Tito Livraghi

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.)

Percutaneous etharrol injection in the treatment of hepatocellular carcinoma in cirrhosis. A study on 207 patients

In 207 cirrhotic patient carriers of hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) was administered with ultrasound guidance. The patients were classified as Childs Class A, 136; B, 54; and C, 17. Their mean age was 63.5 years, and the male‐female ratio was 3.5:1. There was a single HCC less than 5 cm in diameter in 162 patients; 45 had more than one HCC. The follow‐up ranged from 5 to 71 months (mean, 25 months). No noteworthy complications occurred during or after 2485 treatments. The 1‐year, 2‐year, and 3‐year survival percentages (by the Kaplan‐Meier method) for the patients with one HCC were 90%, 80%, and 63%, respectively. The corresponding percentages by Childs class were 97%, 92%, and 76% for Class A; 88%, 68%, and 42% for B; and 40%, 0%, and 0% for C. The 1‐year, 2‐year, and 3‐year survival rates for patients with more than one HCC were 90%, 67%, and 31%, respectively. These results were similar to those found by others and showed that PEI was a safe, reproducible, easy‐to‐do, and low‐cost therapeutic technique. In terms of survival, these PEI results were better than the published results of no treatment and equivalent to those of surgery. In uncontrolled series, bias can play an important role. Therefore, additional trials would be useful. Cancer 1992; 69: 925–929.

Image-guided Tumor Ablation: Standardization of Terminology and Reporting Criteria—A 10-Year Update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

Image-guided tumor ablation: standardization of terminology and reporting criteria.

The field of interventional oncology with use of image-guided tumor ablation requires standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison between treatments that use different technologies, such as chemical (ethanol or acetic acid) ablation, and thermal therapies, such as radiofrequency (RF), laser, microwave, ultrasound, and cryoablation. This document provides a framework that will hopefully facilitate the clearest communication between investigators and will provide the greatest flexibility in comparison between the many new, exciting, and emerging technologies. An appropriate vehicle for reporting the various aspects of image-guided ablation therapy, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings, are outlined. Methods for standardizing the reporting of follow-up findings and complications and other important aspects that require attention when reporting clinical results are addressed. It is the groups intention that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication in this field that lead to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes. The intent of this standardization of terminology is to provide an appropriate vehicle for reporting the various aspects of image-guided ablation therapy.

No treatment, resection and ethanol injection in hepatocellular carcinoma: a retrospective analysis of survival in 391 patients with cirrhosis

BACKGROUND/AIMS This retrospective study was undertaken to obtain information relevant to the therapeutic strategy in single hepatocellular carcinoma associated with Childs A and B cirrhosis. METHODS From a total of 1108 consecutive patients with hepatocellular carcinoma, 391 patients with single, small (< or = 5 cm) hepatocellular carcinoma (260 in Child A class and 131 in Child B class) were observed: 120 were treated by surgical resection, 155 by percutaneous ethanol injection and 116 were untreated. The end point of the study was 3-year survival. The log rank test was used to compare survival among the different groups. RESULTS In the Child A group the cumulative 3-year survival was 79% for surgery, 71% for percutaneous ethanol injection and 26% for no treatment (p < 0.001 for surgery versus no treatment, p < 0.001 for percutaneous ethanol injection vs no treatment). In patients comparable to the surgical group, i.e. potentially operable, survival was 80% for percutaneous ethanol injection and 30% for no treatment. In the Child B group the 3-year survival was 40% for surgery, 41% for percutaneous ethanol injection and 13% for no treatment (p < 0.01 for surgery vs no treatment and p < 0.001 for percutaneous ethanol injection vs no treatment). CONCLUSIONS Surgery and percutaneous ethanol injection improve survival in single hepatocellular carcinoma associated with Child A and B cirrhosis compared to untreated patients in the same Child class. A controlled study to identify factors affecting the choice of treatment is justified.

Percutaneous Ethanol Injection in the Treatment of Hepatocellular Carcinoma: A Multicenter Survey of Evaluation Practices and Complication Rates

BACKGROUND Percutaneous ethanol injection (PEI) has become a widely used procedure in the treatment of hepatocellular carcinoma (HCC). However, the criteria for selecting patients are not standardized, and little information is available about the complications of the procedure. METHODS A questionnaire was sent to 11 experienced Italian centers. It investigated: the size and the number of HCC nodules suitable for treatment and the Child-Pugh risk class of the associated cirrhosis; the performance of the procedure; the number and characteristics of the patients treated; and, finally, any complications. RESULTS Most of the centers performed PEI in single HCC nodules less than 5 cm in diameter or in multiple nodules if fewer than three, the larger being less than 3 cm. Patients in Child-Pughs classes A, B, and C with single nodules were generally considered for PEI. A prothrombin time of less than 40% and a platelet count of less than 40,000/mm3 contraindicated PEI in most of the centers. PEI was generally performed on outpatients, using Chiba or spinal needles. One thousand and sixty-six patients (8118 sessions) were enrolled; 74% had a single HCC nodule and 26% multiple nodules. All except four had cirrhosis; 53% were in Child class A, 38% in class B, and 9% in class C. The mean number of sessions needed to destroy an HCC nodule was 6.7 (range, 2-14), with a mean alcohol injection volume of 5.0 ml per session (range, 2-20 ml). One death (0.09%) and 34 complications (3.2%) were reported. Among the complications we call attention to the hemorrhagic ones (eight cases) and tumoral seeding (seven cases). Severe pain experienced during the maneuver led to discontinuation of the procedure in 3.7% of the patients; 13.5% of the patients required analgesics and 24% had fever after PEI. CONCLUSIONS Some procedural aspects of PEI treatment differ among the various centers a standardization is advisable. In the present survey PEI is a low-risk technique.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update.

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes.

Ultrasound-guided fine-needle biopsy of focal liver lesions: techniques, diagnostic accuracy and complications: A retrospective study on 2091 biopsies

Two thousand and ninety-one ultrasound-guided fine-needle biopsies were performed in 1946 patients to diagnose focal liver lesions. The diagnostic accuracy of fine-needle biopsies is very high (only one false positive was observed), both for aspiration biopsy (93.4%) and for cutting biopsy (95.1%). The difference is not statistically significant. In cases of hepatocellular carcinoma (but not in cases of metastasis or hepatic lymphoma), double biopsy (aspiration and cutting) showed higher diagnostic sensitivity than single methods. A certain number of benign focal liver lesions were also diagnosed. In the present series, no case of death following liver puncture was observed. Intraperitoneal hemorrhage was the most common complication. The risk with a cutting needle being higher than with an aspirative needle.

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.)