Percutaneous Treatment Of Hepatocellular Carcinoma Research Articles

Thermal ablation of hepatocellular carcinoma.

Percutaneous treatment of hepatocellular carcinoma (HCC) by means of thermal ablation (TA) has been introduced in clinical guidelines as a potentially curative treatment for the early stages of the disease since the early 2000s. Due to its safety profile and cost-effectiveness, TA can be offered as a first-line treatment for patients with HCC smaller than 3 cm. Thermal ablative techniques are in fact widely available at many centres worldwide and include radiofrequency (RF) and microwave (MW) ablation, with the latter increasingly applied in clinical practice in the last decade. Pre-clinical studies highlighted, as potential advantages of MW-based ablation, the ability to achieve higher temperatures (>100°C) and larger ablation zones in shorter times, with less susceptibility to blood flow-induced heat sink effects. Despite these advantages, there is no evidence of superior overall survival in patients treated with MW as compared to those treated with RF ablation. Local control has been proven to be superior to MW ablation with a similar complication rate. It is expected that further improvement of TA results in the treatment of HCC will result from the refinement of guidance and monitoring tools and the careful assessment of ablation margins. Thermal ablative treatments may also be performed on nodules larger than 3 cm by applying multiple devices or combining percutaneous and intra-arterial approaches. The role of novel immunotherapy regimens in combination with ablation is also currently under evaluation in clinical trials, with several potential benefits. In this review, indications, technical principles, results, and future prospects of TA for the treatment of HCC will be examined.

Eighty percent partial splenic embolization is a safe and effective procedure in management of cirrhotic hypersplenism

Background: Partial splenic embolization (PSE) has been proposed in patients with cirrhotic hypersplenism in cases when thrombocytopenia causes clinical manifestations or if there are contraindications to subsequent therapeutic procedures. We provide a retrospective review of the safety and favorable treatment results of 80% splenic embolization in patients with cirrhotic hypersplenism in our institute. Methods: Thirteen consecutive patients with cirrhotic hypersplenism were included in a 4-year study period. The indications for PSE were as follows: percutaneous treatment of hepatocellular carcinoma (HCC) (n = 3), transarterial chemoembolization plus hepatic arterial infusion chemotherapy for HCC (n = 2), preparation for major surgery (n = 5), and severe purpura (n = 3). PSE was performed with up to 80% reduction of splenic blood flow by radiological intervention. A tight protocol of prophylactic antibiotics was introduced. Patient demographics, procedure-related complication, and efficacy of PSE were analyzed. Results: The mean follow-up time was 26.1 ± 12.3 months. All the patients tolerated the procedure. The minor complication of postembolization syndromes such as fever and abdominal pain occurred in 38.5% and 61.5% of patients, respectively. Only a major complication of transient ascites needs diuretic therapy occurred in two patients. Pre-PSE platelet count was 35,077 ± 11,049/mm3, and it significantly increased 1 week after PSE, with a mean increase of platelet count to 384% of pre-PSE level (P Conclusion: Our series demonstrated that 80% PSE is a safe and effective method to treat patients with cirrhotic hypersplenism. It could not only increase the platelet count within a short period of time but also maintain it at an acceptable level for a long duration. Under a tight protocol of prophylactic antibiotic and delicate technique of PSE, there was no any septic complication developed in our series.

Percutaneous treatment of hepatocellular carcinoma in patients with cirrhosis: A comparison of the safety of cryoablation and radiofrequency ablation

PurposeTo compare the safety of image-guided percutaneous cryoablation and radiofrequency ablation in the treatment of hepatocellular carcinoma in patients with cirrhosis. Materials and methodsThis retrospective HIPAA-compliant study received institutional review board approval. Forty-two adult patients with cirrhosis underwent image-guided percutaneous ablation of hepatocellular carcinoma from 2003 to 2011. Twenty-five patients underwent 33 cryoablation procedures to treat 39 tumors, and 22 underwent 30 radiofrequency ablation procedures to treat 39 tumors. Five patients underwent both cryoablation and radiofrequency ablation procedures. Complication rates and severity per procedure were compared between the ablation groups. Potential confounding patient, procedure, and tumor-related variables were also compared. Statistical analyses included Kruskal–Wallis, Wilcoxon rank sum, and Fisher's exact tests. Two-sided P-values <0.05 were considered significant. ResultsThe overall complication rates, 13 (39.4%) of 33 cryoablation procedures versus eight (26.7%) of 30 radiofrequency ablation procedures and severe/fatal complication rates, two (6.1%) of 33 cryoablation procedures versus one (3.3%) of 30 radiofrequency ablation procedures, were not significantly different between the ablation groups (both P=0.26). Severe complications included pneumothoraces requiring chest tube insertion during two cryoablation procedures. One death occurred within 90 days of a radiofrequency ablation procedure; all other complications were managed successfully. ConclusionNo significant difference was seen in the overall safety of image-guided percutaneous cryoablation and radiofrequency ablation in the treatment of hepatocellular carcinoma in patients with cirrhosis.

Percutaneous ethanol injection before liver transplantation in the hepatocellular carcinoma

Background/objectives. The study evaluates the outcome of patients who performed orthotopic liver transplantation (LT) as treatment for hepatocellular carcinoma (HCC), with percutaneous ethanol injection (PEI) while on the waiting list, verifying the effectiveness of this treatment in producing tumor necrosis and avoiding dropout and identifying treatment-related complications.Material and methods.Medical records of 97 patients on the waiting list for LT at Hospital Clinic of Barcelona were examined. Sixty-two (56.3%) patients had been treated with PEI (group 1); 35 (31.8%) had not received any anti-tumor therapy before LT (group 2).Results.Complete necrosis of the tumor was observed in 38/59 (64.3%) patients. The presence of additional nodules in the explant and the diameter of the main tumor of group 1 was significantly lower than in group 2 (p = 0.002). Dropout related to tumor progression occurred in 4.8% and 8.5%, and tumor recurrence in 5% and 6.2% for groups 1 and 2, respectively. Major complications were not evidenced after 421 PEI sessions and there was no tumor implant in the needle traject.Conclusions. In conclusion, the percutaneous treatment of HCC with PEI is a safe and effective method before the LT.

T1579 Bile Duct Hamartomas: Results of Surgical Treatment On Symptomatic Patients

Background and Objective: The role of CT in follow up of hepatocellular carcinoma (HCC) after local ablative therapy have been demonstrated in many clinical experience, whereas the role of contrast enhanced ultrasonography (CEUS) is still under evaluation. The aim of this study is to evaluate the role of immediate CEUS in prediction 30-days CT follow up after single local ablative therapy with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI). Methods:100 consecutive patients with HCC treated 2006 to 2007 were prospectively included into the study. All the patients were treated with single session of PEI or RFA. After each single percutaneous procedure CEUS was performed in order to identify residual disease (persistence of contrast enhanced pattern). Three different CEUS patters were identified: 1-isovascular-hypervascular pattern, 2-ipovascular pattern, 3-avascular pattern. After 30 days complete necrosis of HCC was evaluated with contrast-enhanced CT scan in all cases. Results: Patients included into the study were submitted to RFA (43 patients) or PEI (57 patients) for HCCs with a mean diameter of 2.7 cm (range 1.5-5 cm). After RFA, isovascular pattern was found in 2% (1/43) of patients resulting in incomplete necrosis at CT; ipovascular pattern was found in 12% (5/43) patients that resulted in incomplete necrosis in 3/5 (60%); in 86% (37/43) avascular pattern was found with complete necrosis at CT in 28/37(76%) cases. Among the PEI group, isovascular pattern was found in 5% (3/57) of patients case resulting incomplete necrosis in 1/3 (33%) case; ipovascular pattern was found in 44% (25/57) of patients that resulted CT incomplete necrosis in 17/ 25(68%) ; in 19% (11/57) of patients avascular pattern was found with complete necrosis at CT in 2/11(18%) cases. Sensitivity, specificity, positive and negative predictive values for complete necrosis at CT of the CEUS avascular pattern after RFA were 93%, 31%, 76% and 67%,respectively, while the positive predictive value after PEI treatments was 18%. Conclusions Immediate CEUS control after percutaneous treatment of HCC have high predictive value after RFA where the avascular pattern is highly related with complete necrosis at 30 day CT. On the contrary predictive value of immediate CEUS after PEI is limited

Influence of an artificial pleural effusion technique on cardio-pulmonary function and autonomic activity

Percutaneous treatment of hepatocellular carcinoma (HCC) located directly under the diaphragm is problematic because ultrasonic imaging is difficult, and the lung may be injured during the procedure. It has been reported that an infusion of 5% glucose solution into the thoracic cavity enables percutaneous treatment in such cases. However, the safety aspects of this have not been investigated. In this study, variations in heart rate and changes in circulatory and respiratory dynamics were examined during the infusion of artificial pleural effusion directly under the diaphragm in patients with HCC. The subjects were 13 patients with an HCC directly under the diaphragm. About 500 ml of a 5% glucose solution was infused into the thoracic cavity, and mean blood pressure, heart rate, and oxygen saturation were measured. Holter electrocardiography was simultaneously recorded to evaluate autonomic nerve function. To analyze variations in heart rate, the low-frequency waves (LF: 0.04-0.15 Hz), high-frequency waves (HF: 0.15-0.40 Hz, an index of parasympathetic nerve activity), and the LF/HF ratio (index of sympathetic nerve activity) were examined. The above parameters were measured before, during (when infusion of the half the planned volume was complete), and after infusion were compared. No significant changes in the mean blood pressure or heart rate were found. Oxygen saturation was significantly decreased during and after the infusion. The HF value was slightly higher after infusion and the LF value was significantly increased during infusion. The LF/HF ratio was significantly increased during infusion, and this increase persisted after infusion. The infusion of artificial pleural effusion had no effect on circulatory dynamics, but transiently affected respiratory functions. It was also revealed that infusion stimulated the parasympathetic nerves.

Percutaneous radiofrequency thermal ablation for hepatocellular carcinoma

Radiofrequency thermal ablation is the first therapeutic option in percutaneous treatment of hepatocellular carcinoma but data on its long-term efficacy and safety are not conclusive. This study reports a prospective survey on radiofrequency thermal ablation in north-east Italy. Data were collected on 401 patients with hepatocellular carcinoma (males 301, mean age: 68 years) treated by radiofrequency thermal ablation in 13 centres. Indication to treatment was: single nodule not eligible for surgery in 77% of patients, 2-3 nodes in 18% and multiple lesions in 5%. Mean size was 3 cm (1-8 cm). Treatment response was assessed at 1 month by spiral computerized tomography and then with ultrasound examination and new spiral computerized tomography. Complete response was obtained in 67% of patients and in 27% response was 75-99%. Complete response raised to 77% in lesions smaller than 3 cm. The morbidity rate was 34%; the mortality was 0.5%, seeding was observed in four patients. Ten patients presented an unexpected rapid disease progression. The above data show that by radiofrequency thermal ablation, complete response can be achieved only in about two-third of the cases, clearly less than expected, and that, beyond seeding, unexpected progression can be observed.

Percutaneous Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts

To assess the role of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and transjugular intrahepatic portosystemic shunts (TIPS). Between January 1999 and September 2004, 6 patients with HCC and TIPS were treated with either TACE (n = 3) or TACE in combination with PEI (n = 3). One patient had a known advanced, untreated HCC prior to TIPS. In the remaining 5 patients HCC was diagnosed 14, 17, 51, 69, and 76 months respectively after elective TIPS. TACE was performed using a mixture of 30-60 mg of epirubicin and 10 ml of lipiodol following superselective catheterization of tumor-feeding vessels. PEI was performed under CT guidance. The mean follow-up time after treatment of HCC was 26.2 months (range 7-46 months). During follow-up, all patients were free of rebleeding. Two patients died 7 and 38 months after one session of TACE and PEI (77 months after TIPS) and three sessions of TACE (91 months after TIPS), respectively. The cause of death was liver failure (Child-Pugh class C) and peritonitis, respectively. A third patient underwent liver transplantation 24 months after TIPS and several sessions of TACE. In the remaining 3 patients, the HCC is well controlled 13, 30, and 46 months after repetitive percutaneous treatment without signs of hepatic deterioration or metastasis. Transcatheter arterial superselective chemoembolization and percutaneous ethanol injection seems to be beneficial even in HCC patients treated with TIPS, provided that the liver function is adequate.

Review article: percutaneous treatment of hepatocellular carcinoma.

In early stage hepatocellular carcinoma (HCC), liver transplantation, surgical resection and percutaneous techniques are classified as radical treatments, and may be offered to about 25% of all patients with HCC evaluated in referral centres. The restricted inclusion criteria for surgical resection and the shortage of liver donors for transplantation have stimulated an increasing demand for minimally invasive treatments able to achieve effective and reproducible percutaneous tumour ablation, with less associated morbidity and lower cost than other interventions. Among percutaneous techniques, ethanol injection has proven to be highly effective in single HCC up to 3 cm, with a rate of complete response of 80%, being well tolerated and with a limited risk of minor complication. In larger and/or multinodular HCC the efficacy is reduced to 50% of complete response in nodules between 3 and 5 cm, and to lower rate in larger tumours. Alternative options to ethanol injection have been recently proposed, including radiofrequency, microwave and laser thermal ablation, aimed to extend the necrotic area thus improving the rate of complete response. To date, radiofrequency is the most used technique, with a reported rate of complete response of 90-98% in nodules smaller than 3 cm, and with the advantage of fewer sessions, otherwise counteracted by a higher rate of side-effects. Microwave and laser are promising technologies, but only few clinical data are available. Randomized controlled trials are needed in order to assess treatment response, long-term survival, rate of complication and cost-efficacy of newer technologies in comparison to ethanol injection.

Successful treatment of oral acetic acid poisoning with plasmapheresis

Injudicious use of acetic acid can result in acute or chronic poisoning. Chronic ingestion of large amount of 5% acetic acid has been reported to be a cause for hypokalemia, hyper-reninemia and osteoporosis. Acute poisoning can occur after percutaneous treatment of hepatocellular carcinoma or after oral ingestion. Most of the reported cases are from Russia before 1980s. We report an adult with acute accidental poisoning with 30% acetic acid leading to severe intravascular hemolysis, hemoglobulinuria, acute hepatitis, coagulopathy, and acute gastrointestinal bleeding and acute renal failure. Plasmapheresis was started soon after intoxication with good recovery and we discuss its possible role in the management of acetic acid poisoning.

Ultrasound-guided percutaneous treatment of hepatocellular carcinoma by radiofrequency hyperthermia with a ‘cooled-tip needle’. A preliminary clinical experience

Objective: Radiofrequency hyperthermia using the newly-developed ‘cooled-tip’ needle has recently been proposed as a therapeutic modality for hepatocellular carcinoma (HCC). Herein we report our preliminary results on feasibility and effectiveness of the thermal ablation of mono- or pauci-focal hepatocellular carcinoma with the cooled-tip needle . Materials and methods: We treated 15 cirrhotic patients (mean age 68.8 years; 12 males; 14 HCV-positive; 13 in Child’s Class A and 2 in Class B) with 20 hepatocellular carcinoma nodules (mean diameter 28.1 mm; range 10–43 mm; nine lesions with diameter greater than 3 cm). None of the patients had portal thrombosis and/or extrahepatic spread. We used a radiofrequency generator (100 W of power) connected to a 18 g perfusion electrode needle with an exposed tip of 2–3 cm. The circuit was closed through a dispersive electrode positioned under the patient’s thighs. A peristaltic pump infused a chilled (2–5°C) saline solution to guarantee the continuous cooling of the needle tip. The needle was placed into target lesions under US guidance. The interventional procedure was carried out in general anesthesia without intubation. Dynamic helical CT was carried out 15–20 days after thermal ablation to assess therapeutic efficacy. Results: In all, 38 areas of coagulation necrosis (at 1000–1200 mA for 10–15 min) were generated in 24 sessions in the 20 hepatocellular carcinoma nodules (mean 1.9 lesions per nodule and 1.2 sessions per nodule). Complete necrosis as assessed at dynamic CT (lack of enhancement during the arteriographic phase) was achieved in 75% of cases in a single session; after a second RF session success rate was 90% (18 out of 20 nodules). A self-limited pleurisy along with a 5-fold increase in transaminases occurred in one patient; a 3-fold elevation of transaminases was encountered in three other patients. During the follow-up (median 15 months) five patients had recurrent hepatocellular carcinoma with a 1-year disease free interval of 64%. Of the three recorded deaths, two were due to intrahepatic tumor diffusion. Conclusions: In our experience radiofrequency hyperthermia with the cooled-tip needle afforded an effective and safe percutaneous ablative method for HCC in cirrhosis and shortened treatment time.