Percutaneous Ablation of Hepatocellular Carcinoma (HCC)
Background
- 3rd most frequent cause of cancer death worldwide
- Incidence of 840’000 new patients and mortality of 780'000 patients per year1
- 50% of HCC patients diagnosed are stage 0 or A and therefore candidates for surgery/ablation2
Indications for Ablation
- BCLC very early or early stage (BCLC 0 or A) with up to 3 solitary lesions < 3 cm
- Bridge to transplant
- Contraindications against resection or transplantation
Ablation Technique
- MWA or RFA
- CT-based treatment and margin assessment aiming for margin ≥ 10mm (Local Tumour Progression of 0%)
- Track ablation mandatory
Guidelines
- European Association for the Study of the Liver (EASL), European Society for Medical Oncology (ESMO): recommended for BCLC stage 0 or A patients with solitary lesions or up to 3 lesions <3 cm3,4
- ESMO: recommended additionally for patients with waiting time >3 month for transplants4
- (AASLD): ablation considered asbest option for patients with non-resectable disease5
Stage (BCLC) |
Very early (0) |
Early (A) |
Intermediate (B) |
Advanced (C) |
Terminal (D) |
Criteria |
Single <2 cm |
Single or 2-3 nodules <3 cm |
Multinodular Unresectable |
Portal invasion Extrahepatic spread |
End stage |
AASLD |
1. Resection |
1. Resection |
Locoregional therapy |
Systemic therapy |
Best supportive care |
APASL |
1. Ablation |
1. Resection or ablation (in CPA & B) |
1. TACE |
Sorafenib |
Best supportive care |
EASL |
1. Ablation |
1. Ablation |
Locoregional therapy |
1st line: sorafenib or lenvatinib |
Best supportive care |
For the role of thermal ablation in different guidelines, see also6
Key:
AASLD: American Association for the Study of Liver Diseases
BCLC: Barcelona Clinic Liver Cancer
APASL: Asian Pacific Association for the Study of the Liver
Quality Ablation with CAS-One IR: Standardized procedures with reproducible outcomes. More patients, better results. PPT
- Improved Accuracy over US with CT/MRI Planning
- Safely Treat more patients with challenging tumours
- Consistently lower recurrence rates utilizing Ablation Validation
- Intuitive treatment planning using dedicated 2D and 3D views
- Localize "invisible lesions" using image fusion with preoperative data7
- Less repositioning reduces risk of bleeding and tumour seeding8
- Simulate your ablation zone volume with over 75+ needles9
- Multifunctional arm with solid guider can reduce human error10,11
Safely treat more patients with challenging tumours
- Precision ablation planning enables confidence near structures of risk
- Treat multiple or/and large tumours (>3 cm) with overlapping ablation zones12
- Complex cases with high angulation are feasible12
- Reduced intervention time enables treatment of more patients13
Consistently lower recurrence rate utilizing ablation validation
- Ablation validation can confirm treatment success14
- Safe and reliable ablations for low recurrence rates (<10%) to qualify ablation for first-line treatment15
- Standardized process enables reproducible results with less focus on operator expertise
Relevant Studies
- No difference in overall survival between ablation and surgery16,17
- Lower mortality and major complication rates than alternative treatments17
- Keep all options open for treatments of future tumours as 64% of HCC patients will develop more tumours over time9 and 38% of patients require more than one ablation treatment18
- Prevent dropout from transplant list by controlling number and size of lesions19
- Downstaging to meet Milano criteria for transplant listing19
- Complete tumour necrosis from ablation reduces post-transplant recurrence rate19,20
- Resection and transplantation produce the best results for HCC Stage A16
- Overall survival of patients with tumours ≤ 30 mm is similar for ablation and resection21-23
- For tumours > 30 mm, local recurrence after increases and requires sophisticated technique to achieve low local recurrence rates. Complete pathological response of 97.9% achievable with stereotactic ablation24
- Few studies available and different results depending on ablation technique
- Technical efficiency of 88.2% achievable for tumours > 80 mm16
References
- Bray, F. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA. Cancer J. Clin. 68, 394–424 (2018).
- Torzilli, G. et al. A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: Is it adherent to the EASL/AASLD recommendations? An observational study of the HCC east-west study group. Ann. Surg. 257, 929–937 (2013).
- Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J. Hepatol. 69, 182–236 (2018).
- Vogel, A. et al. Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. 30, 871–873 (2019).
- Marrero, J. A. et al. Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 68, 723–750 (2018).
- Foerster, F. & Galle, P. R. Comparison of the current international guidelines on the management of HCC. JHEP Reports 1, 114–119 (2019)
- Cathomas, M., Mertineit, N., Kim-Fuchs, C. et al.Value of MRI/CT Image Fusion for Targeting “invisible” Lesions in Stereotactic Microwave Ablation (SMWA) of Malignant Liver Lesions: A Retrospective Analysis. Cardiovasc Intervent Radiol 43, 1505–1514 (2020).
- Tinguely P, Frehner L, Lachenmayer A, Banz V, Weber S, Candinas D and Maurer MH (2020) Stereotactic Image-Guided Microwave Ablation for Malignant Liver Tumors—A Multivariable Accuracy and Efficacy Analysis. Front. Oncol. 10:842. doi: 10.3389/fonc.2020.00842
- CAS-One IR Software Release 3.1.3
- Wallach D, Toporek G, Weber S, Bale R, Widmann G. Comparison of freehand-navigated and aiming device-navigated targeting of liver lesions. Int J Med Robot. 2014 Mar;10(1):35-43. doi: 10.1002/rcs.1505. Epub 2013 Jul 8. PMID: 23832927.
- Beyer LP, Pregler B, Nießen C, Schicho A, Haimerl M, Jung EM, Stroszczynski C, Wiggermann P. Stereotactically-navigated percutaneous Irreversible Electroporation (IRE) compared to conventional IRE: a prospective trial. PeerJ. 2016 Aug 11;4:e2277. doi: 10.7717/peerj.2277. PMID: 27602266; PMCID: PMC4991851.
- Lachenmayer A, Tinguely P, Maurer MH, Frehner L, Knöpfli M, Peterhans M, Weber S, Dufour JF, Candinas D, Banz V. Stereotactic image-guided microwave ablation of hepatocellular carcinoma using a computer-assisted navigation system. Liver Int. 2019 Oct;39(10):1975-1985. doi: 10.1111/liv.14187. Epub 2019 Jul 28. PMID: 31276296.
- Beyer LP, Pregler B, Nießen C, Schicho A, Haimerl M, Jung EM, Stroszczynski C, Wiggermann P. Stereotactically-navigated percutaneous Irreversible Electroporation (IRE) compared to conventional IRE: a prospective trial. PeerJ. 2016 Aug 11;4:e2277. doi: 10.7717/peerj.2277. PMID: 27602266; PMCID: PMC4991851.
- Laimer G, Schullian P, Jaschke N, Putzer D, Eberle G, Alzaga A, Odisio B, Bale R. Minimal ablative margin (MAM) assessment with image fusion: an independent predictor for local tumor progression in hepatocellular carcinoma after stereotactic radiofrequency ablation. Eur Radiol. 2020 May;30(5):2463-2472. doi: 10.1007/s00330-019-06609-7. Epub 2020 Jan 30. PMID: 32002642; PMCID: PMC7160081.
- Mazzaferro, V., Lencioni, R. & Majno, P. Early hepatocellular carcinoma on the procrustean bed of ablation, resection, and transplantation. Semin. Liver Dis. 34, 415–426 (2014).
- Bruix, J., Reig, M. & Sherman, M. Evidence-Based Diagnosis, Staging, and Treatment of Patients with Hepatocellular Carcinoma. Gastroenterology vol. 150 835–853 (2016).
- Livraghi, T. et al. Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice? Hepatology 47, 82–89 (2008).
- Beermann, M. et al. 1000 consecutive ablation sessions in the era of computer assisted image guidance – Lessons learned. Eur. J. Radiol. Open 6, 1–8 (2019).
- Lee, M. W. et al. Radiofrequency ablation of hepatocellular carcinoma as bridge therapy to liver transplantation: A 10-year intention-to-treat analysis. Hepatology 65, 1979–1990 (2017).
- Bale, R. et al. Stereotactic radiofrequency ablation of hepatocellular carcinoma ‐ A histopathological study in explanted livers. Hepatology hep.30406 (2018) doi:10.1002/hep.30406.
- Feng, K. et al. A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma. J. Hepatol. 57, 794–802 (2012).
- Salati, U., Barry, A., Chou, F. Y., Ma, R. & Liu, D. M. State of the ablation nation: a review of ablative therapies for cure in the treatment of hepatocellular carcinoma. Futur. Oncol. 13, 1437–1448 (2017).
- Mazzaferro, V., Lencioni, R. & Majno, P. Early hepatocellular carcinoma on the procrustean bed of ablation, resection, and transplantation. Semin. Liver Dis. 34, 415–426 (2014).
- Schullian, P. et al. Safety and efficacy of stereotactic radiofrequency ablation for very large (≥8 cm) primary and metastatic liver tumors. Sci. Rep. 10, 1618 (2020).