Arnaud Hocquelet

Liver and spleen elastography using supersonic shear imaging for the non-invasive diagnosis of cirrhosis severity and oesophageal varices

BACKGROUND Elastography is a promising non-invasive approach for assessing liver fibrosis. We assessed diagnostic performances of liver and spleen stiffness using supersonic shear imaging for diagnosing cirrhosis severity and oesophageal varices. METHODS 401 consecutive cirrhotic patients were prospectively enrolled from November 2012 to March 2014. All patients underwent liver and spleen stiffness measurement with supersonic shear imaging and Fibroscan. RESULTS Failures of measurement were 6.2% and 29.2% for liver and spleen stiffness (supersonic shear imaging), and 18.4% for liver stiffness (Fibroscan). Liver and spleen stiffness were correlated with severity of cirrhosis, with values increasing according to Child-Pugh subclasses and presence of complications. With a negative predictive value ≥90%, liver stiffness cut-offs for high-risk oesophageal varices, history of ascites, Child-Pugh B/C, variceal bleeding and clinical decompensation were 12.8, 19, 21.4, 30.5, and 39.4 kPa, respectively. Areas under the curve of spleen and liver stiffness (supersonic shear imaging), and liver stiffness (Fibroscan) were 0.80, 0.77 and 0.73 respectively for detection of oesophageal varices. CONCLUSION Liver stiffness using supersonic shear imaging is a relevant diagnostic tool for assessing cirrhosis severity and its complications. Spleen stiffness shows promising results for the detection of oesophageal varices but is not yet sufficiently robust for clinical practice owing to high failure rates.

Comparison of no-touch multi-bipolar vs. monopolar radiofrequency ablation for small HCC

BACKGROUND & AIMS The primary aim of this study was to compare the rate of global radiofrequency ablation (RFA) failure between monopolar RFA (MonoRFA) vs. no-touch multi-bipolar RFA (NTmbpRFA) for small hepatocellular carcinoma (HCC) ⩽5cm in cirrhotic patients. METHODS A total of 362 cirrhotic patients were included retrospectively across four French centres (181 per treatment group). Global RFA failure (primary RFA failure or local tumour progression) was analysed using the Kaplan-Meier method after coarsened exact matching. Cox regression models were used to identify factors associated with global RFA failure and overall survival (OS). RESULTS Patients were well matched according to tumour size (⩽30/>30mm); tumour number (one/several); tumour location (subcapsular and near large vessel); serum AFP (<10; 10-100; >100ng/ml); Child-Pugh score (A/B) and platelet count (</⩾100G/L), p=1 for all. One case of perioperative mortality was observed in the NTmbpRFA group and the rate of major complications was 7.2% in both groups (p=1). The cumulative rates of global RFA failure at 1, 3 and 5years were respectively 13.3%, 31% and 36.7% for MonoRFA vs. 0.02%, 7.9% and 9.2% for NTmbpRFA, p<0.001. Monopolar RFA, tumour size >30mm and HCC near large vessel were independent factors associated with global RFA failure. Five-year OS was 37.2% following MonoRFA vs. 46.4% following NTmbpRFA p=0.378. CONCLUSIONS This large multicentre case-matched study showed that NTmbpRFA provided better primary RFA success and sustained local tumour response without increasing severe complications rates, for HCC ⩽5cm. LAY SUMMARY Using no-touch multi-bipolar radiofrequency ablation for hepatocellular carcinoma ⩽5cm provide a better sustained local tumour control compared to monopolar radiofrequency ablation.

Radiofrequency ablation versus surgical resection for hepatocellular carcinoma within the Milan criteria: A study of 281 Western patients

Abstract Objectives: The aim of this study was to compare survival between radiofrequency ablation (RFA) and surgical resection (SR) in patients with hepatocellular carcinoma (HCC) within Milan criteria. Methods: From January 2004 to December 2013 we consecutively and retrospectively included all patients with first occurrence of HCC within Milan criteria receiving SR or RFA as first-line treatment. The cumulative overall survival (OS) and disease-free survival (DFS) were compared after inverse probability weighting (including confounding factor). Results: A total of 281 patients (RFA 178, SR 103) were enrolled. In multivariate Cox regression RFA and SR were not independent predictors of survival or recurrence. The respective weighted 5 years OS and DFS for patients with propensity scores between 0.1–0.9 in the SR and RFA groups were 54–33% and 60–16.9%, P = 0.695 and P = 0.426, respectively. Local tumour progression rate did not differ according to treatment (P = 0.523). Major complication rate was higher in the SR group, P = 0.001. Hospitalisation duration was lower in the RFA group (mean 2.19 days, range 2–7) than in the SR group (mean 10.2 days, range 3–30), P < 0.001. Conclusion: This large Western study has shown that OS and DFS did not differ after RFA (using mainly multipolar devices) and SR, for HCC within the Milan criteria in a European population, with a shorter hospitalisation time and a lower complication rate for RFA.

MR relaxometry in chronic liver diseases: Comparison of T1 mapping, T2 mapping, and diffusion-weighted imaging for assessing cirrhosis diagnosis and severity

BACKGROUND MR relaxometry has been extensively studied in the field of cardiac diseases, but its contribution to liver imaging is unclear. We aimed to compare liver and spleen T1 mapping, T2 mapping, and diffusion-weighted MR imaging (DWI) for assessing the diagnosis and severity of cirrhosis. METHODS We prospectively included 129 patients with normal (n=40) and cirrhotic livers (n=89) from May to September 2014. Non-enhanced liver T1 mapping, splenic T2 mapping, and liver and splenic DWI were measured and compared for assessing cirrhosis severity using Child-Pugh score, MELD score, and presence or not of large esophageal varices (EVs) and liver stiffness measurements using Fibroscan(®) as reference. RESULTS Liver T1 mapping was the only variable demonstrating significant differences between normal patients (500±79ms), Child-Pugh A patients (574±84ms) and Child-Pugh B/C patients (690±147ms; all p-values <0.00001). Liver T1 mapping had a significant correlation with Child-Pugh score (Pearsons correlation coefficient of 0.46), MEDL score (0.30), and liver stiffness measurement (0.52). Areas under the receiver operating characteristic curves of liver T1 mapping for the diagnosis of cirrhosis (O.85; 95% confidence intervals (CI), 0.77-0.91), Child-Pugh B/C cirrhosis (0.87; 95%CI, 0.76-0.93), and large EVs (0.75; 95%CI, 0.63-0.83) were greater than that of spleen T2 mapping, liver and spleen DWI (all p-values<0.01). CONCLUSION Liver T1 mapping is a promising new diagnostic tool for assessing cirrhosis diagnosis and severity, showing higher diagnostic accuracy than liver and spleen DWI, while T2 mapping is not reliable.

Magnetic resonance-guided high-intensity focused ultrasound for uterine fibroids: Mid-term outcomes of 36 patients treated with the Sonalleve system

Abstract Objectives: This study sought to assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MRgFUS) (Sonalleve system) for uterine fibroids. Methods: We retrospectively included patients treated by MRgFUS controlled by real-time MR-thermometry. Clinical efficacy was defined as the minimum reduction of ten points in the Transformed Symptom Severity Score (tSSS) without additional treatment. Fibroid volumes were assessed at 6 months, and patients were contacted to assess mid-term efficacy using tSSS. Results: Thirty-six patients were included; 22 patients (61.1%) exhibited clinical efficacy with a mean follow-up duration of 21.4 (95%CI: 16.3–26.5) months. In addition, the tSSS mean decreased significantly from 42.8 ± 16 to 25.4 ± 18 (p < 0.0001). MRgFUS exhibited a preferential effect on menorrhagia (p = 0.001) and symptoms related to pelvic heaviness and swelling (p = 0.004). The volume reduction was 27% (p < 0.001) and was correlated with the non-perfused volume (NPV) after treatment (r = 0.373; p = 0.028). Cumulative re-intervention rates (surgery or uterine artery embolisation) at 12 months, 18 months and 24 months were 2.8%, 8.5% and 21.6%, respectively. No serious adverse events were reported. Two pregnancies occurred during the follow-up period. Conclusions: Treatment of uterine fibroids by MRgFUS is efficient and results in low morbidity and satisfactory clinical efficacy with a mean follow-up of 21.4 months.

Three-Dimensional Measurement Of hepatocellular carcinoma Ablation Zones And Margins For Predicting Local Tumor Progression

PURPOSE To propose a postprocessing technique that measures tumor surface with insufficient ablative margins (≤ 5 mm) on magnetic resonance (MR) imaging to predict local tumor progression (LTP) following radiofrequency (RF) ablation. MATERIALS AND METHODS A diagnostic method is proposed based on measurement of tumor surface with a margin ≤ 5 mm on MR imaging. The postprocessing technique includes fully automatic registration of pre- and post-RF ablation MR imaging, a semiautomatic segmentation of pre-RF ablation tumor and post-RF ablation volume, and a subsequent calculation of the three-dimensional exposed tumor surface area. The ability to use this surface margin ≤ 5 mm to predict local recurrence at 2 years was then tested on 16 patients with cirrhosis who were treated by RF ablation with a margin ≤ 5 mm in 2012: eight with LTP matched according to tumor size and number and α-fetoprotein level versus eight without local recurrence. RESULTS The error of estimated tumor surface with a margin ≤ 5 mm was less than 12%. Results of a log-rank test showed that patients with a tumor surface area > 425 mm(2) had a 2-year LTP rate of 77.5%, compared with 25% for patients with a tumor surface area ≤ 425 mm(2) (P = .018). CONCLUSIONS This proof-of-concept study proposes an accurate and reliable postprocessing technique to estimate tumor surface with insufficient ablative margins, and underscores the potential usefulness of tumor surface with a margin ≤ 5 mm to stratify patients with HCC treated by RF ablation according to their risk of LTP.

Transarterial chemoembolization for early stage hepatocellular carcinoma decrease local tumor control and overall survival compared to radiofrequency ablation

Background & Aims To compare treatment failure and survival associated with ultrasound-guided radiofrequency ablation (RFA) and trans-arterial chemoembolization (TACE) for early-stage HCC in Child-Pugh A cirrhosis patients. Methods 122 cirrhotic patients (RFA: 61; TACE: 61) were well matched according to cirrhosis severity; tumor size and serum alpha-fetoprotein. TACE was performed in case of inconspicuous nodule on US or nodule with “at risk location”. Treatment failure was defined as local tumor progression (LTP) and primary treatment failure (failing to obtain complete response after two treatment session). Treatment failure and overall survival (OS) were compared after coarsened exact matching. Cox proportional model to assess independent predictive factors was performed. Results No significant difference was seen for baseline characteristics between the two groups. Mean tumor size was 3cm in both group with 41% HCC>3cm. Treatment failure rates after TACE was 42.6% (14 primary treatment failures and 12 LTP) and 9.8% after RFA (no primary treatment failure and 6 LTP) P < 0.001. TACE was the only predictive factor of treatment failure (Hazard ratio: 5.573). The 4-years OS after RFA and TACE were 54.1% and 31.5% (P = 0.042), respectively. Conclusion For Child-Pugh A patients with early-stage HCC, alternative treatment as supra-selective TACE to RFA regarded as too challenging using common US guidance decrease significantly the local tumor control and overall survival. Efforts to improve feasibility of RFA especially for inconspicuous target have to be made.

Aggressive Intrasegmental Recurrence of Periportal Hepatocellular Carcinoma after Radiofrequency Ablation: Role of Ablative Technique and Heat-Sink Effect?

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Could Monopolar Mode be a Suitable Strategy of Energy Deposition for Performing No-Touch Radiofrequency Ablation of Liver Tumor ≤ 5 cm?

Dear Editor, We read with great interest the study by Chang et al. [1]. Pursuing their considerable efforts in bringing scientific evidence of usefulness of no-touch ablation concept for the treatment of liver tumors [2, 3], they compared no-touch radiofrequency ablation (RFA) of patients bearing hepatocellular carcinoma up 5 cm in size, using multimonopolar (mM) versus multi-bipolar (mB) modes. While multi-bipolar mode required less number of ablations within shorter overall ablation times, they concluded that either mode could be favorably used for no-touch ablation of HCCs B 5 cm because local tumor progression (LTP)free survival rates were comparable in both groups. In our opinion, this apparent cautious conclusion is questionable regarding their results of preclinical and clinical studies. Although difference of LTP rates between the two groups was not statically significant, as authors mentioned, due to retrospective design of the study they did not emitted hypothesis and proper calculation of sample size. Thus, regarding the small number of patients recruited, the trend to achieve with mB better sustained local tumor control in shorter time with less electrodes repositioning would support a conclusion a little bit more favorable to this mode for applying no-touch ablation concept. In fact, as the authors have already nicely demonstrated in their previous experimental study [2], the centripetal energy deposition allowed by a given multi-straight-needle RF device working in mB mode is a strong physical rational for choosing it instead of mM mode [4]. Moreover, although authors did not use the same device in the two arms, the mB mode had again far better efficiency in delivering energy at the tumors since with less electrodes repositioning, and energy produced, it induced comparable volume of ablation within shorter time. It is of interest to point out that authors produced approximately twofolds more energy in mM than in mB arm for the treatment of comparable nodules in size. This apparently paradoxical result seems contradict the relationship existing between the amount of energy delivered at the tissue and the volume of ablation induced [5]. In reality, because half of energy produced with mM mode is delivered at ground pads, the energetic efficiency of such device is divided by 2 in comparison with mB mode. Thus, not surprisingly the volumes of tissue ablated were comparable between the two technics on condition to produce with mM mode twice more RF energy than with mB mode. A last technical point which calling some comments is the authors’ claim that internally cooled wet (ICW) electrode devices for performing mB procedures were mandatory because the internally cooled dry method (ICD) & Olivier Seror olivier.seror@aphp.fr

Optimal multibipolar parameters should overcome heat-sink effect

We read with great interest the well-written and very informative article of Franz G. M. Poch and co-worker assessing the vascular cooling effect in hepatic multibipolar radiofrequency ablation (RFA) [1] and concluded that multibipolar RFA is significantly impacted by heat-sink effect. As recalled by the authors, heat-sink effect is a major cause of local tumour progression and multibipolar RFA has been developed to overcome this problem by delivering higher energy than monopolar RFA. In our recent study, we found that multibipolar RFA provides improved sustained tumour control compared with monopolar RFA for hepatocellular carcinoma near vessels >3mm diameter [2]. The local progression rates for multipolar vs. monopolar RFA were 12.5 and 40%, respectively. We wish to discuss several points on the RFA procedure that could explain the discordance between our clinical results vs. the ex vivo results of Poch et al.: