Franca Meloni

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice?

If liver transplantation is not feasible, partial resection is considered the treatment of choice for hepatocellular carcinoma (HCC) in patients with cirrhosis. However, in some centers the first‐line treatment for small, single, operable HCC is now radiofrequency ablation (RFA). In the current study, 218 patients with single HCC ≤ 2.0 cm (very early or T1 stage) underwent RFA. We assessed 2 primary end points that could be easily compared with those reported for resective surgery: (1) the rate of sustained, local, complete response and (2) the rate of treatment‐related complications. The secondary end point was 5‐year survival in the 100 patients whose tumors had been considered potentially operable. After a median follow‐up of 31 months, sustained complete response was observed in 216 patients (97.2%). In the remaining 6, percutaneous ethanol injection, selective intraarterial chemoembolization, or resection were used as salvage therapy. Perioperative mortality, major complication, and 5‐year survival rates were 0%, 1.8%, and 68.5%, respectively. Conclusion: Compared with resection, RFA is less invasive and associated with lower complication rate and lower costs. RFA is also just as effective for ensuring local control of stage T1 HCC, and it is associated with similar survival rates (as recently demonstrated by 2 randomized trials). These data indicate that RFA can be considered the treatment of choice for patients with single HCC ≤ 2.0 cm, even when surgical resection is possible. Other approaches can be used as salvage therapy for the few cases in which RFA is unsuccessful or unfeasible. (HEPATOLOGY 2007.)

Radiofrequency thermal ablation of hepatocellular carcinoma.

Radiofrequency (RF) ablation resulted in a higher complete necrosis than percutaneous ethanol injection (PEI), above all in infiltrating lesions, and requires fewer treatment sessions in the treatment of small size tumors. We achieved 90% of complete necrosis in hepatocellular carcinoma (HCC)<3 cm, 71% in medium (3-5 cm) and 45% in large (5.1-9 cm) HCC. However, near complete necrosis was obtained in the majority of the remaining tumors. PEI is preferable in lesions at risk with RF, i.e. adjacent to main biliary ducts or to intestinal loops. Our current 3-yr survival in child A patient with single HCC<5 cm is 85%.

Multimodal image-guided tailored therapy of early and intermediate hepatocellular carcinoma: Long-term survival in the experience of a single radiologic referral center

The best treatment policy for some patients with hepatocellular carcinoma (HCC) and compensated cirrhosis is still controversial. The aim of this study was to evaluate the long‐term survival and related prognostic factors of patients with early and intermediate HCC (Liver Unit of Barcelona classification) treated in a radiologic referral center by a multimodal image‐guided tailored therapy (MIGTT), applied over time, choosing the procedure patient by patient according to the presentation of the disease. Between May 1996 and May 2003, 374 patients (210 with early and 164 with intermediate HCC) were treated with MIGTT. Radiofrequency ablation was considered the first choice; ethanol injection was preferred for nodules at risk for radiofrequency; and selective chemoembolization was preferred for nodules not recognizable at ultrasound examination, those not retreatable after an unsuccessful ablation technique, or for satellites. The rate of perioperative mortality and major complications was 0.2% and 4.5%, respectively. The 1‐, 3‐, and 5‐year survival rates were 90%, 69%, and 49% and 83%, 43%, and 28% for patients with early and intermediate HCC, respectively. At the univariate analysis, the indicators of a poor prognosis were Childs class B, portal hypertension, abnormal bilirubin, infiltrating tumor, and abnormal serum alpha‐fetoprotein (AFP) level. In conclusion, within the limits of historical comparisons, in early HCC, MIGTT should be considered an appropriate option for unresectable patients or for resectable patients presenting with adverse prognostic factors. In intermediate HCC, the 3‐year survival rate obtained with MIGTT was better than the best survival rate reported with conventional chemoembolization; however, the benefit for patients presenting with poor prognostic factors remains unclear. (Liver Transpl 2004;10:S98–S106.)

Recall strategies for patients found to have a nodule in cirrhosis: is there still a role for CEUS?

Development of liver tumors and their evolution to hepatocellular carcinoma (HCC) is a multi-step process in which different HCC-etiologies induce continuous rounds of hepatocyte damage and regeneration. Over an extended time, this triggers cirrhosis which is a pathological state of the liver in which lesions can progress to become dysplastic nodules. Later, these nodules may evolve into HCC and occasionally generate metastatic events. To provide optimal care, patients with liver cancer should be managed using a multidisciplinary approach in specialized centers in which all the diagnostic and therapeutic resources are available. Among the different imaging modalities the introduction on contrast agents for ultrasound use has opened new further applications in different clinical settings. In fact, contrast enhanced ultrasound (CEUS) has been applied for more than ten years and plays increasingly important roles in the management of HCC. Since early 2000, international societies including the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific association for the Study of the Liver (APASL), the Japanese society of Hepatology (JSH), the Italian society for the study of the liver (AISF), the World Federation for Ultrasound in Medicine and Biology (WFUMB), and the European Federation of Societies for Ultrasound in Medicine and Biology (EFUSMB) have discussed the important role of CEUS in the diagnosis of HCC. In the present review an update of the literature and a detailed discussion of the present Guidelines regarding the role of CEUS in the evaluation of nodules in cirrhotic patients is offered.

Percutaneous Ablation Therapy of Hepatocellular Carcinoma

Local-regional therapies are those treatment modalities which, by the percutaneous route, allow the introduction of a damaging agent directly into the neoplastic tissue. It is understood that such therapies are indicated only for those pathologies limited to a single organ, like hepatocellular carcinoma (HCC) not in an advanced stage. Local-regional therapies may be based on the use of means capable of destroying the tissue chemically, such as with ethyl alcohol (percutaneous ethanol injection, PEI) or acetic acid, or physically (thermal), as with laser, microwave or radiofrequency (RF). PEI was the first to be proposed (1). On the basis of its rationale and the results obtained, the other therapies were subsequently designed (2-5). This chapter considers mainly PEI, which is the most diffused and codified, and RF therapy, whose recent results indicate a wide development.