Image-guided thermal ablation of hepatocellular carcinoma

https://doi.org/10.1016/j.critrevonc.2008.01.003Get rights and content

Abstract

Hepatocellular carcinoma (HCC) is increasingly diagnosed at an early, asymptomatic stage owing to surveillance of high-risk patients. Given the complexity of the disease, multidisciplinary assessment of tumor stage, liver function, and physical status is required for proper therapeutic planning. Patients with early-stage HCC should be considered for any of the available curative therapies, including surgical resection, liver transplantation and percutaneous image-guided ablation. Resection is currently indicated among patients with solitary HCC and extremely well-preserved liver function, who have neither clinically significant portal hypertension nor abnormal bilirubin. Liver transplantation benefits patients who have decompensated cirrhosis and one tumor smaller than 5 cm or up to three nodules smaller than 3 cm, but donor shortage greatly limits its applicability. This difficulty might be overcome by living donation that, however, is still at an early stage of clinical application. Image-guided percutaneous ablation is the best therapeutic choice for nonsurgical patients with early-stage HCC. While ethanol injection has been the seminal percutaneous technique, radiofrequency ablation has emerged as the most effective method for local tumor destruction and is currently used as the primary ablative modality at most institutions.

Introduction

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infection [1], [2], [3], [4]. Patients with cirrhosis are at the highest risk of developing HCC and should be monitored every 6 months to diagnose the tumor at an asymptomatic stage [5], [6], [7], [8]. In most solid malignancies, tumor stage at presentation determines prognosis and treatment management. Most patients with HCC, however, have two diseases – liver cirrhosis and HCC – and complex interactions between the two have major implications for prognosis and treatment choice [9]. Therefore, the TNM system has limited usefulness in the clinical decision making process, because it does not take into account hepatic functional status. Several scoring systems have been developed in the past few years in attempts to stratify patients according to expected survival. However, the only system that links staging with treatment modalities is the Barcelona Clinic Liver Cancer (BCLC) staging system [10].

The BCLC includes variables related to tumor stage, liver functional status, physical status, and cancer related symptoms and provides an estimation of life expectancy that is based on published response rates to the various treatments. In the BCLC system, early-stage HCC includes patients with Eastern Cooperative Oncology Group performance status of 0, preserved liver function (Child–Pugh class A or B), and solitary tumor or up to three nodules smaller than 3 cm in size each, in the absence of macroscopic vascular invasion and extrahepatic spread. If the patient has Child–Pugh class A cirrhosis and a solitary tumor smaller than 2 cm in size, the stage may be defined as very early. Patients with multinodular HCC with neither vascular invasion nor extrahepatic spread are classified as intermediate-stage according to the BCLC staging system, provided that they have a performance status of 0 and Child–Pugh class A or B cirrhosis [10]. Patients with portal vein invasion or extrahepatic disease are classified as advanced stage. The terminal stage includes patients who have either severe hepatic decompensation (Child–Pugh class C) or performance status greater than 2.

Section snippets

Triage of early-stage hepatocellular carcinoma

Patients with early-stage HCC can benefit from curative therapies, including surgical resection, liver transplantation and percutaneous ablation, and have the possibility of long-term cure, with 5-year survival figures ranging 50–75% [5]. However, there is no firm evidence to establish the optimal first-line treatment for early-stage HCC because of the lack of randomized controlled trials (RCTs) comparing radical therapies. Patients should be evaluated in referral centers by multidisciplinary

Thermal ablation

Application of localized heating or freezing enables in situ destruction of malignant liver tumors preserving normal liver parenchyma. The thermal ablative therapies involved in clinical practice can be classified as either hepatic hyperthermic treatments – including radiofrequency (RF) ablation, microwave ablation, and laser ablation – or hepatic cryotherapy. Hepatic hypertermic treatments are mostly performed via a percutaneous approach, while an open or laparoscopic approach has been widely

Conclusions

Several image-guided ablation techniques have been developed to treat nonsurgical patients with HCC. These minimally invasive procedures can achieve effective and reproducible tumor destruction with low morbidity. Percutaneous ablation is accepted as the best therapeutic choice for patients with early-stage HCC when resection or transplantation are precluded. On the basis of the current evidence, RF ablation seems to offer higher cumulative survival and recurrence-free survival rates compared

Conflict of interest

None.

Reviewers

Professor Denys A., CHUV - Centre Hospitalier Universitaire Vaudois, Department of Radiology, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.

Professor Helmberger T., Chairman, Institut für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Klinikum Bogenhausen, Englschalkinger Str. 77, D-81925 Munich, Germany.

Professor Johnson PJ., Professor of Oncology, Director of Clinical Trials Unit, University of Birmingham, Cancer Research UK, Institute for Cancer Studies, Vincent Drive,

Riccardo Lencioni has been Associate Professor of Radiology in the Department of Oncology, Transplants and Advanced Technologies in Medicine at the University of Pisa, Italy, since 2000. Having focused much of his research on interventional oncologic radiology, Riccardo Lencioni has been involved as principal investigator in several clinical trials on interventional techniques for tumor ablation. He has received several international awards for his scientific contributions, including “most

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    Riccardo Lencioni has been Associate Professor of Radiology in the Department of Oncology, Transplants and Advanced Technologies in Medicine at the University of Pisa, Italy, since 2000. Having focused much of his research on interventional oncologic radiology, Riccardo Lencioni has been involved as principal investigator in several clinical trials on interventional techniques for tumor ablation. He has received several international awards for his scientific contributions, including “most cited paper” of European Radiology for his pilot study on percutaneous ablation of liver metastases. He has also taken an active role in numerous scientific societies: He is currently a member of the Executive Committee and Chairman of the Standards of Practice Committee of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), a member of the Steering Committee of the World Conference on Interventional Oncology (WCIO), Chairman of the “Abdominal and Gastrointestinal” subcommittee for the European Congress of Radiology (ECR) and a member of the Founding Board and the Council of the International Liver Cancer Association (ILCA). Professor Lencioni serves as an editorial board member or reviewer for 23 peer-reviewed international journals. He has authored 85 journal articles or editorials (cumulative impact factor, 213) and numerous book chapters in textbooks of radiology, gastroenterology and surgery. He has been the editor of seven books. Citations of his publications (self-citations excluded) currently number in excess of 3000. Riccardo Lencioni has been an invited lecturer for more than 300 international meetings, courses, or conferences.

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