Wednesday, October 18, 2017

Percutaneous treatment of hepatocellular carcinoma: state of the art and innovations

Journal of Hepatology
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Percutaneous treatment of hepatocellular carcinoma: state of the art and innovations
Jean-Charles Nault, Olivier Sutter, Pierre Nahon, Nathalie Ganne-CarriƩ


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Percutaneous treatment of hepatocellular carcinoma (HCC) encompasses a vast range of techniques, including monopolar radiofrequency ablation (RFA), multibipolar RFA, microwave ablation, cryoablation and irreversible electroporation. RFA is considered to be one of the main curative treatments for HCC of less than 5 cm developing on cirrhosis, together with surgical resection and liver transplantation. However, controversies exist concerning the respective roles of ablation and liver resection for HCC of less than 3 to 5 cm on cirrhosis. In line with the therapeutic algorithm of early HCC, percutaneous ablation could also be used as a bridge to liver transplantation or in a sequence of upfront percutaneous treatment, followed by transplantation if tumor relapses. Moreover, several innovations in ablation methods may help to efficiently treat early HCC initially considered as “non-ablatable”, and might, in some cases, extend ablation criteria beyond early HCC in order to treat the largest number of patients using a curative approach.

Key Points
  1. Classical monopolar RFA appears to provide the same long-term results as surgical resection in cases of HCC of less than 2-3 cm developing on cirrhosis
  2. Morbi-mortality of percutaneous ablation of HCC on cirrhosis is low
  3. While local recurrence may be efficiently controlled by additional percutaneous approaches, long-term results are impaired by a high rate of distant tumor recurrence
  4. Up to 30 % of small HCC were classically considered as « non-ablatable » due to « high-risk location » or « at-risk patients », but several techniques are now available to efficiently and safely treat these patients
  5. Percutaneous ablation could be used as a bridge to transplantation, or via a sequence of « ablation first » followed by salvage liver transplantation if the tumor recurs
  6. Several new methods of percutaneous ablation (multi-bipolar No-touch RFA, microwave, irreversible electroporation, cryoablation, etc.) seek to increase the safety and efficacy of these treatments and to extend their indications into the algorithm of HCC treatment
  7. Ablation therapies combined with transarterial chemo-embolization may improve sustained local control of tumors of over 3 cm in diameter compared to monopolar RFA
Survival of patients with hepatocellular carcinoma (HCC) is poor, with 5-year overal survival of around 10 to 15 %, mainly explained by diagnosis of the tumor at an advanced stage inaccessible to curative treatment [1]. Ultimately, application of a curative treatment at an early stage is the cornerstone to improving overall survival of cirrhotic patients with HCC [2]. To achieve this goal, the first step is to identify the “at-risk population”, mainly cirrhotic patients for whom HCC screening will be cost-effective. The second step is to perform a well-conducted screening program using ultrasonography every 6 months in cirrhotic patients [3]. Screening aims to identify HCC falling within Milan criteria that will be treated by a curative approach [4]. The final step consists of using curative treatment for all small HCC detected by screening. Each of these steps has defects in its application to real-life cases that need to be improved. In the field of therapeutics, three major types of curative treatment exist in HCC: liver resection, liver transplantation and percutaneous ablation. Each has its limitations that may be partially overcome in order to curatively treat the highest number of patients and avoid premature use of palliative treatment for small HCC [[5], [6]]. However, the term of “curative” treatment for resection or ablation of HCC in cirrhotic patients is discussed because the patients are still exposed to de novo carcinogenesis on cirrhosis. Percutaneous ablation includes a vast range of techniques that have changed over the 20 last years, enabling treatment of an increasing number of patients, with improved efficacy in local control [7]. Moreover, extension of the criteria for borderline HCC treatment using advanced percutaneous techniques, or combinations with endo-arterial approaches, have also been proposed in order to augment the size and number of treatable tumors [8]. In this review, we summarize the different types of percutaneous treatment, discuss their role within the perspective of the therapeutic algorithm of early HCC, and describe innovations in the field that seek to increase efficacy and extend the boundaries of indications for ablation.

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