Percutaneous Ablation of Hepatocellular Carcinoma: Current Status

doi:10.1016/j.jvir.2009.11.025

Journal of Vascular and Interventional Radiology

Volume 21, Issue 8, Supplement, August 2010, Pages S204-S213

https://doi.org/10.1016/j.jvir.2009.11.025 Get rights and content

Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.

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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Hepatocellular carcinoma (HCC) is one of the most deadly and frequent cancers worldwide, although great advancement in the treatment of this malignancy have been made within the past few decades. It continues to be a major health issue due to an increasing incidence and a poor prognosis. The majority of patients have their HCC diagnosed at an intermediate or advanced stage in theUSA or China. Curative therapy such as surgical resection or liver transplantation is not considered anoption of treatment at these stages.
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To evaluate whether antitumor immunity is enhanced by combining radiofrequency (RF) ablation and anti-cytotoxic T-lymphocyte–associated protein 4 (CTLA-4) therapy and to evaluate its effect on untreated tumors.
First, 40 mice with tumors established in the bilateral flanks were randomly divided into 4 groups: the control group, the RF ablation-alone group, the anti-CTLA-4-alone group, and the RF ablation + anti-CTLA-4 group. In each group, 8 mice were used for untreated tumor evaluation and survival observation, and another 2 mice were killed for histopathologic study. Then, a rechallenge test was performed in another 32 mice to determine whether systemic antitumor immunity was established.
Although the volume of the untreated tumors continued to increase until the end of the observation in all groups, tumor growth rates in the RF ablation + anti-CTLA-4 group were significantly smaller than tumor growth rates in the other 3 groups (all P < .05). The overall survival time of mice in the RF ablation + anti-CTLA-4 group was significantly longer than that of mice in the other 3 groups (all P < .05). Histopathologic studies of the untreated tumors showed more CD4-and CD8+ lymphocyte infiltration in mice from the RF ablation + anti-CTLA-4 group than in mice from the other 3 groups (all P < .05). After a tumor rechallenge, tumor rejection was apparent in 75% of the mice in the RF ablation + anti-CTLA-4 group, in 25% of the mice in the RF ablation group, and in 0% of the mice in the control and anti-CTLA-4 groups.
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: None of the authors have identified a conflict of interest.

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Review articlePercutaneous Ablation of Hepatocellular Carcinoma: Current Status

Section snippets

Treatment Planning

Percutaneous Ethanol Injection

Percutaneous Ablation Versus Surgical Resection

Percutaneous Ablation for Recurrent HCC

Percutaneous Ablation for Large HCC

Treatment Follow-up

Conclusion

Gastroenterology

J Hepatology

J Am Coll Surg

J Am Coll Surg

Crit Rev Oncol Hematol

Transplant Proc

Clin Radiol

J Hepatol

J Vasc Interv Radiol

J Vasc Interv Radiol

Gastroenterology

Gastroenterology

J Gastrointest Surg

J Vasc Interv Radiol

Pathology

Gastroenterology

Cryobiology

Cryobiology

HPB (Oxford)

J Gastrointest Surg

J Gastrointest Surg

Hepatol Res

Gastroenterology

Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

N Engl J Med

EUROCARE-3 summary: cancer survival in Europe at the end of the 20th century

Ann Oncol

Hepatic ablation using radiofrequency electrocautery

Invest Radiol

Ultrasonically guided percutaneous microwave coagulation therapy for small hepatocellular carcinoma

Cancer

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

Hepatology

Early detection of hepatocellular carcinoma increases the chance of treatment: Hong Kong experience

Hepatology

Ultrasound-guided percutaneous thermal ablation of hepatocellular carcinoma using microwave and radiofrequency ablation

Clin Radiol

Hepatocellular carcinoma: radiofrequency ablation of medium and large lesions

Radiology

Early-stage hepatocellular carcinoma in patients with cirrhosis: long-term results of percutaneous image-guided radiofrequency ablation

Radiology

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: is surgery still the treatment of choice?

Hepatology

Percutaneous radiofrequency ablation of hepatocellular carcinoma abutting the diaphragm and gastrointestinal tracts with the use of artificial ascites: safety and technical efficacy in 143 patients

Eur Radiol

Minimizing diaphragmatic injury during radiofrequency ablation: efficacy of intraabdominal carbon dioxide insufflation

AJR Am J Roentgenol

Percutaneous radiofrequency ablation of painful spinal tumors adjacent to the spinal cord with real-time monitoring of spinal canal temperature: a prospective study

Cardiovasc Intervent Radiol

Minimizing central bile duct injury during radiofrequency ablation: use of intraductal chilled saline perfusion—initial observations from a study in pigs

Radiology

Percutaneous ethanol injection therapy for hepatocellular carcinoma: results in 146 patients

AJR Am J Roentgenol

Treatment of small hepatocellular carcinoma with percutaneous ethanol injection: analysis of prognostic factors in 105 Western patients

Cancer

Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection

Radiology

Factors that predict intrahepatic recurrence of hepatocellular carcinoma in 81 patients initially treated by percutaneous ethanol injection

Cancer

Predictive factors for intrahepatic recurrence after percutaneous ethanol injection therapy for small hepatocellular carcinoma

Cancer

Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection

Radiology

Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies

Hepatology

Radiofrequency thermal ablation versus percutaneous ethanol injection for small hepatocellular carcinoma in cirrhosis: meta-analysis of randomized controlled trials

Am J Gastroenterol

Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection

Radiology

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

Hepatology

Review article
Percutaneous Ablation of Hepatocellular Carcinoma: Current Status