Combined Transarterial Chemoembolization and Percutaneous Radiofrequency Ablation: More Promising Evidence of Effectiveness in Treating Solitary, Medium-Sized Hepatocellular Carcinoma.

Abstract

Locoregional therapy (LRT) has become a cornerstone in the management of patients with surgically unresectable hepatocellular carcinoma (HCC). Transarterial chemoembolization and percutaneous radiofrequency (RF) ablation—both prototypical LRTs with long track records of use—prolong overall survival (OS) in HCC patients ( 1 Lo C.M. Ngan H. Tso W.K. et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002; 35: 1164-1171 Crossref PubMed Scopus (2200) Google Scholar , 2 Llovet J.M. Real M.I. Montana X. et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002; 359: 1734-1739 Abstract Full Text Full Text PDF PubMed Scopus (2871) Google Scholar , 3 Lencioni R. Cioni D. Crocetti L. et al. Early-stage hepatocellular carcinoma in patients with cirrhosis: long-term results of percutaneous image-guided radiofrequency ablation. Radiology. 2005; 234: 961-967 Crossref PubMed Scopus (708) Google Scholar ) but have shortcomings when used independently ( 4 Carmi L. Georgiades C. Combination percutaneous and intraarterial therapy for the treatment of hepatocellular carcinoma: a review. Semin Intervent Radiol. 2010; 27: 296-301 Google Scholar ). Although transarterial chemoembolization is the current standard of care for patients with Barcelona Clinic Liver Cancer stage B (intermediate-stage) HCC, it is considered a palliative treatment rather than a curative treatment. To this end, rates of complete (ie, 100%) pathologic necrosis are modest—ranging as low as 20%–35% ( 5 Riaz A. Lewandowski R.J. Kulik L. Ryu R.K. Mulcahy M.F. Baker T. et al. Radiologic-pathologic correlation of hepatocellular carcinoma treated with chemoembolization. Cardiovasc Intervent Radiol. 2010; 33: 1143-1152 Crossref PubMed Scopus (78) Google Scholar , 6 Shim J.H. Han S. Shin Y.M. et al. Optimal measurement modality and method for evaluation of responses to transarterial chemoembolization of hepatocellular carcinoma based on enhancement criteria. J Vasc Interv Radiol. 2013; 24: 316-325 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar )—and result in unacceptably high tumor progression rates, with median time-to-progression of 3.1–13.5 months ( 7 Lencioni R. de Baere T. Soulen M.C. Rilling W.S. Geschwind J.F. Lipiodol transarterial chemoembolization for hepatocellular carcinoma: a systematic review of efficacy and safety data. Hepatology. 2016; 64: 106-116 Crossref PubMed Scopus (391) Google Scholar ), ensuring that most HCC patients succumb to cancer despite repeated transarterial chemoembolization aimed at disease control. Conversely, RF ablation is considered a definitive therapy for Barcelona Clinic Liver Cancer stage A (early-stage) HCC tumors ≤3 cm, although as tumor size exceeds 3 cm, there is a significant reduction in the rate of complete coagulative necrosis due to heat dissipation with increasing distance from the RF ablation electrode, which results in higher local tumor progression rates, as confirmed in a study of nearly 1500 early-stage HCC tumors treated with RF ablation ( 8 Kim Y.S. Lim H.K. Rhim H. et al. Ten-year outcomes of percutaneous radiofrequency ablation as first-line therapy of early hepatocellular carcinoma: analysis of prognostic factors. J Hepatol. 2013; 58: 89-97 Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar ). In addition, RF ablation is susceptible to heat sink effects, or convective heat loss due to blood flow in adjacent vessels, which may limit therapeutic efficacy ( 9 McGhana J.P. Dodd 3rd, G.D. Radiofrequency ablation of the liver: current status. AJR Am J Roentgenol. 2001; 176: 3-16 Crossref PubMed Scopus (572) Google Scholar , 10 Lu D.S. Yu N.C. Raman S.S. et al. Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver. Radiology. 2005; 234: 954-960 Crossref PubMed Scopus (320) Google Scholar ). Moreover, HCCs larger than 2 cm are more frequently associated with satellite tumors and microscopic vascular invasion, which may precipitate treatment failure or disease recurrence despite satisfactory target tumor ablation ( 11 European Association for Study of Liver, European Organisation for Research and Treatment of CancerEASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. Eur J Cancer. 2012; 48: 599-641 Abstract Full Text Full Text PDF PubMed Scopus (374) Google Scholar ). Given the individual limitations of transarterial chemoembolization and RF ablation, there is a pressing need to validate more effective treatment permutations to enhance the efficacy of LRT. Chemoembolization Combined with Radiofrequency Ablation for Medium-Sized Hepatocellular Carcinoma: A Propensity-Score AnalysisJournal of Vascular and Interventional RadiologyVol. 30Issue 10PreviewTo compare survival outcomes of patients with single medium-sized hepatocellular carcinomas (HCCs) who underwent treatment with transarterial chemoembolization, radiofrequency (RF) ablation, or a combination of the 2 therapies. Full-Text PDF