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

Role of Ablation in Current HCC Management Guidelines

All of the major hepatology societies have proposed HCC management guidelines to assess the scientific evidence and to provide the best guidance for clinicians treating these patients. The Asia-Pacific, American, and European societies have all recently published updated their guidelines[4–8] and these are presented below.

The Asia-Pacific Association of the Study of Liver (APASL) Guidelines currently recommend local ablation for the following conditions: (I) Child-Pugh class A or B patients with HCC (<3 in number and smaller than 3 cm in diameter); (II) for 2 cm or smaller in Child-Pugh class A or B cirrhosis, RFA is a first-line treatment;[5] and (III) where cases are concerning the safety after RFA, ethanol injection can be considered.

The current American Association of the Study of Liver Disease (AASLD) HCC guidelines states the following: (I) thermal ablation is the best modality for HCCs smaller than 3 cm in diameter, although MWA now has the potential to show better tumoral control than RFA; (II) resection, local ablation, or transarterial chemoembolization (TACE) can be considered to minimize the risk of tumor progression as a 'bridge' to transplant; and (III) RFA or MWA may be considered as first-line treatment in very early-stage disease (BCLC 0).[6]

The European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) Clinical Practice Guidelines suggest the following: (I) RFA is recommended as a first-line treatment for very early-stage disease (tumors <2 cm diameter); (II) RFA has been adopted as an alternative first-line option for patients with early-stage HCC, considering survival benefit similar to that of surgery in RCTs and meta-analyses; (III) MWA is comparable to RFA, but has the potential advantage for being able to treat 3–5-cm tumors but the reduced impact of the cooling effect of large vessels remains unknown; (IV) for exophytic tumors or tumors abutting the gallbladder, liver hilum, or intestine, laparoscopic surgery may be better than thermal ablation and (V) thermal ablation is superior to ethanol injection except for small lesions.[4]

According to a recent comparative review of the three major HCC treatment guidelines,[37] in AASLD guideline, locoregional treatment can be considered for cirrhotic patients with HCC (e.g., T2 or T3, no vascular involvement), if not candidates for transplantation or resection while in the APASL guideline, ablation is recommended as an alternative to resection for Child-Pugh class A or B patients with ≤3 tumors that are each ≤3 cm. Furthermore, ablation is recommended as a first-line treatment for very early stage (single, ≤2 cm). In EASL guideline, ablation is considered as the "standard of care" for unresectable BCLC 0 and A tumors, an alternative to resection in single tumors that are 2 to 3 cm, and even as a potential first-line therapy for resectable BCLC-0 HCCs with favorable locations. Therefore, ablation as an alternative to resection has been validated by comparable outcomes and with minimal morbidity (Figure 1).

Figure 1.

Summary of stage-dependent recommendations of international guidelines for HCC treatment. BCLC, Barcelona Clinic Liver Cancer; APASL, Asian Pacific Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; EASL, European Association for the Study of the Liver; LT, liver transplantation; SIRT, selective internal radiation therapy; TACE, transarterial chemoembolization; HCC, hepatocellular carcinoma.

In addition to the guidelines discussed above, Chinese HCC management guidelines proposed by the National Health and Family Planning Commission of the People's Republic of China state the following: First, local ablation is recommended for a single tumor <5 cm or up to three tumors <3 cm without vascular invasion or extrahepatic metastasis as the outcomes are similar in patients with Child-Pugh class A or B. The tumor-free survival rate of RFA, however, is slightly lower than that of surgical resection for patients with tumors that are ≤3 cm. Second, local ablation is often considered in combination with TACE for patients with unresectable tumors (3–7 cm). Third, RFA is the most commonly used minimally invasive therapy in China for liver cancer due to its many advantages including ease of use, favorable efficacy, and cost-effectiveness (Figure 2).[7]

Figure 2.

Chinese guideline for treatment of liver cancer. HCC, hepatocellular carcinoma; TACE, transarterial chemoembolization.

Finally, the Korean Liver Cancer Association (KLCA)-National Cancer Center (NCC) Korea Practice Guidelines for the Management of HCC recommend RFA with the following options: (I) as an alternative to resection in patients with a single nodular HCC (≤3 cm), considering comparable outcomes and better safety; (II) RFA is superior to ethanol injection except for smaller (<2 cm) tumor or unfavorable location for RFA; (III) TACE combined with RFA is recommended for 3–5 cm unresectable HCCs and (IV) MWA and cryoablation are expected to provide comparable outcomes and safety compared to RFA.[8]

Based on the extensive, accumulated clinical experience and the scientific evidence regarding HCC ablation since 1990, all currently available HCC management guidelines from major academic societies accept ablation therapy as a curative treatment option for early stage HCC, especially for patients whose hepatic reserve is insufficient and for those who have a co-morbidity that prohibits resection. Furthermore, ablation therapy could be an adjunctive option as a combined treatment for intermediate stage HCC. However, there is no specific recommendation regarding ablation energy or guiding modality due to limited evidence so far.[4–8,37]

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