% (2/34), and 0% (0/15) in tumors with the thinnest ablative margin of > or = 0, > or = 1, > or = 2, and > or = 3 mm, respectively. An insufficient ablative margin was the sole significant factor associated with local tumor progression.
When the thickness of the ablative margin is evaluated by CT image fusion, a margin of 3 mm or more appears to be associated with a lower rate of local tumor progression after percutaneous RFA of HCC.
Objectives
Previous attempts at meta-analysis and systematic review have not provided clear recommendations for the clinical application of thermal ablation in metastatic colorectal cancer. Many ...authors believe that the probability of gathering randomised controlled trial (RCT) data is low. Our aim is to provide a consensus document making recommendations on the appropriate application of thermal ablation in patients with colorectal liver metastases.
Methods
This consensus paper was discussed by an expert panel at The Interventional Oncology Sans Frontières 2013. A literature review was presented. Tumour characteristics, ablation technique and different clinical applications were considered and the level of consensus was documented.
Results
Specific recommendations are made with regard to metastasis size, number, and location and ablation technique. Mean 31 % 5-year survival post-ablation in selected patients has resulted in acceptance of this therapy for those with technically inoperable but limited liver disease and those with limited liver reserve or co-morbidities that render them inoperable.
Conclusions
In the absence of RCT data, it is our aim that this consensus document will facilitate judicious selection of the patients most likely to benefit from thermal ablation and provide a unified interventional oncological perspective for the use of this technology.
Key Points
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Best results require due consideration of tumour size, number, volume and location.
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Ablation technology, imaging guidance and intra-procedural imaging assessment must be optimised.
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Accepted applications include inoperable disease due to tumour distribution or inadequate liver reserve.
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Other current indications include concurrent co-morbidity, patient choice and the test-of-time approach.
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Future applications may include resectable disease, e.g. for small solitary tumours.
To evaluate the added value of diffusion-weighted (DW) imaging in combination with T2-weighted magnetic resonance (MR) imaging compared with T2-weighted imaging alone for predicting tumor clearance ...of the mesorectal fascia (MRF) after neoadjuvant chemotherapy and radiation therapy (CRT) in patients with locally advanced rectal cancer.
This retrospective study was approved by the institutional review board, and informed consent was waived. Forty-five patients with rectal cancer with clinically suspected MRF invasion who underwent neoadjuvant CRT and subsequent surgery were enrolled. All patients underwent pre- and post-CRT 3.0-T rectal MR imaging with DW imaging. Two observers independently reviewed a set of T2-weighted images and a combined set of T2-weighted and DW images and rated them by using a five-point scale. Diagnostic performance was evaluated for each observer with receiver operating characteristic (ROC) curve analysis. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were assessed. The standard of reference was histopathologic findings in the surgical specimen. Pairwise comparison of the ROC curves was used to compare diagnostic performance between the two image sets; the McNemar test was used to compare accuracy, sensitivity, and specificity.
The diagnostic performance (area under the ROC curve A(z)) with respect to MRF tumor clearance of both observers improved significantly after additional review of DW images: A(z) improved from 0.770 to 0.918 (P = .017) for observer 1 and from 0.847 to 0.960 (P = .026) for observer 2. The diagnostic accuracy of DW combined with T2-weighted imaging (observer 1, 89% 40 of 45; observer 2, 93% 42 of 45), sensitivity (observer 1, 94% 31 of 33; observer 2, 97% 32 of 33) and NPV (observer 1, 82% nine of 11; observer 2, 91% 10 of 11) were significantly higher than those of T2-weighted imaging alone (accuracy: observer 1, 40% 18 of 45, P < .001; observer 2, 69% 31 of 45, P = .022; sensitivity: observer 1, 21% seven of 33, P < .001; observer 2, 67% 22 of 33, P = .002; NPV: observer 1, 30% 11 of 37, P = .013; observer 2, 45% nine of 20, P = .025). Interobserver agreement of confidence levels was fair for T2-weighted imaging alone (κ = 0.212) but was excellent for the combined set of DW and T2-weighted images (κ = 0.880).
Adding DW imaging to T2-weighted imaging can improve the prediction of tumor clearance in the MRF after neoadjuvant CRT compared with T2-weighted imaging alone in patients with locally advanced rectal cancer.
To determine if the combination of gadoxetic acid-enhanced magnetic resonance (MR) imaging and diffusion-weighted (DW) imaging helps to increase accuracy and sensitivity in the diagnosis of small ...hepatocellular carcinomas (HCCs) compared with those achieved by using each MR imaging technique alone.
The institutional review board approved this retrospective study and waived the requirement for informed consent. The study included 130 patients (95 men, 35 women) with 179 surgically confirmed small HCCs (≤2.0 cm) and 130 patients with cirrhosis (90 men, 40 women) without HCC who underwent gadoxetic acid-enhanced MR imaging and DW imaging at 3.0 T between May 2009 and July 2010. Three sets of images were analyzed independently by three observers to detect HCC: a gadoxetic acid set (unenhanced, early dynamic, and hepatobiliary phases), a DW imaging set, and a combined set. Data were analyzed by using alternative-free response receiver operating characteristic analysis. Diagnostic accuracy (area under the receiver operating characteristic curve A(z)), sensitivity, specificity, and positive predictive value were calculated.
The mean A(z) values for the combined set (0.952) were significantly higher than those for the gadoxetic acid set (A(z) = 0.902) or the DW imaging set alone (A(z) = 0.871) (P ≤ .008). On a per-lesion basis, observers showed higher sensitivity in their analyses of the combined set (range, 91.1%-93.3% 163-167 of 179) than in those of the gadoxetic acid set (range, 80.5%-82.1% 144-147 of 179) or the DW imaging set alone (range, 77.7%-79.9% 139-143 of 179) (P ≤ .003). Positive predictive values and specificity for all observers were equivalent for the three imaging sets.
The combination of gadoxetic acid-enhanced MR imaging and DW imaging yielded better diagnostic accuracy and sensitivity in the detection of small HCCs than each MR imaging technique alone.
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