Journal of Vascular and Interventional Radiology
Review articlePercutaneous Ablation of Hepatocellular Carcinoma: Current Status
Section snippets
Treatment Planning
The use of biomarkers and surveillance imaging with ultrasound (US), computed tomography (CT), and magnetic resonance (MR) imaging has facilitated the early detection of HCC (12). Multiphase contrast-enhanced CT or MR imaging of the liver should be performed in all patients to define the size and number of tumors, their location, and their relationship to vital structures.
At our institution, treatment decisions for hepatocellular carcinoma are made in the setting of a multidisciplinary tumor
Percutaneous Ethanol Injection
One of the first methods devised to ablate liver tumors involved percutaneous ethanol injection (PEI). Several nonrandomized trials in the 1990s (25, 26, 27) confirmed that PEI can safely achieve complete necrosis of small HCCs, with 5-year survival rates of 32%–38%. However, the technique suffered from the need for multiple treatment sessions, uncertainty of the ablation zone, and a high local progression rate of 17%–38% (28, 29).
Several randomized controlled trials compared PEI versus RF
Percutaneous Ablation Versus Surgical Resection
Two randomized controlled trials (75, 76) have been performed to compare the outcomes of percutaneous thermal ablation versus surgical resection in small to medium-sized HCC. Both demonstrated no difference in overall or disease-free survival at 3–4 years. Three well matched retrospective studies (77, 78, 79) have also been performed in patients who were candidates for either resection or RF ablation, and all three demonstrated no significant differences in overall or disease-free survival.
Percutaneous Ablation for Recurrent HCC
Although surgical resection is the gold standard treatment for HCC, the 5-year recurrence rate is 70%–85% (85, 86, 87), reflecting the underlying carcinogenesis of the cirrhotic liver. Repeat hepatectomy is the accepted treatment for recurrence, with a 5-year survival rate of 40%–52%, but most patients are not candidates as a result of impaired liver function or excessive tumor burden (86, 88, 89, 90, 91). Chemoembolization and PEI have been studied as treatment alternatives for recurrence
Percutaneous Ablation for Large HCC
Given its success in small and medium-sized HCC, interest has grown in the use of percutaneous ablation for large (> 5 cm) HCC. One study (102) examined the use of MW or RF ablation in a subgroup of 20 patients with HCC measuring 5–7 cm, including recurrent and multifocal tumors and a high proportion of patients with Child class B disease. Complete ablation was achieved in 80%, usually in a single session, and the rate of local progression was 31%. The 5-year survival rate was 17%, regardless
Treatment Follow-up
After ablation, contrast-enhanced multiphase CT or MRI is performed within 1 month to determine technical success; complete ablation appears as hypoattenuation without enhancement. Thereafter, many groups monitor for recurrence using α-fetoprotein levels and US at 3–6-month intervals, with CT or MR imaging performed for any suspicious findings; other groups perform CT or MR imaging at each follow-up regardless of suspicion. At our institution, cross-sectional imaging, labs, and clinic visit
Conclusion
Percutaneous RF and MW ablation are effective treatment modalities for de novo and recurrent HCCs as large as 5 cm, with high technical success rates and 5-year survival rates similar to those associated with hepatic resection. Complications are rare and morbidity rates are low. Recurrent or new sites of disease are frequent, but can usually be treated with repeat ablation. In larger HCC, recent advances in RF and MW probe design are making percutaneous therapy increasingly feasible.
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None of the authors have identified a conflict of interest.