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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): Ablation recommended for BCLC stage 0 or A patients with solitary lesions or up to 3 lesions <3 cm3,4
  • ESMO: Ablation 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
2. Ablation
3. LT

1. Resection
2. Ablation
3. LT

Locoregional therapy

Systemic therapy

Best supportive care

APASL

1. Ablation
2. Resection
3. LT

1. Resection or ablation (in CPA & B)

1. TACE
2. SIRT
3. Radiotherapy

Sorafenib

Best supportive care

EASL

1. Ablation
2. Resection
3. LT

1. Ablation
2. Resection
3. LT

Locoregional therapy

1st line: sorafenib or lenvatinib
2nd line: regorafenib or cabozantinib

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

  • 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

First-line treatment for BCLC Stage 0 (very early HCC ≤ 20 mm)
  • 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
Bridge to transplant
  • 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
Treatment for non-surgical candidates with BCLC stage A (up to 3 lesions ≤ 30 mm or 1 lesion ≤ 50 mm)
  • 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
Tumours > 50 mm
  • Few studies available and different results depending on ablation technique
  • Technical efficiency of 88.2% achievable for tumours > 80 mm16

References

1. 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).
2. 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).
3. Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J. Hepatol. 69, 182–236 (2018).
4. 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).
5. 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).
6. Foerster, F. & Galle, P. R. Comparison of the current international guidelines on the management of HCC. JHEP Reports 1, 114–119 (2019)
7. 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).
8. 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
9. CAS-One IR Software Release 3.1.3
10. 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.
11. 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.
12. 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.
13. 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.
14. 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.
15. 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).
16. Bruix, J., Reig, M. & Sherman, M. Evidence-Based Diagnosis, Staging, and Treatment of Patients with Hepatocellular Carcinoma. Gastroenterology vol. 150 835–853 (2016).
17. 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).
18. 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).
19. 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).
20. 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.
21. 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).
22. 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).
23. 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).
24. 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).