HomeRadiology: Imaging CancerVol. 1, No. 1 Previous Research HighlightsFree AccessCombination of Chemoembolization plus Radiofrequency Ablation May Provide Better Survival Outcomes than Monotherapy for HCCLuke R. WilkinsLuke R. WilkinsLuke R. WilkinsPublished Online:Sep 27 2019https://doi.org/10.1148/rycan.2019194005MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Take-Away Points■ Major focus: Comparing survival outcomes of patients with single medium-sized hepatocellular carcinoma (HCC) who underwent treatment with transarterial chemoembolization (TACE), radiofrequency (RF) ablation, or a combination of the two therapies.■ Key result: The 10-year overall survival rates of combination therapy were significantly better than those of either treatment modality alone (41.8% with combined therapy, 28.4% with chemoembolization alone, and 11.9% with RF ablation alone; P = .022).■ Impact: Using combined TACE plus ablation as first-line therapy for single medium-sized (3.1–5.0 cm), HCC may provide a survival advantage in patients ineligible for liver transplant.Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide and is staged according to both tumor characteristics and the underlying liver disease. The Barcelona Clinic Liver Cancer staging system is the most widely used to classify patients according to their tumor and liver burden while outlining the appropriate treatment for the HCC at its current stage. Surgical resection, ablation, and liver transplant are recommended as potential curative treatment options for HCC. However, there are multiple medical and psychosocial reasons a patient may be a poor surgical candidate and be ineligible for either liver transplant or surgical resection. In this setting, a curative intent is desirable to increase overall survival in this patient population.Previous studies have demonstrated safety and efficacy for radiofrequency (RF) ablation in treatment of HCC for small tumors (≤ 3 cm). However, treatment with RF ablation alone in medium-sized tumors (3.1–5.0 cm) is more challenging due to the limited capacity of RF ablation to produce a sufficiently large and homogeneous region of tumor destruction. Theoretically, chemoembolization prior to ablation will decrease heat-sink effects during ablation and may increase the zone of ablation. Additionally, medium-sized HCC tumors are more likely to have satellite nodules that will be controlled through embolization. However, these theoretical advantages have yet to be fully validated in the literature. The present study evaluated 538 patients who underwent combined chemoembolization and RF ablation (n = 109), chemoembolization alone (n = 314), or RF ablation alone (n = 115) as first-line treatment for a single medium-sized HCC. Baseline demographic data (age, sex, etiology, Eastern Cooperative Oncology Group performance status, presence of liver cirrhosis, and serum bilirubin, albumin, and α-fetoprotein levels) were similar among groups except for Child-Pugh class, albumin level, and tumor size. The authors performed a propensity-score analysis with inverse probability weighting (IPW) to reduce any bias in treatment selection and other potential confounding factors. This method incorporated generalized boosting models, a nonparametric machine learning classifier. The search limit was set to 10 000 trees, and the 10 pretreatment variables of age, sex, etiology, Eastern Cooperative Oncology Group performance status, Child-Pugh score, presence or absence of liver cirrhosis, tumor size, serum bilirubin level, serum albumin level, and serum α-fetoprotein level were used to calculate the per-patient score. After calculating weights for the average treatment effect for those treated (to match chemoembolization plus RF ablation), the pairwise standardized effect difference for each variable was calculated. Median follow-up time was 46.2 months. Before IPW, overall survival (OS) durations were significantly different among the three groups (median, 85 months for combined therapy, 56.5 months for chemoembolization alone, and 52.1 months for RF ablation alone; P = .01). The 10-year OS rates were 40.1%, 25.5%, and 19.5% for the combined, chemoembolization-only, and RF ablation–only groups, respectively. After IPW, OS remained superior in the combined chemoembolization plus RF ablation group compared with the monotherapy groups (10-year OS, 41.8% with combined therapy, 28.4% with chemoembolization alone, and 11.9% with RF ablation alone; P = .022).This article successfully shows that using combined TACE plus ablation as first-line therapy for single medium-sized (3.1–5.0 cm) HCC may provide a survival advantage in patients ineligible for liver transplant. Additional research evaluating alternative ablative techniques (eg, microwave ablation) would be beneficial to more fully validate the theoretical advantages. In addition, tumor location, distance from liver margin, and relation to adjacent vascular structures, would all be beneficial variables to evaluate in future research.Highlighted Article Chu HH, Kim JH, Yoon H, et al. Chemoembolization combined with radiofrequency ablation for medium-sized hepatocellular carcinoma: a propensity-score analysis. J Vasc Interv Radiol 2019. (in press) https://doi.org/10.1016/j.jvir.2019.06.006.Highlighted ArticleChu HH, Kim JH, Yoon H, et al. Chemoembolization combined with radiofrequency ablation for medium-sized hepatocellular carcinoma: a propensity-score analysis. J Vasc Interv Radiol 2019. (in press). 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