Guidewire-catheter induced hydrodissection to assist radiofrequency ablation for subcapsular hepatocellular carcinoma with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

PURPOSE: We aimed to evaluate the usefulness of guidewire-catheter induced hydrodissection (GIH) to assist radiofrequency ablation (RFA) for subcapsular hepatocellular carcinoma (HCC) with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion. METHODS: This retrospective study included 17 patients with small subcapsular HCC ineligible for ultrasonography-guided RFA who received RFA under guidance of fluoroscopy and cone-beam computed tomography immediately after iodized oil transarterial chemoembolization (TACE) between April 2011 and January 2016. In the study patients, creation of artificial ascites to protect the perihepatic structures failed due to perihepatic adhesion and GIH was attempted to separate the perihepatic structures from the ablation zone. The technical success rate of GIH, technique efficacy of RFA with GIH, local tumor progression (LTP), peritoneal seeding, and complications were evaluated. RESULTS: The technical success rate of GIH was 88.24% (15 of 17 patients). Technique efficacy was achieved in all 15 patients receiving RFA with GIH. During an average follow-up period of 48.1 months, LTP developed in three patients. Cumulative LTP rates at 1, 2, 3, and 5 years were 13.3%, 20.6%, 20.6%, and 20.6%, respectively. No patient had peritoneal seeding. Two of the 15 patients receiving RFA with GIH had a CIRSE grade 3 liver abscess, but none had complications associated with thermal injury to the diaphragm or abdominal wall near the ablation zone. CONCLUSION: GIH can be a useful method to assist RFA for subcapsular HCC with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

Iodized Oil Transarterial Chemoembolization and Radiofrequency Ablation for Small Periportal Hepatocellular Carcinoma: Comparison with Nonperiportal Hepatocellular Carcinoma.

PURPOSE: This study aims to evaluate the treatment outcomes of iodized oil transarterial chemoembolization (TACE) and subsequent radiofrequency ablation (RFA) for small (≤3 cm) periportal hepatocellular carcinoma (HCC) compared with nonperiportal HCC. METHODS: Twenty-three patients [periportal group (PG); mean age, 59.8 years; 22 men, 1 woman] with periportal HCC (in contact with the portal vein >3 mm in diameter) and 279 patients [nonperiportal group (NPG); mean age, 59.1 years; 234 men, 45 women] with nonperiportal HCC were treated between March 2010 and January 2014. All cases were contraindicated for ultrasound-guided RFA or resection. Mean tumor size was 1.2 cm in each group. The baseline characteristics were not different between the groups, except for alpha-fetoprotein level (41.0 ng/dL in NPG vs. 8.8 ng/dL in PG, p = 0.001). Local tumor progression (LTP), disease-free survival (DFS), overall survival (OS), intrasegmental recurrence, and complications were analyzed using the Kaplan-Meier method and Fisher's exact test. RESULTS: TACE and RFA were successfully performed in all patients. Mean follow-up period of PG and NPG was 33.8 and 42.8 months, respectively. LTP (p = 0.701), DFS (p = 0.718), and OS (p = 0.359) were not different between the two groups. Intrasegmental recurrence occurred in two patients (one in each group), and its incidence was not different (p = 0.212). Complications requiring further treatment occurred in 1/23 (4.3%) in PG and 5/279 (1.8%) in NPG. No procedure-related mortality occurred. CONCLUSIONS: Iodized oil TACE and subsequent RFA are effective alternative treatments for small periportal HCC (≤3 cm) when percutaneous ultrasound- or CT-guided RFA or resection is not feasible.

Combination treatment of trans-arterial chemo-embolisation, radiotherapy and hyperthermia (CERT) for hepatocellular carcinoma with portal vein tumour thrombosis: Interim analysis of prospective phase II trial.

Objectives This study evaluated the objective response to and toxicity of trans-arterial chemo-embolisation (TACE) followed by radiotherapy and hyperthermia (CERT) in hepatocellular carcinoma patients with portal vein tumour thrombosis. Methods The study design was a single-centre prospective phase II trial. Patients were first treated with TACE, with the first hyperthermia session 1 week later. Respiration-gated radiotherapy (RT) was delivered in 10 fractions of 3-5 Gy after another week. Six sessions of hyperthermia were delivered twice a week according to an energy escalation protocol. Response evaluation was planned at 1 month after RT completion using the modified Response Evaluation Criteria in Solid Tumors (RECIST). Toxicity was determined using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results Interim analysis was conducted on patients enrolled from October 2013 to November 2014. During this period, 46 patients (90.2%) who received at least one hyperthermia session were eligible and enrolled. Median follow-up was 6.7 months (range 2.0-15.0 months). Complete response was observed in 10 (21.7%) patients and partial response in 27 (47.8%). Most toxicities were grade I or II. One death was related to severe pneumonia of unknown cause in the left lung and one patient could not complete planned treatment because of continuous elevation of bilirubin after TACE. Late, asymptomatic gastroduodenal toxicities were noticed in 13 (28.3%) patients. Conclusion Preliminary evaluation of CERT showed a promising response rate with acceptable toxicities.

Efficacy of RECIST and mRECIST criteria as prognostic factors in patients undergoing repeated iodized oil chemoembolization of intermediate stage hepatocellular carcinoma.

BACKGROUND: Given that transarterial chemoembolization (TACE) is usually a repeated procedure for treatment of hepatocellular carcinoma (HCC), repeated radiologic response assessments rather than a single time point assessment may have different clinical implications through the repeated course of TACE. PURPOSE: To evaluate the efficacy of RECIST and mRECIST criteria as a survival predictor across early time points after repeated TACE of HCC. MATERIAL AND METHODS: Ninety-eight patients with intermediate stage HCC received repeated iodized oil TACE. Treatment response was assessed according to RECIST and mRECIST criteria at 1, 3, and 6 months after initial TACE. Cox proportional model was used for survival analysis and the predicting power of each time point response was evaluated with C-statistics and time-dependent area under the receiver operating characteristic curve (AUC). Inter-method agreement was assessed with the κ coefficient. RESULTS: mRECIST was not applicable in 15 patients because of patchy uptake of iodized oil after TACE. On multivariate analysis, responders at 6 months by RECIST, responders at 3 months, and 6 months by mRECIST showed better survival than non-responders (P < 0.05). Predicting power of response criteria improved over time and mRECIST at 6 months showed the best performance. The degree of agreements was poor or fair between RECIST and mRECIST. CONCLUSION: mRECIST predicted long-term survival as early as 3 months after TACE of intermediate stage HCC. The predicting power of the uni-dimensional response criteria tended to be stronger over time.

Radiofrequency ablation combined with chemoembolization for intermediate-sized (3-5 cm) hepatocellular carcinomas under dual guidance of biplane fluoroscopy and ultrasonography.

OBJECTIVE: To assess the technical feasibility and local efficacy of percutaneous radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) for an intermediate-sized (3-5 cm in diameter) hepatocellular carcinoma (HCC) under the dual guidance of biplane fluoroscopy and ultrasonography (US). MATERIALS AND METHODS: Patients with intermediate-sized HCCs were treated with percutaneous RFA combined with TACE. RFA was performed under the dual guidance of biplane fluoroscopy and US within 14 days after TACE. We evaluated the rate of major complications on immediate post-RFA CT images. Primary technique effectiveness rate was determined on one month follow-up CT images. The cumulative rate of local tumor progression was estimated with the use of Kaplan-Meier method. RESULTS: Twenty-one consecutive patients with 21 HCCs (mean size: 3.6 cm; range: 3-4.5 cm) were included. After TACE (mean: 6.7 d; range: 1-14 d), 20 (95.2%) of 21 HCCs were visible on fluoroscopy and were ablated under dual guidance of biplane fluoroscopy and US. The other HCC that was poorly visible by fluoroscopy was ablated under US guidance alone. Major complications were observed in only one patient (pneumothorax). Primary technique effectiveness was achieved for all 21 HCCs in a single RFA session. Cumulative rates of local tumor progression were estimated as 9.5% and 19.0% at one and three years, respectively. CONCLUSION: RFA combined with TACE under dual guidance of biplane fluoroscopy and US is technically feasible and effective for intermediate-sized HCC treatment.

The current practice of transarterial chemoembolization for the treatment of hepatocellular carcinoma.

Despite remarkable advancement in the surveillance and treatment of hepatocellular carcinoma (HCC) and the availability of novel curative options, a great proportion of HCC patients are still not eligible for curative treatment due to an advanced tumor stage or poor hepatic functional reserve. Therefore, there is a continuing need for effective palliative treatments. Although practiced widely, it has only recently been demonstrated that the use of transarterial chemoembolization (TACE) provides a survival benefit based on randomized controlled studies. Hence, TACE has become standard treatment in selected patients. TACE combines the effect of targeted chemotherapy with the effect of ischemic necrosis induced by arterial embolization. Most of the TACE procedures have been based on iodized oil utilizing the microembolic and drug-carrying characteristic of iodized oil. Recently, there have been efforts to improve the delivery of chemotherapeutic agents to a tumor. In this review, the basic principles, technical issues and complications of TACE are reviewed and recent advancement in TACE technique and clinical applicability are briefed.

Hepatocyte transplantation for glycogen storage disease type Ib.

Glycogen storage disease type I (GSD-I) is a group of autosomal recessive disorders with an incidence of 1 in 100,000. The two major subtypes are GSD-Ia, caused by a deficiency of glucose-6-phosphatase (G6Pase), and GSD-Ib, caused by a deficiency of glucose-6-phosphate transporter (G6PT). We report that a substantial improvement was achieved following several infusions of hepatocytes in a patient with GSD-Ib. Hepatocytes were isolated from the unused cadaveric whole livers of two donors. At the first transplantation, approximately 2 x 10(9) cells (2% of the estimated recipient's total hepatocytes) were infused. Seven days later 1 x 10(9) (1% of liver mass) cryopreserved hepatocytes from the same donor were infused, and an additional 3 x 10(9) (3% of liver mass) cells from the second donor were infused 1 month after the second transplantation. After the hepatocyte transplantation, the patient showed no hypoglycemic symptoms despite the discontinuation of cornstarch meals. Liver biopsies on posttransplantation days 20 and 250 showed a normal level of glucose-6-phosphatase activity in presolubilization assay that was very low before transplantation. This was the first and successful clinical hepatocyte transplantation in Korea. In this study, hepatocyte transplantation allowed a normal diet in a patient with GSD-Ib, with substantial improvement in their quality of life. Hepatocyte transplantation might be an alternative to liver transplantation and dietary therapy in GSD-Ib.