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Ablation of hepatocellular carcinoma

https://doi.org/10.1016/j.bpg.2014.08.011Get rights and content

Abstract

Radiofrequency ablation (RFA) has gained a wide acceptance as a first-line therapeutic option for small hepatocellular carcinoma (HCC). For very early-stage HCC, despite a higher rate of local tumour progression, RFA is considered as a viable alternative to surgical resection owing to its comparable long-term survival, reduced morbidity, and greater preservation of hepatic parenchyma. For HCCs larger than 2 cm, RFA can contribute to near-curative therapy when combined with chemoembolization. RFA can be used as part of a multimodal treatment strategy for more advanced or recurrent cases, and could be a useful bridging therapy for patients who are waiting for liver transplantation. However, the use of RFA is still limited in treating large tumours and some tumours in high-risk locations. To overcome its current limitations, other ablation techniques are being developed and it is important to validate the role of other techniques for enhancing performance of ablation therapy for HCC.

Section snippets

Bioeffects of RFA

Alternating electrical current (300–1,000 kHz) emitted from the RF electrode tip induces heat reaching temperatures of 60–100 °C. When the tumour is exposed to this heat, near immediate coagulation necrosis occurs as irreversible damage. The size of the ablation zone achieved by one application of commercially-available RF devices is up to 3–5 cm in diameter [1]. Because of the possible microvascular invasion, as well as microscopic satellite nodules of HCC, the ablation zone needs to contain

Techniques for larger ablation zones

A conventional RF electrode could induce coagulation necrosis of no greater than 1.6 cm in diameter [1]. This limitation is worsened by vaporization and/or carbonization that act as an insulator of electrical currents. To overcome this inherent limitation, several adaptations have been adopted for currently available RF devices, including expandable multi-tined designs, internal cooling by chilled saline, clustered design, pulsing of RF energy, and concomitant saline infusion into the tissue.

Optimal candidates for RFA

Regarding tumour burden, many institutions have used the Milan criteria (i.e., single HCC <5 cm in diameter; multiple HCCs ≤3 in number and each <3 cm in diameter) as their inclusion criteria for RFA. The limitation of tumour number in cases of multiple HCCs may be dependent on several clinical considerations such as the patient's general condition and ability to tolerate the procedure, the operator's skill and experience, and procedure time. Therefore, the number of tumours treatable in one

Complications of RFA

Bertot et al [20] reviewed 24 studies of RFA (9,531 patients) and reported a major complication rate of 4.1% and mortality rate of 0.15%. Minor complication rates were reported to be 5.0–8.9% [21]. According to their causes, complications of RFA can be classified into collateral thermal damage, direct mechanical injury, or other miscellaneous complications. Common collateral thermal injury includes gastrointestinal tract injury with/without perforation, diaphragm injury, pleural effusion, bile

Local tumour progression

Reported rates of LTP after RFA of HCC are quite variable. Shiina et al [30] and Kim et al [31] recently published their ten-year follow-up results, which showed a considerable difference in LTP rates (Table 1). This discrepancy might be caused by different etiologies of HCC (hepatitis C virus[HCV]- and hepatitis virus B[HBV]-dominant, respectively), different strategies for coping with an insufficient ablative margin, different strategies regarding combination with TACE (27.7% and 0% of the

RFA versus surgery

As a result of excellent clinical outcomes of RFA to date, there have been debates over whether RFA can replace resection as a first-line therapy. To answer this question, many investigators have performed cohort studies or randomized controlled trials (RCTs) that directly compared the two methods. There are also several meta-analyses that comprehensively integrate such studies.

According to several recently published meta-analyses [54], [55], [56], [57], [58], a large number of retrospective

Role of RFA in multimodal treatment strategy

According to the BCLC system, RFA or other ablation therapy, hepatic resection, and liver transplantation are recommended procedures for treatment with curative intent in very early- or early-stage HCC [15], whereas TACE, chemotherapy, or radiation therapy can play a palliative role.

RFA can be concomitantly performed with hepatic resection when the tumour size, number, and/or distribution exceed the limitation of either modality. This combination provides a chance of cure that is otherwise

Percutaneous ethanol injection

PEI therapy involves the injection of 99% dehydrated ethanol into the tumour under US guidance to induce ‘chemical burn’ of HCC as well as obliteration of tumour-supplying microvasculature. PEI can achieve five-year survival rates of 32–52% in HCC <5 cm in Child-Pugh class A patients [72], [73]. PEI suffers from the need for multiple treatment sessions because of inhomogeneous distribution of ethanol in the tumour, uncertainty of ablation zone, and a high rate of LTP (33% in HCC <3 cm, 43% in

Summary and future perspective

Among a variety of local ablation therapies, RFA has been most frequently used worldwide, and has gained a wide acceptance as a safe and effective first-line therapeutic option for early- or very early-stage HCC. For very early-stage HCC, in spite of a higher rate of local recurrence, RFA appears to be superior to, or at least equivalent to, resection because of its comparable long-term survival, less morbidity, shorter hospital stay, and greater preservation of hepatic parenchyma. For HCC

Conflict of interest

None.

Acknowledgement

This work was supported by a Samsung Medical Center grant (#GFO1130071). The sponsor provided help in writing the manuscript.

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