Outcome of salvage hepatic resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy

doi:10.1016/j.surg.2014.10.019

Surgery

Volume 157, Issue 3, March 2015, Pages 463-472

https://doi.org/10.1016/j.surg.2014.10.019 Get rights and content

Background

Although radiofrequency ablation (RFA) is an effective local ablative technique for the treatment of hepatocellular carcinoma (HCC), the optimal treatment for recurrence after RFA has not been established.

Methods

Between September 2002 and December 2011, 46 hepatectomies (salvage group) were performed for intrahepatic (local or multifocal) recurrent HCC after RFA. The difference between the imaging findings before RFA and at the time of salvage resection, especially in the Local recurrent group, and the short-term and long-term outcomes after salvage surgery were analyzed retrospectively by comparing them with those for a matched control group (n = 46) and with those of patients who underwent a second hepatic resection for HCC recurrence after an initial hepatic resection during the same period (n = 155).

Results

The tumor-occupying region was more distributed widely before the salvage resection compared with that before RFA, and a more extensive operation would have been required (rather than the RFA) in the local group. An evaluation of the short-term outcomes revealed that salvage resection required a longer operative time and was associated with a greater frequency of morbidity. The long-term outcomes of the salvage group were poorer than those of patients who underwent repeat hepatic resection for HCC recurrence after an initial hepatic resection.

Conclusion

The indications for RFA should be determined carefully, because recurrence after RFA may be associated with a more aggressive pattern of recurrence, and the long-term results after salvage resection are unsatisfactory.

Section snippets

Patients

Between September 2002 and December 2011, 974 hepatic resections were performed for HCC at our institution. Among them, salvage resection was performed for intrahepatic, recurrent HCC after RFA in 46 consecutive patients. The RFA was not performed by a surgeon but by a gastroenterological physician at our institution or at another local institution using a percutaneous, transhepatic approach guided by ultrasonography. These patients comprised the study population (Salvage group) and were

Patient characteristics (Table I)

As for the treatments performed before salvage resection, 32 of the 46 patients (70%) had undergone transcatheter arterial chemoembolization treatment at least once. Between the recurrence after RFA and the salvage resection, selective transcatheter arterial chemoembolization was performed in 11 patients as a preoperative treatment in an attempt to decrease tumor thrombi. As for the tumor status before RFA, the median tumor number was 1 (range, 1–3), and the median tumor size was 26 mm (range,

Discussion

Although salvage resection for recurrent HCC after RFA has been sporadically reported,7, 11, 14, 19, 20 few reports have summarized the short-term and long-term outcomes. Our findings suggested that salvage resection for recurrent HCC after RFA was technically demanding when performed according to an adjacent organ-preserving policy; as a result, the operative plan needed to be changed based on the intraoperative findings in 83% of the procedures, mainly because of extensive adhesions to the

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The purpose of this study was to develop a nanoparticle (NP) drug-loading system that enhances the efficiency of indocyanine green (ICG) entry into the tissue under focused ultrasound optimization and, in turn, enables more efficient identification and photothermal therapy (PTT) of the tumor. The new NPs were prepared by assembling intermolecular disulfide bonds to form human serum albumin (HSA) NPs and then conjugating those with ICG dye. The NP material was used to test the sensitivity of near-infrared fluorescence imaging and photoacoustic tumor imaging in vitro and in vivo. In addition, the combination of HSA-ICG NPs, focused ultrasound, and microbubbles was used to test PTT on the tumor. HSA-ICG NPs had good biocompatibility and were only a little toxic to cells and mice. In addition, they obviously enhanced tumor near-infrared fluorescence and photoacoustic bimodal imaging. Combined with HSA-ICG NPs, the depth of photoacoustic imaging was increased. Moreover, ICG that was absorbed in the HSA NPs promoted optical absorption in the near-infrared region, which greatly enhanced the PTT treatment's efficiency. This new bimodal tumor-imaging agent enhances the therapeutic effect of PTT and improves the detection of tumors in vivo, thus presenting great potential for use in clinical studies.
Oncologic superiority of anatomic resection of hepatocellular carcinoma by ultrasound-guided compression of the portal tributaries compared with nonanatomic resection: An analysis of patients matched for tumor characteristics and liver function
2018, Surgery (United States)
Citation Excerpt :
In addition, the NAR group had a greater incidence of multinodular recurrence. Similar data have been previously reported by Shindon et al.11 Of note, a similar aggressive behavior has been reported for the local failure of nonoperative treatments.47,48 The lesser local disease control and the more aggressive disease presentation at recurrence in the NAR group could have some relevance in explaining the worse prognosis.
The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound-guided compression of the tumor-feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection.
Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1-to-2 with nonanatomic resection cases based on the Child-Pugh class, Model for End-Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/>1), and hepatocellular carcinoma size (>30, 30–50, and >50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90-day mortality (0 compression technique anatomic resection), non–cancer-related death, and follow-up <12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases.
All patients were Child-Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5-year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2-year local recurrence-free survival (94% vs 78%; P = .012). Nonlocal recurrence-free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3-year survival after recurrence (65% vs 42%; P = .043).
Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma–bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.
Efficacy and safety of combination therapy of chemoembolization and radiofrequency ablation with different time intervals for hepatocellular carcinoma patients
2017, Surgical Oncology
Combination of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) has become an effective alternative therapy for hepatocellular carcinoma (HCC). In clinical practice, the choice of time interval between TACE and RFA is a key point for curative effect, but optimal time interval is uncertain in guidelines. We aim to explore the optimal time interval for HCC patients of Child-Pugh classification A or B.
Two hundred and thirty-three HCC patients of Child A or B who had undergone TACE and RFA were enrolled and divided into seven groups according to different time intervals (1–7weeks). Tumor damage, liver function, complications and survival time of patients after treatment were analyzed.
Complete remission rate and total effective rate decreased in groups with the prolonged time interval (p < 0.05). Average Child-Pugh score of patients in first three groups significantly increased one month after combination treatment (p < 0.01). While that not happened in other groups. Complications occurred in 16.7% patients, similarly occurred in groups (p > 0.1). Median survival time in groups four and five were 42 months, longer than other groups (p < 0.01).
A period of 3–5 weeks is the optimal time interval between TACE and RFA for HCC patients of Child-Pugh classification A or B.
Salvage hepatectomy for local recurrence of hepatocellular carcinomas offers survival comparable to that of matched patients who undergo primary hepatectomies
2017, European Journal of Surgical Oncology
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Salvage hepatectomy for HCCs was first proposed by Sitzmann et al. to treat downstaged, initially unresectable tumors.26 As RFA has become more common as a loco-regional treatment, data on outcomes of SH or local recurrence after RFA have become widely available.16–20 In these studies, survival after SH for local recurrence after RFA or PEI was compared with those after repeat or primary hepatectomy, or repeat RFA; most showed comparable OS, except in Yamashita et al.'s study, which showed poorer RFS and OS in patients with SH than in those who underwent second hepatectomies for recurrent HCCs.19
The feasibility of salvage hepatectomy for locally recurrent hepatocellular carcinomas (HCCs) is unclear, especially for patients with viable parts of previously multinodular tumors.
We reviewed charts of patients who underwent initial hepatectomies between 2000 and 2014 to select those with local recurrences (LR) after non-surgical treatments. Their postoperative outcomes, including morbidity, recurrence-free survival (RFS), and overall survival (OS) were compared with matched patients who underwent initial hepatectomies for primary HCCs (PR). Their local recurrence patterns were divided into recurrent solitary tumors (Subgroup A); and recurrent parts of multinodular tumors (Subgroup B).
Among 664 patients, hepatectomy for LR was performed in 62 patients. Matched 59 patients were selected as PR. Clinicopathologic profiles at initial surgery were comparable between the LR and PR groups. Incidence of major morbidity (LR vs. PR, 7% vs. 5%, P = 1.00), 5-year RFS (21% vs. 37%, P = 0.28), and 5-year OS (69% vs. 69%, P = 0.62) were comparable. In the LR group, Subgroup B showed worse 5-year RFS (A vs. B, 29% vs. 0%, P < 0.01) and 5-year-OS (80% vs. 53%, P = 0.01). Postoperative recurrence occurred in 46 patients, but local and extrahepatic recurrence was seen only in 2 patients and 2 patients, respectively.
Salvage hepatectomy for locally recurrent HCCs is feasible, and results in prognosis comparable with hepatectomy for primary HCCs. Although the risk of postoperative recurrence was high in Subgroup B, rare local recurrence suggests the usefulness of salvaging uncontrolled tumor by nonsurgical treatment.
Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases
2016, Surgery (United States)
The feasibility of parenchymal-sparing hepatectomy has yet to be assessed based on the tumor location, which affects the choice of treatment in patients with colorectal liver metastases.
Sixty-three patients underwent first curative hepatectomy for deep-placed colorectal liver metastases whose center was located >30 mm from the liver surface. Operative outcomes were compared among patients who underwent parenchymal-sparing hepatectomy or major hepatectomy (≥3 segments).
Parenchymal-sparing hepatectomy and major hepatectomy were performed for deep-placed colorectal liver metastases in 40 (63%) and 23 (37%) patients, respectively. Resection time was longer in the parenchymal-sparing hepatectomy than in the major hepatectomy group (57 vs 39 minutes) (P = .02) and cut-surface area was wider (120 vs 86 cm²) (P < .01). Resected volume was smaller in the parenchymal-sparing hepatectomy than in the major hepatectomy group (251 vs 560 g) (P < .01). No differences were found between the 2 groups for total operation time (306 vs 328 minutes), amount of blood loss (516 vs 400 mL), rate of major complications (10% vs 13%), and positive operative margins (5% vs 4%). Overall, recurrence-free, and liver recurrence-free survivals did not differ between the 2 groups. Direct major hepatectomy without portal venous embolization could not have been performed in 40% of the parenchymal-sparing hepatectomy group (16/40) because of the small liver remnant volume.
Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.
Survival outcome of salvage hepatectomy in patients with local, recurrent hepatocellular carcinoma who underwent radiofrequency ablation as their first treatment
2016, Surgery (United States)
Citation Excerpt :
In addition, these factors were related to microscopic vascular invasion. Previous studies showed that the 5-year survival after salvage hepatectomy ranged from 52.3–67%.17,18 In contrast, participants with these risk factors had an unfavorable prognosis, and their 5-year survival rates after salvage hepatectomy were 0% in patients with noncurative resection, 24% in patients with DCP >40mAU/mL, and 30% in patients with multiple preceding treatments.
Local recurrence is a specific problem after radiofrequency ablation of small hepatocellular carcinoma, and additional treatment is an important issue. We aimed to investigate the outcome of salvage hepatectomy in patients who develop local, recurrent hepatocellular carcinoma after treatment with radiofrequency ablation.
From 2001–2013, we reviewed 58 patients from 6 university hospitals with local, recurrent hepatocellular carcinoma who underwent salvage hepatectomy after their initial radiofrequency ablation treatment. Pathologic characteristics and prognostic factors influencing overall survival were analyzed.
Noncurative resection, des-gamma carboxy prothrombin levels >40 mAU/mL, and multiple preceding treatments before salvage hepatectomy were negative prognostic factors for overall survival. The 5-year survivals for the prognostic factors were 0%, 24%, and 30%, respectively, after salvage hepatectomy, and 0%, 54%, and 54% after initial radiofrequency ablation treatment, respectively. As for the pathologic finding of local, recurrent hepatocellular carcinoma after radiofrequency ablation, vascular invasion was observed frequently in patients with increases in des-gamma carboxy prothrombin levels and with multiple preceding treatments before salvage hepatectomy with a frequency of 59% and 53%, respectively (P < .01 and .05).
Noncurative resection, increases in serum des-gamma carboxy prothrombin, and multiple preceding treatments were prognostic factors for subsequent salvage hepatectomy; nevertheless, survival outcomes were still acceptable when a curative salvage hepatectomy was performed. Increases in serum des-gamma carboxy prothrombin and multiple preceding treatments were positive predictors for pathologic vascular invasion. These factors should be taken into consideration when selecting treatment modalities for locally recurrent hepatocellular carcinoma following radiofrequency ablation. Repetition of unsuccessful, loco-regional treatment would appear to decrease the potential survival.

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Liver/PancreasOutcome of salvage hepatic resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy

Background

Methods

Results

Conclusion

Section snippets

Patients

Patient characteristics (Table I)

Discussion

Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma < or = 4 cm

Gastroenterology

Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less

Gut

A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma

Gastroenterology

Radiofrequency ablation versus ethanol injection for early hepatocellular carcinoma: a randomized controlled trial

Scand J Gastroenterol

Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies

Hepatology

The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review

Ann Surg

Locoregional recurrences are frequent after radiofrequency ablation for hepatocellular carcinoma

J Am Coll Surg

Radiofrequency ablation for hepatocellular carcinoma: 10-year outcome and prognostic factors

Am J Gastroenterol

Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic in 235 Western patients with cirrhosis

Hepatology

Risk of tumor progression in early-stage hepatocellular carcinoma after radiofrequency ablation

Br J Surg

Rapid and aggressive recurrence accompanied by portal tumor thrombus after radiofrequency ablation for hepatocellular carcinoma

Int J Clin Oncol

A case of rapid intrahepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation

Am J Surg

Risk of tumour seeding after percutaneous radiofrequency ablation for hepatocellular carcinoma

Br J Surg

Hepatocellular carcinoma with sarcomatous change arising after radiofrequency ablation for well-differentiated hepatocellular carcinoma

Hepatol Res

Percutaneous treatment of small hepatic tumors by an expandable RF needle electrode

AJR Am J Roentgenol

Percutaneous radiofrequency ablation of small hepatocellular carcinoma: long-term results

Eur Radiol

Early-stage hepatocellular carcinoma in patients with cirrhosis: long-term results of percutaneous image-guided radiofrequency ablation

Radiology

Percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma as a first-line treatment: long-term results and prognostic factors in a large single-institution series

Eur Radiol

Liver/Pancreas
Outcome of salvage hepatic resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy