Thermal ablation for hepatocellular carcinoma: a large-scale analysis of long-term outcome and prognostic factors

doi:10.1016/j.crad.2016.07.002

Clinical Radiology

Volume 71, Issue 12, December 2016, Pages 1270-1276

https://doi.org/10.1016/j.crad.2016.07.002 Get rights and content

Highlights

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Investigate the long-term outcome of treating HCC with thermal ablation.
•
The prognostic factors were analyzed by univariate and multivariate analyses.
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A large-scale analysis of 10-year follow-up outcome.

Aim

To investigate the long-term outcome and prognostic factors when treating hepatocellular carcinoma (HCC) with thermal ablation.

Materials and methods

A total of 846 HCC patients, diagnosed histopathologically and/or radiologically, underwent thermal ablation from October 2001 to May 2013. Thermal ablation included both radiofrequency ablation (RFA) and microwave ablation (MWA), and was performed by percutaneous, open, and laparoscopic approaches. Clinical data, especially focused on disease-free survival, were retrospectively analysed by univariate and multivariate analyses.

Results

A total of 1,185 thermal ablation treatments were performed, corresponding to 1,240 tumours. The complete ablation rate was 97.1%. The 12-, 24-, 36-, and 60-month disease-free survival rates after thermal ablation were 72.3%, 52.7%, 33.5%, and 16.1%, respectively. Multivariate analysis indicated that the serum alkaline phosphatase levels (ALP) and the number of tumours were independent risk factors affecting disease-free survival. The 12-, 36-, 60-, 84-, and 120-month overall survival rates of all patients were 92.9%, 74.7%, 58.1%, 41.3%, and 15.8%, respectively. Multivariate analysis indicated that age, ALP, number of tumours, and treatment sessions per case were independent risk factors related to overall survival.

Conclusions

Thermal ablation was a relatively safe and effective procedure. Patients with increased serum ALP levels and/or multiple tumours had a higher incidence of recurrence and poorer prognosis, and therefore, should be monitored closely in clinical practice.

Introduction

Primary liver cancer, especially hepatocellular carcinoma (HCC), is the fifth most frequent type of malignant tumour.1, 2 HCC has a high incidence rate, with approximately 500,000–1,000,000 cases each year globally and is also the third most lethal type of cancer.1, 2 Image-guided local thermal ablation, especially radiofrequency ablation (RFA) and microwave ablation (MWA), represents the third most effective radical treatment method for HCC after liver transplantation and surgical resection.3, 4 Liver transplantation may be considered the best option as it removes both the cancer and the underlying diseased liver, but lack of liver grafts is a major limitation. Surgical resection allows a 5-year survival rate of approximately 50% and is often considered as the first-line treatment, especially when liver function is acceptable. Globally, only 10–20% of patients are eligible to undergo transplantation or resection.5, 6 Thermal ablation is increasingly considered as a possible first-line treatment, even outside the classical contraindications of surgery, such as major liver dysfunction, co-morbidities, or patient refusal3, 7; however, although thermal ablation for treating HCC has achieved significant results, its long-term outcome has been variously appreciated.8, 9, 10 In particular, few studies have covered a 10-year outcome.¹¹ The aim of the present study was to investigate the long-term outcome and prognostic factors when treating hepatocellular carcinoma (HCC) with thermal ablation, based on the retrospective analysis of a large series of patients followed for up to 10 years.

Section snippets

Patients

From October 2001 to May 2013, a total of 1,210 patients with malignant liver tumours received local thermal ablation therapy at Tianjin Third Central Hospital, China. Among the patients, 1,121 cases were diagnosed as having HCC, and 846 cases meeting the inclusion criteria were enrolled in the present study. Diagnosis of HCC included needle biopsy-based histopathological diagnosis and/or radiological diagnosis: 638 (75.4%) cases were diagnosed at histopathology and 208 (24.6%) were diagnosed

Basic clinical characteristics of patients

Patients were predominantly males with cirrhosis (87.5%) of viral origin (related to hepatitis B virus [HBV] in 77%). Six hundred and ninety-five patients were Child–Pugh Class A. One hundred and ninety-seven patients received RFA, and 649 patients underwent MWA. The numbers of patients who underwent one to seven ablation sessions were 604, 171, 56, 9, 3, 1, and 2, respectively, with a mean of 1.4 ± 0.76 sessions per case. Complete ablation was obtained in 97.1% of the cases (1204/1240; Table 2

Discussion

HCC accounts for >80% of patients with primary liver cancer. Most HCC patients develop from pre-existing cirrhosis, mainly attributable to alcoholic cirrhosis or hepatitis B or C virus infection.¹⁴ The 5-year survival rate for HCC is <5% in all patients. More than 30% of patients are diagnosed at early stages and surgical resection or liver transplantation have long been considered as the first options.¹⁵ In the last two decades, thermal ablation has been increasingly applied to HCC, with

Acknowledgements

This work was supported by grant from Tianjin Health Industry Key Research Project (no. 13KG111).

References (30)

E.C. Lai et al.
The continuing challenge of hepatic cancer in Asia
Surgeon
(2005)
S.N. Goldberg et al.
Image-guided tumor ablation: standardization of terminology and reporting criteria
J Vasc Interv Radiol
(2009)
H.B. el-Serag
Epidemiology of hepatocellular carcinoma
Clin Liver Dis
(2001)
J. Ding et al.
Complications of thermal ablation of hepatic tumours: comparison of radiofrequency and microwave ablative techniques
Clin Radiol
(2013)
R.T. Poon et al.
Evaluation of the new AJCC/UICC staging system for hepatocellular carcinoma after hepatic resection in Chinese patients
Surg Oncol Clin N Am
(2003)
N. Ballem et al.
Laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma: long-term follow-up
HPB (Oxford)
(2008)
J. Ferlay et al.
Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008
Int J Cancer
(2010)
W.Y. Lau et al.
The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review
Ann Surg
(2009)
P. Tombesi et al.
Resection vs thermal ablation of small hepatocellular carcinoma: what's the first choice?
World J Radiol
(2013)
J. Bruix et al.
American Association for the Study of Liver D. Management of hepatocellular carcinoma: an update
Hepatology
(2011)

W.Y. Lau et al.

Hepatocellular carcinoma: current management and recent advances

Hepatobiliary Pancreat Dis Int

(2008)

Z.W. Peng et al.

Radiofrequency ablation versus hepatic resection for the treatment of hepatocellular carcinomas 2 cm or smaller: a retrospective comparative study

Radiology

(2012)

L. Kikuchi et al.

Percutaneous radiofrequency ablation for early hepatocellular carcinoma: risk factors for survival

World J Gastroenterol

(2014)

G. N'Kontchou et al.

Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic factors in 235 Western patients with cirrhosis

Hepatology

(2009)

D. Choi et al.

Percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma as a first-line treatment: long-term results and prognostic factors in a large single-institution series

Eur Radiol

(2007)

Cited by (18)

Therapeutic efficacy of microwave coagulation versus liver resection for hepatocellular carcinoma within the Milan criteria: A propensity score matching analysis
2022, European Journal of Surgical Oncology
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Three-dimensional fusion imaging may be a useful future modality; this novel guiding technique allows the operator to observe the anatomical relationships between the lesion and surrounding vital structures, facilitating achievement of a higher complete ablation rate for large lesions [32]. Tumor number affected DFS rate, in relation with early intrahepatic HCC micrometastases and multicentric occurrence [33]. In the present study, HBV and HCV infections were close to achieving significance with DFS rates (p = 0.057).
Introduction: This study aimed to compare the therapeutic efficacy of resection (RES) and microwave ablation (MWA) for hepatocellular carcinoma (HCC) within the Milan criteria.
Materials and Methods: Between 2011 and 2019, 426 HCC patients within the Milan criteria were treated at our institution (RES: n = 291; MWA: n = 135). We compared overall survival (OS), disease-free survival (DFS), complications, and hospital stay in these patients using propensity score matching (PSM) and determined the prognostic factors using multivariate Cox analysis.
Results: Following 1:1 matching using PSM, 121 patients were matched in each group. The 1-, 3-, and 5-year OS rates were 98.3%, 84.7%, and 69.6% for the MWA group and 96.5%, 81.8%, and 78.1% for the RES group (p = 0.667). The corresponding DFS rates for the MWA and RES groups were 81.8%, 54.4%, and 42.3% and 85.4%, 67.8%, and 57.9%, respectively (p = 0.174). The MWA group had less blood loss and shorter hospital stays (both p < 0.001) than the RES group.
Conclusion: MWA resulted in survival outcomes that were similar to those of RES for HCC within the Milan criteria. However, it had more favorable hospital stay and blood loss outcomes than RES.
Evaluation of probe angles for synchronous waveform 915-MHz microwave ablation
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Citation Excerpt :
LT antenna use resulted in a statistically significant increased ZA when compared to the ST antenna (10.9 ± 4.3 versus 6.5 ± 2.4; P = 0.01). Thermal ablation is increasingly becoming integrated into the multimodal management of unresectable solid organ tumors, with outcomes comparable to surgical resection in patients with early-stage hepatocellular carcinomas.10-12 It additionally presents a reasonable option for resectable patients who are unfit for a major operation.
The purpose of this study is to compare the ablation performance between a synchronous microwave ablation (MWA) system and a commercially available asynchronous system in ex vivo bovine liver and evaluate the efficacy of ablation at varying entrance angles.
Two 915-MHz MWA systems were used in bench top ex vivo bovine livers with various conditions (synchronous versus asynchronous). Using synchronous technology ablations to liver, kidney, or lung at angles of 0, 15, 30, and 90° were evaluated.
Synchronous and asynchronous MWA systems created mean ablation zone volumes of 26.4 and 15.8 cm³, 62.9 and 45.4 cm³, 90.8 and 56.4, and 75.7 and 54.8 cm³ with single, double (2 microwave probes in use simultaneous) (2 cm spacing), and triple (three probes in use simultaneously) (2 cm and 3 cm spacing) antennae configurations, respectively; adjusted P-values ≤ 0.006. Ablation defects were similar across all groups when evaluated for entrance angle. Specifically, when comparing 0-degree angle to all other angles, achieved zones of ablation (ZA) were similar (mean ± standard deviation for 0-degree versus all other angles: 8.72 ± 4.84 versus 9.38 ± 4.11 cm², P = 0.75). The use of the long-tip probe resulted in a statistically significant increase in the achieved ZA when compared to the short tip probe (10.9 ± 4.3 versus 6.5 ± 2.4, respectively; P = 0.01).
Newly developed synchronous microwave technology creates significantly larger ablation zones when compared to an existing asynchronous commercially available system. The angle of approach does not affect the resulting ZA. This is clinically relevant as true 0-degree angle is often difficult to obtain.
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Microwave ablation (MWA) is becoming a competitor for RFA (Fig 1). Both techniques achieve the same effectiveness and survival in solitary HCC <2 cm24,25 with portal hypertension as the main determinant of patient outcome.7 Early-stage disease includes patients with preserved liver function (Child–Pugh A and B) with solitary HCC or up to 3 nodules <3 cm in size.
Hepatocellular carcinoma (HCC) represents one of the few cancers for which locoregional treatments are recognised as being able to cure and/or prolong survival and are included in international guidelines. This is due to the unique nature of HCC, in most cases occurring in patients with underlying virus- or alcohol-related cirrhosis. The treatment choice in patients with HCC is therefore driven not only by tumour staging, as in the great majority of cancers, but also by careful evaluation of liver function and physical status. Another specific feature of HCC is that it is the only tumour that can be cured by organ transplantation, with the aim of treating both the cancer and underlying liver disease. These characteristics configure a complex scenario and prompt the need for close cooperation among interventional oncologists, surgeons, hepatologists, and anaesthesiologists. In patients with limited hepatic disease, preserved hepatic function and good performance status, categorised as very early and early-stage HCC according to the Barcelona Clinic Liver Cancer (BCLC) classification, image-guided tumour ablation is included among the curative treatments. More than half of patients with HCC are, however, diagnosed late, despite the widespread implementation of surveillance programmes, when curative treatments cannot be applied. For patients presenting with multinodular HCC and relatively preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread transcatheter arterial chemoembolisation (TACE) is the current standard of care. Although anti-tumour activity and promising survival results has been reported in cohorts of patients with advanced HCC treated with radio-embolisation, systemic treatment with the multi-kinase inhibitor, sorafenib, is still recommended for patients at this stage. In this article, current treatment strategies for HCC according to tumour stage are discussed, underlining the latest advances in the literature and technical developments.
Repeat hepatectomy versus thermal ablation therapy for recurrent hepatocellular carcinoma: a systematic review and meta-analysis
2024, Frontiers in Oncology
A meta-analysis and systematic review of the comparison of laparoscopic ablation to percutaneous ablation for hepatic malignancies
2023, International Journal of Clinical Oncology
Microwave ablation of multifocal primary liver cancer guided by real-time 3.0T MRI
2023, International Journal of Hyperthermia

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View full text

Thermal ablation for hepatocellular carcinoma: a large-scale analysis of long-term outcome and prognostic factors

Highlights

Aim

Materials and methods

Results

Conclusions

Introduction

Section snippets

Patients

Basic clinical characteristics of patients

Discussion

Acknowledgements

Surgeon

J Vasc Interv Radiol

Clin Liver Dis

Clin Radiol

Surg Oncol Clin N Am

HPB (Oxford)

Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008

Int J Cancer

The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review

Ann Surg

Resection vs thermal ablation of small hepatocellular carcinoma: what's the first choice?

World J Radiol

American Association for the Study of Liver D. Management of hepatocellular carcinoma: an update

Hepatology

Hepatocellular carcinoma: current management and recent advances

Hepatobiliary Pancreat Dis Int

Radiofrequency ablation versus hepatic resection for the treatment of hepatocellular carcinomas 2 cm or smaller: a retrospective comparative study

Radiology

Percutaneous radiofrequency ablation for early hepatocellular carcinoma: risk factors for survival

World J Gastroenterol

Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic factors in 235 Western patients with cirrhosis

Hepatology

Percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma as a first-line treatment: long-term results and prognostic factors in a large single-institution series

Eur Radiol