Thermal Ablation for Hepatocellular Carcinoma: What's New in 2019

Feipeng Zhu; Hyunchul Rhim

Disclosures

Chin Clin Oncol. 2019;8(6):58 

In This Article

Abstract and Introduction

Abstract

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, but a major proportion of patients are not appropriate candidates for surgical resection or transplantation. For this reason, image-guided tumor ablation using thermal energy for early-stage HCC has become an accepted curative treatment option in all HCC treatment guidelines due to its minimal invasiveness and proven outcomes. In recent years, microwave ablation (MWA) has been gaining popularity worldwide over radiofrequency ablation (RFA) due to its better performance with high temperature heating and lack of heat sink effects. However, more high-level evidence of real survival gain is required before MWA will completely replace RFA. Although cryoablation and irreversible electroporation are promising for safe and effective ablation in the liver, clinical evidence for these remains limited. In addition to specific ablative modalities, therapeutic outcomes can be improved by current technological advances in fusion imaging, contrast-enhanced ultrasound, and post-ablation antiviral therapy. In fact, immuno-ablation has the great potential to maximize therapeutic outcomes after ablation. The purpose of this review is to briefly illustrate the current status of ablation in HCC treatment guidelines and update on recently introduced therapeutic outcomes and new advances in ablation-related techniques.

Introduction

Liver cancer is currently the sixth most common cancer and fourth leading cause of cancer-related death worldwide. Hepatocellular carcinoma (HCC) is the most common primary liver tumor and its incidence has been increasing worldwide in recent decades.[1–3] Due to the complex nature of this disease, many factors are considered when determining the best treatment option for HCC, including tumor extent and location, the underlying liver function, presence or absence of extra-hepatic disease, patient performance status, and co-morbidities. For this reason, all potential curative therapies for HCC (e.g., ablation, resection, transplantation) should be utilized as first-line treatments, whenever feasible.[4]

Thermal ablation for HCC is accepted as a curative treatment option in many HCC treatment guidelines because of the excellent outcomes performed in a more minimally invasive manner.[4–8] In fact, during the past decade, many cohort and comparative studies have shown that ablation for early HCC provides promising survival gains comparable to those of surgical resection.[9–17] Given this, EASL-EROTC guidelines recently recommended ablation as a first line option for very early stage (single, smaller than 2 cm in diameter) HCC rather than surgical resection.[4]

From a technical standpoint, complete and accurate ablation is essential to achieve the best outcomes after ablation for HCC. Therefore, many technological advances are continually introduced to improve upon the effectiveness of thermal ablation. In an attempt to tailor therapy to a specific patient and tumor (e.g., size, location, histology, etc.), diverse energy sources are now used. Microwave ablation (MWA) has recently gained popularity around the world because of its intrinsic advantages of faster ablation with high temperature and less susceptibility to heat sink effect when compared to radiofrequency ablation (RFA).[18–26] In addition, novel guidance systems using fusion or contrast-enhanced ultrasound techniques have become more common, especially in countries where sonographic guidance is the predominant imaging guidance modality.[27–29] Furthermore, the benefits of "no-touch" techniques using multiple RF electrodes to achieve sufficient ablative margins without the need for direct tumor puncture have recently been reported.[30–35] Lastly, antiviral treatment has contributed to overall improved outcomes after thermal ablation for HCC by decreasing tumor recurrence.[36]

The purpose of this review, therefore, is to highlight the current state of ablation in HCC treatment guidelines and update on recently introduced therapeutic outcomes and new advances in ablation-related techniques.

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