Nicolas Sellier

Radiofrequency ablation of hepatocellular carcinoma: Long‐term results and prognostic factors in 235 Western patients with cirrhosis

For the treatment of small hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) is in some centers considered a first‐line therapeutic option. However, such a strategy is still under debate with regard to tumor and patient characteristics. In this single‐center study we assessed the 5‐year survival and prognosis factors in 235 consecutive patients with cirrhosis (Child‐Pugh A/B: 205/30) who received RFA as first‐line treatment for up to three HCC ≤5 cm (307 tumors; mean diameter: 29 ± 10 mm; 53 multinodular forms). Among these patients, 67 satisfied the criteria for resection according to the Barcelona Clinic Liver Cancer. Complete ablation was obtained in 222 patients (94%). Overall, 337 RFA sessions were performed including iterative RFA for recurrence. Major complications occurred in three patients (0.9%), including one treatment‐related death. After 27 ± 20 months of mean follow‐up, local or distant, or both, tumor recurrence occurred in 16, 88, and 11 patients, respectively. Twenty‐nine patients underwent transplantation and were removed from the study at this point. Overall 5‐year, recurrence‐free, and tumor‐free (including results of iterative RFA) survival rates were, respectively, 40%, 17%, and 32%. The overall 5‐year survival rate was 76% for operable patients. Factors associated with overall survival were prothrombin activity (hazard ratio [HR] = 0.97, 0.96–0.98; P < 0.0001) and serum levels of α‐fetoprotein (AFP) (HR = 1.02, 1.02–1.02; P < 0.0001), and factors associated with tumor recurrence were multinodular forms (HR = 2.34; 1.52–3.6; P = 0.0001) and serum AFP levels (HR = 1.015, 1.014–1.016; P = 0.015). Tumor size was associated with local recurrence but not with overall and tumor‐free survival. Conclusion: RFA is a safe and effective first‐line treatment of HCC up to 5 cm in diameter, especially for patients with a single tumor, a low serum AFP level, and well‐preserved liver function. (HEPATOLOGY 2009.)

Large (≥5.0-cm) HCCs: Multipolar RF Ablation with Three Internally Cooled Bipolar Electrodes—Initial Experience in 26 Patients

PURPOSE To prospectively evaluate the safety and effectiveness of percutaneous multipolar radiofrequency (RF) ablation for the treatment of large (>or=5.0 cm in diameter) hepatocellular carcinomas (HCCs). MATERIALS AND METHODS Twenty-six patients (four women, 22 men; median age, 72 years) with cirrhosis (Child-Pugh class A disease, 22 patients; Child-Pugh class B disease, four patients) and at least one 5.0-9.0-cm-diameter HCC without invasion of the portal trunk or main portal branches were treated with multipolar RF ablation performed by a single operator. The procedure was performed with three separate bipolar linear internally cooled electrodes with ultrasonographic guidance. Twenty-seven of the 33 tumors treated had a diameter of 5.0 cm or greater (median diameter, 5.7 cm; range, 5.0-8.5 cm); 12 of these 27 tumors were infiltrative, and four invaded segmental portal vein branches. Ten patients had a serum alpha-fetoprotein level higher than 400 microg/L. Results were assessed by using computed tomography. Primary effectiveness, complications, tumor progression, and survival rates were recorded. Probabilities of survival were calculated by using the Kaplan-Meier method. RESULTS One to two RF ablation procedures per patient (mean, 1.15 +/- 0.43 [standard deviation]) led to the complete ablation of 22 (81%) of the 27 tumors (18 tumors after one and four tumors after two procedures), including three tumors that showed segmental portal vein invasion. All patients experienced postablation syndrome, and one experienced subcapsular hematoma and a segmental liver infarct, but no major complication occurred. After a mean follow-up of 14 months (range, 3-34 months), local and distant tumor progression and actual survival rates were 14% (three of 22), 24% (five of 21), and 65% (17 of 26), respectively. The probabilities of 1- and 2-year survival, respectively, were 68% (95% confidence interval: 49%, 86%) and 56% (95% confidence interval: 51%, 81%). CONCLUSION HCCs larger than 5.0 cm (but smaller than 9.0 cm)--even those that are infiltrative and those that involve a segmental portal vein--can be completely and safely ablated with multipolar RF ablation.

L'imagerie de susceptibilité magnétique : théorie et applications

Resume L’imagerie de susceptibilite magnetique (ou SWI pour Susceptibility Weighted Imaging) est une nouvelle technique d’imagerie par resonance magnetique exploitant l’effet BOLD et les differences de susceptibilite magnetique entre tissus. Elle utilise une sequence 3D en echo de gradient caracterisee d’une part, par un temps d’echo long, choisi de facon a annuler de facon optimale le signal des veines et d’autre part un post-traitement specifique faisait intervenir les images de phase comme source de contraste supplementaire. Elle est particulierement utile pour la detection des veines normales ou pathologiques. Elle detecte les hemorragies, notamment celles de petite abondance mieux que les sequences en echo de gradient conventionnel. Son utilisation est encore limitee du fait d’un temps d’acquisition long et de la persistance d’artefacts.

Survival after radiofrequency ablation and salvage transplantation in patients with hepatocellular carcinoma and Child-Pugh A cirrhosis

BACKGROUND & AIMS In patients with hepatocellular carcinoma (HCC) within the Milan criteria, liver transplantation (LT) may be the best therapeutic option. However, the shortage of grafts, leads to attempt liver resection (LR) or radiofrequency ablation (RFA) as a first-line treatment for patients with Child-Pugh A cirrhosis. METHODS We report results, obtained between 2000 and 2007 from a single center, involving 67 patients (mean age: 57 years) eligible for LT, who were treated with RFA, followed by LT if there was recurrence or liver failure. RESULTS Eighty three tumors were treated (mean size: 29±9 mm; 16 binodular forms). RFA achieved complete ablation in 96% of nodules. No mortality occurred. During a post-RFA median follow-up of 48 months, 38 patients experienced recurrence, corresponding to a 5-year recurrence rate of 58%. Of these, 14 patients did not receive a transplant because they fell outside the Milan criteria, 21 were transplanted, and 3 were treated by RFA after refusing LT. Binodularity (95% CI HR=2, 1.0-4.0; p=0.049) was the unique risk factor for recurrence. By the studys end-point, 24 patients had undergone LT (21 for HCC recurrence and three for liver failure). No HCC recurrence occurred after LT. Among the 43 non-transplant patients, 12 died due to HCC progression, and 27 were alive without detectable viable tumor. The probability rates for 5-year overall and tumor-free survival were 74% and 69%, respectively. CONCLUSIONS First line RFA followed by salvage LT allows survival figures that are at least as good as a first-line LT, while limiting the number of grafts.

Radiofrequency Ablation for the Treatment of Liver Tumors in the Caudate Lobe

PURPOSE To evaluate the effectiveness of radiofrequency (RF) ablation for liver tumors located in the caudate lobe. MATERIALS AND METHODS Ten patients (46-79 years of age; median, 70 y), eight with hepatocellular carcinoma (HCC) and cirrhosis and two with colorectal metastases in the caudate lobe, were treated with 5.8% NaCl tissue-perfused monopolar (n=7) or bipolar (n=3) RF ablation. The median tumor diameter was 41 mm (range, 25-70 mm). Procedures were performed under ultrasound and computed tomography (CT) guidance in eight and two patients, respectively. One month later, the treatment response was assessed by CT. RESULTS Transhepatic right intercostal and transomental anterior epigastric routes were used for tumor puncture in eight and two patients, respectively. The entire RF ablation treatment required one or two procedures (median, 1.5), including two to 15 electrode repositionings (median, 6). After RF ablation procedure, one patient experienced jaundice that resolved spontaneously. In one patient, CT follow-up showed asymptomatic segmental biliary duct dilations. Median total hospital stay was 3 days (range, 2-9 d). Complete ablation was achieved in nine of 10 tumors. In one patient, ethanol ablation was necessary to complete RF ablation treatment. After a median follow up of 9.5 months (range, 5-25 mo), three patients remained tumor-free and seven had tumor relapse: two local, four distant, and one mixed. Repeat RF ablation was successfully performed in four cases. CONCLUSION RF ablation of liver tumors located in the caudate lobe is effective despite the deep location of tumors and the vicinity of major vessels.

Hepatocellular Carcinoma within Milan Criteria: No-Touch Multibipolar Radiofrequency Ablation for Treatment—Long-term Results

Purpose To assess the long-term outcome in 108 consecutive patients treated with no-touch multibipolar radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) that met the Milan criteria. Materials and Methods This retrospective study was approved by the ethical review board, and the need to obtain informed consent was waived. Between November 1, 2006, and December 31, 2011, 132 HCC tumors (diameter, 10-45 mm; 39 tumors ≥ 30 mm) in 108 consecutive patients (106 with cirrhosis) that met Milan criteria were treated with no-touch multibipolar RFA, which consisted of activating, in bipolar mode, three or four electrodes inserted just beyond the tumor margins. Follow-up was performed every 3 months for 2 years and every 6 months thereafter with computed tomographic or magnetic resonance imaging. Survival probabilities were computed by using the Kaplan-Meier method. Predictive factors of tumor progression and overall survival were assessed by using the Cox proportional hazard model. Results No technical failure occurred, and complete ablation was achieved for all the nodules. After a median of 40.5 months (range, 2-84 months) of follow-up, 3- and 5-year local and overall tumor progression-free survival were 96%, 94%, 52%, and 32%, respectively. Neither tumor diameter greater than 30 mm nor location abutting a large vessel were associated with local tumor progression. Tumor diameter greater than 30 mm was the only parameter predictive of overall tumor progression (P = .0036). Independent factors associated with shorter overall survival were Child-Pugh class B disease, age greater than 65 years, and platelet count of less than 150 g/L (P < .003). Three major complications occurred (2.7%): hemothorax in one patient and liver failure in two, with major portal-systemic shunts. One patient (0.9%) died, and one underwent transplantation. Conclusion No-touch multibipolar RFA for HCC tumors that meet Milan criteria provides a high local tumor progression-free survival rate. An ongoing randomized trial might help to clarify the role of this new approach for the treatment of early HCC. (©) RSNA, 2016 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on March 30, 2016.

Ethanol versus radiofrequency ablation for the treatment of small hepatocellular carcinoma in patients with cirrhosis: A retrospective study of efficacy and cost

OBJECTIVE To compare cost effectiveness of radio-frequency (RF) ablation versus percutaneous ethanol (Pe) ablation for treatment of small hepatocellular carcinoma. METHODS 57 patients with 72 hepatocellular carcinomas (HCC) treated with ethanol ablation were retrospectively compared with 60 new patients who had 72 HCC treated with RF ablation. All patients had Child-Pugh A cirrhosis and HCC less than 3.5 cm in diameter. Therapeutic efficacy was evaluated with tri-phase spiral computed tomography. Cost of hospital stay, supplies and follow-up including complications were calculated. Survival was estimated by Kaplan-Meier method and prognostic value of treatment methods by Log Rank test and multivariate Cox proportional hazard model. RESULTS The two groups had similar baseline characteristics. The rate of severe complications associated with RF was 15% (9/60) vs 6,9% (9/60) with Pe (P=0,11) The two-year overall survival, disease free survival and local tumor free survival in the ethanol and radiofrequency groups were 70.8% vs. 91.2% (Odd Ratio=3.7, P=0.006), 48.6% vs. 71.1% (Odd Ratio=2.2, P=0.01), and 68.5% vs. 80.7%, (Odd Ratio=1.9; P=0.09), respectively. The treatment method was the sole significant factor related to overall and tumor free survival. Costs per patient of ethanol and radiofrequency treatments were 1534 euro and 1196 euro, respectively. CONCLUSION This retrospective study suggests that RF is the most cost effective strategy, with higher 2-year disease free survival rate.

Radiofrequency Ablation with Internally Cooled versus Perfused Electrodes for the Treatment of Small Hepatocellular Carcinoma in Patients with Cirrhosis

PURPOSE To compare the results of radiofrequency (RF) ablation with internally cooled electrodes (ICEs) versus perfused electrodes (PEs) in patients with cirrhosis with small (<or=3 cm) hepatocellular carcinoma ineligible for resection. MATERIALS AND METHODS Patients treated with RF ablation over two consecutive periods were analyzed retrospectively. From 2000 to 2002, 45 patients were treated with 17-gauge ICEs, and from 2002 to 2004, 44 patients were treated with 15-gauge PEs. The two groups were similar in age, sex, Child-Pugh stage, serum alpha-fetoprotein (AFP) level, and size and number of tumors (54 tumors in each group). Results were assessed by contrast medium-enhanced CT. RESULTS In both groups, 52 of 54 tumors (96.3%) were completely ablated. Eight of 54 tumors (14.8%) treated with ICEs and 39 of 54 tumors (72.2%) treated with PEs required multiple RF applications (P<.00005). In the respective groups, one of 54 tumors (1.8%) and seven of 54 tumors (12.9%) required multiple RF sessions (P=.03). Complication rates were similar. The 2-year probabilities of local and distant (ie, separated from the ablation zone) tumor progression in the ICE and PE groups were 11% and 15%, respectively (P=.65), and 31% and 64% (P=.01), respectively. On multivariate analysis, serum AFP level greater than 100 ng/mL (P=.006) and the use of a PE (P=.003) were risk factors for distant tumor progression. CONCLUSIONS RF ablation with the use of a PE requires more applications and sessions and is associated with a higher risk of distant tumor progression compared with the use of an ICE.

Bone mineral density assessed by dual-energy X-ray absorptiometry in patients with viral or alcoholic compensated cirrhosis. A prospective study

BACKGROUND/AIM Cirrhosis is considered as a risk factor for osteoporosis whose prevalence is poorly known. The aim was to assess prospectively bone mineral density (BMD) in patients with alcoholic or viral compensated cirrhosis. METHODS From 2006 to 2008, patients with viral or alcoholic compensated cirrhosis had BMD assessment by dual-energy X-ray absorptiometry. The prevalence of osteopenia (-2.5SD <T-score<-1SD) and osteoporosis (T-score ≤-2.5SD), and the influence of age, gender and aetiology of cirrhosis were assessed using univariate and multiple regression analysis. RESULTS One hundred and nine patients were studied (72 men, 55.3 ± 11.4 years and 37 women, 65.2 ± 11.0); with HBV (n=35), HCV (n=43), or alcoholic cirrhosis (n=31). At the lumbar spine, 25 patients had osteopenia and 12 had osteoporosis. At the femoral site, 23 had osteopenia and 4 had osteoporosis. Female gender had an independent decreased effect on the total BMD. CONCLUSIONS The prevalence of osteoporosis was up to 11% at the lumbar spine, greater in women independently of age, without significant difference according to the aetiology of cirrhosis.

Percutaneous retrograde endovascular occlusion for pediatric varicocele

BACKGROUND/PURPOSE The aim of this study was to assess whether percutaneous retrograde endovascular occlusion (PREVO) is effective and safe for the treatment of varicocele in pediatric patients. METHODS We retrospectively studied 71 children who underwent PREVO for left-sided varicocele. The primary outcome was the proportion of varicocele-free patients 6 months after PREVO as assessed by ultrasonography. RESULTS Seventy-one boys with left-sided grade III varicocele underwent PREVO at a mean age of 13.2 years. PREVO was performed under local anesthesia in all boys but 2, who required general anesthesia. The procedure was technically feasible in 68 (96%) patients. In the remaining 3 patients, the internal spermatic vein could not be catheterized. Minor short-term complications occurred in 6 patients and resolved fully. No major complications or deaths were recorded. The proportion of varicocele-free patients 6 months after PREVO was 93% (66/71) overall and 97% (66/68) in the patients whose PREVO procedure was feasible. No clinical recurrence was observed during the mean follow-up of 17.5 months. CONCLUSIONS Percutaneous retrograde endovascular occlusion is an effective minimally invasive approach for varicocele treatment in pediatric patients. It can be safely performed on an outpatient basis under local anesthesia.