Thermal ablation for hepatocellular carcinoma

doi:10.1053/j.gastro.2004.09.031

Gastroenterology

Volume 127, Issue 5, Supplement 1, November 2004, Pages S167-S178

https://doi.org/10.1053/j.gastro.2004.09.031 Get rights and content

Thermal ablation, as a form of minimally invasive therapy for hepatocellular carcinoma (HCC), has become an important treatment modality. Because of the limitations of surgery, the techniques of thermal ablation have become standard therapies for HCC in some situations. This article reviews 4 thermal ablation techniques—radiofrequency (RF) ablation, microwave ablation, laser ablation, and cryoablation. Each of these techniques may have a role in treating HCC, and the mechanisms, equipment, patient selection, results, and complications of each are considered. Furthermore, combined therapies consisting of thermal ablation and adjuvant chemotherapy also show promise for enhancing these techniques. Important areas of research into thermal ablation remain, including improving the ability of ablation to treat larger tumors, determining the indications for each thermal ablation modality, optimizing image guidance, and obtaining good outcome data on the efficacy of these techniques.

Section snippets

Overview of thermal ablation

The goal of thermal ablation is to destroy entire tumors, killing the malignant cells using heat—or freezing in the case of cryoablation—with only minimal damage to surrounding liver and without damaging adjacent organs. The principle of operation is similar for each of the thermal ablation techniques. Each requires placement of a needle-like applicator directly into the tumor, the tip of which then produces thermal energy in a concentrated fashion, creating a hyperthermic or hypothermic

RF ablation

The use of RF energy for the treatment of hepatic tumors was pioneered more than a decade ago. In the United States, the current technology for RF ablation was approved for generic tissue ablation by the United States Food and Drug Administration (FDA) in 1997. It has since been approved by the FDA for the treatment of unresectable hepatic tumors. Additionally, both government and private insurers have recognized it as a viable alternative treatment for hepatic tumors and have agreed to

Microwave ablation

The most extensive experience with microwave ablation for HCC has been in Japan and China. Percutaneous microwave ablation was first used as an adjunct to liver biopsy and was subsequently adapted for hepatic tumor ablation. It is now used clinically in Japan and China and is undergoing trials in the United States.

Laser ablation

The concept of thermal ablation by interstitial laser application dates back more than 20 years. Since then, most progress with laser ablation in hepatic tumors has been made in Germany, Italy, and the United Kingdom.

Cryoablation

The oldest treatment modality discussed in this article, cryotherapy for destruction of hepatic tumors, has been practiced for more than 40 years. Early techniques involved applying freezing agents directly to target tissue. Modern cryoablation has refined this process by use of needle-like applicators, or cryoprobes, to induce freezing temperatures in tumors. Until recently, cryoablation has been used mostly as an open surgical technique. Laparoscopic and percutaneous uses have emerged in the

Combined therapy

The thermal ablation techniques have proven successful for treatment of small hepatic tumors, particularly in HCC. This is primarily because of the size of the ablation zones created by existing devices. Although ablation zone sizes may differ slightly between thermal ablation modalities, all of the modalities require multiple overlapping ablations to treat large tumors. This has proven to be a challenging task, with much higher local recurrence rates when this technique is used.¹⁴ Therefore, a

Conclusion

Repeated predictions that minimally invasive therapies, particularly the thermal ablation techniques, will replace surgical resection for treatment of focal HCC are now being realized in certain situations. Certainly, they are essential in situations in which resection is impossible. Moreover, thermal ablation has become an alternative first-line therapy for small HCC, in which the ability to obtain a tumor-free margin is now greater than 90%, comparable with resection, with less morbidity.

References (40)

H. Horigome et al.
Standards for selecting percutaneous ethanol injection therapy or percutaneous microwave coagulation therapy for solitary small hepatocellular carcinomaconsideration of local recurrence
Am J Gastroenterol
(1999)
H.X. Xu et al.
Ultrasound-guided percutaneous thermal ablation of hepatocellular carcinoma using microwave and radiofrequency ablation
Clin Radiol
(2004)
A. Giorgio et al.
Interstitial laser photocoagulation under ultrasound guidance of liver tumorsresults in 104 treated patients
Eur J Ultrasound
(2000)
G.D. Dodd et al.
Minimally invasive treatment of malignant hepatic tumorsat the threshold of a major breakthrough
Radiographics
(2000)
S.N. Goldberg et al.
Image-guided tumor ablationproposal for standardization of terms and reporting criteria
Radiology
(2003)
J.R. Leyendecker et al.
Minimally invasive techniques for the treatment of liver tumors
Semin Liver Dis
(2001)
W.K. Washburn et al.
Radiofrequency tissue ablationeffect of hepatic blood flow occlusion on thermal injuries produced in cirrhotic livers
Ann Surg Oncol
(2003)
S. Chopra et al.
Radiofrequency ablation of hepatic tumors adjacent to the gallbladderfeasibility and safety
AJR Am J Roentgenol
(2003)
H.W. Head et al.
Radiofrequency ablation of hepatic lesions against the dome of the diaphragmfrequency of diaphragmatic injury
(2004)
K.K. Tanabe et al.
Radiofrequency ablationthe experts weigh in
Cancer
(2004)

J.R. Leyendecker et al.

Sonographically observed echogenic response during intraoperative radiofrequency ablation of cirrhotic liverspathologic correlation

AJR Am J Roentgenol

(2002)

R.S. Montgomery et al.

Radiofrequency ablation of hepatic tumorsvariability of lesion size using a single ablation device

AJR Am J Roentgenol

(2004)

G.D. Dodd et al.

Radiofrequency thermal ablationcomputer analysis of the size of the thermal injury created by overlapping ablations

AJR Am J Roentgenol

(2001)

S. Rossi et al.

Percutaneous treatment of small hepatic tumors by an expandable RF needle electrode

AJR Am J Roentgenol

(1998)

S.A. Curley et al.

Radiofrequency ablation of unresectable primary and metastatic hepatic malignanciesresults in 123 patients

Ann Surg

(1999)

T. Livraghi et al.

Small hepatocellular carcinomatreatment with radio-frequency ablation versus ethanol injection

Radiology

(1999)

T. Livraghi et al.

Hepatocellular carcinomaradio-frequency ablation of medium and large lesions

Radiology

(2000)

K. Shirato et al.

Small hepatocellular carcinomatherapeutic effectiveness of percutaneous radio frequency ablation therapy with a LeVeen needle electrode

J Ultrasound Med

(2002)

R.A. Lencioni et al.

Small hepatocellular carcinoma in cirrhosisrandomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection

Radiology

(2003)

G.D. Dodd et al.

Percutaneous radiofrequency ablation of hepatic tumorsPost-ablation syndrome

AJR Am J Roentgenol

(2004)

Cited by (76)

Postoperative SIRS after thermal ablation of HCC: Risk factors and short-term prognosis
2024, Heliyon
We aimed to explore the potential risk factors and short-term prognosis for SIRS after thermal ablation of hepatocellular carcinoma (HCC).
Data from patients with HCC who underwent thermal ablation in the Third Affiliated Hospital of Sun Yat-sen University between January 2015 and August 2021 were retrieved from the perioperative database. Pre-, intra- and postoperative data between SIRS group and non-SIRS group were compared and multivariate logistic regression analysis was performed to identify the risk factors for SIRS after thermal ablation.
A total of 1491 patients were enrolled and 234 (15.7 %) patients developed SIRS after thermal ablation. Compared with those without SIRS, patients with SIRS had a longer hospital stay, higher hospitalization costs and higher risk of more severe postoperative complications. In the multivariate logistic regression analysis, current smoking (OR 1.58, 95 %CI 1.09–2.29), decreased HCT (OR 1.51,95 %CI 1.11–2.04), NEUT < 1.5 × 10⁹/L(OR 1.74, 95 %CI 1.14–2.65), NEUT% < 0.5 or > 0.7 (OR 1.36, 95 %CI 1.01–1.83) and PT > 16.3s (OR 2.42, 95 %CI 1.57–3.74) were significantly associated with postoperative SIRS.
Current smoking, decreased HCT, neutropenia, abnormal percentage of neutrophils and prolonged PT are the independent risk factors for SIRS after thermal ablation of HCC, which worsens outcomes of patients. This study can help identify high-risk population and guide appropriate care so as to reduce the incidence of postoperative SIRS.
A general strategy towards an injectable microwave-sensitive immune hydrogel for combined percutaneous microwave ablation and immunotherapy
2021, Chemical Engineering Journal
The minimal invasive percutaneous microwave ablation (MWA) combined with immunotherapy is a promising technique in clinic for the treatment of primary and metastatic tumors. However, elaborate encapsulation carrier designs, complex cellular engineering, and poor applicability are the vexing problems difficult to solve currently. Herein, a general strategy was proposed for the design of an injectable microwave-sensitive immune hydrogel for combined MWA and immunotherapy in vivo for the first time. The mix-and-use hydrogel composed Food and Drug Administration (FDA)-approved components were fabricated by introducing various immunostimulants regardless of hydrophilicity and hydrophobicity into the alginate (ALG)-Ca²⁺ hydrogel. As a proof of concept, an immunoadjuvant (R837) was employed to synthesize the R837-ALG-hydrogel for systematic studies. This immune hydrogel owns ultra-facile synthesis process, good microwave-sensitivity, adjuvant encapsulation efficiency of nearly 100%, good biocompatibility and syringeability, and large-scale production capability, which could be easily injected into the primary tumor for enhancing MWA. Moreover, the loaded R837 could motivate in situ vaccination by making the utmost of the tumor-associated antigens released after MWA, thereby inducing the robust tumor-specific antitumor immunity to suppress the distant metastatic tumor in vivo. The proposed injectable microwave-sensitive immune hydrogel paves a facile but general avenue with great clinical translation potential for the minimal invasive personalized oncotherapy.
A review of antenna designs for percutaneous microwave ablation
2021, Physica Medica
Citation Excerpt :
Microwave ablation (MWA) is one of the energy-based minimally invasive modalities in the treatment of various tumors, such as liver tumors [1], lung tumors [2], renal tumors [3], and bone tumors [4]. In general, tumor ablation in MWA is achieved with one or more MW antennas inserted into the targeted tissue percutaneously under the guidance of an image-guided device [5–10]. High-frequency electromagnetic energy (commercially available at 915 MHz or 2.45 GHz) generated by a microwave power generator is transferred through a coaxial cable as an antenna into surrounding tissues to cause a rise in temperature to 60 °C or above, which leads to protein denaturation and coagulative necrosis [11–17].
Microwave (MW) antenna is a key element in microwave ablation (MWA) treatments as the means that energy is delivered in a focused manner to the tumor and its surrounding area. The energy delivered results in a rise in temperature to a lethal level, resulting in cell death in the ablation zone. The delivery of energy and hence the success of MWA is closely dependent on the structure of the antennas. Therefore, three design criteria, such as expected ablation zone pattern, efficiency of energy delivery, and minimization of the diameter of the antennas have been the focus along the evolution of the MW antenna. To further improve the performance of MWA in the treatment of various tumors through inventing novel antennas, this article reviews the state-of-the-art and summarizes the development of MW antenna designs regarding the three design criteria.
Argon–helium cryoablation for liver carcinoma in high-risk locations: Safety and efficacy
2019, Cryobiology
Citation Excerpt :
Ablation is a good alternative therapy for patients who are not suitable for excision and who have cirrhosis [16]. At present, the effectiveness and safety of thermal ablation, chemical ablation, radiofrequency ablation and microwave ablation have been proved [3,6,22]. Cryoablation, the use of low temperature to induce local tissue necrosis, which is one of the most widely used ablation techniques.
Non-Invasive Liver Ablation Using Histotripsy: Preclinical Safety Study in an In Vivo Porcine Model
2017, Ultrasound in Medicine and Biology
This study investigates the safety profile for use of histotripsy, a non-invasive ultrasonic ablation method currently being developed for the treatment of liver cancer, for liver ablation in an in vivo porcine model. Histotripsy treatments were applied to the liver and hepatic veins of 22 porcine subjects, with half of the subjects receiving systemic heparinization. Vital signs (heart rate, blood pressure, temperature, electrocardiogram and SpO₂) were monitored throughout the procedure and for 1 h post-treatment. Blood was drawn at six points during the experiment to analyze blood gases, liver function and free hemoglobin levels. All treatments were guided and monitored by real-time ultrasound imaging. After treatment, the tissue was harvested for histological analysis. Results indicated that histotripsy generated well-defined lesions inside the liver and around the treated hepatic veins of all subjects in both treatment groups. Vital signs and blood analysis revealed that animals responded well to histotripsy, with all animals surviving the treatment. One animal in the non-heparinized group had a transient increase in pH and decreases in blood pressure, heart rate and PCO₂ during the 15-min vessel treatment, with these changes returning to baseline levels soon after the treatment. Overall, the results indicate that histotripsy can safely be performed on the liver without the need for systemic heparinization, even in regions containing large hepatic vessels, supporting its future use for the treatment of liver cancer.
Non-Invasive Ultrasound Liver Ablation Using Histotripsy: Chronic Study in an In Vivo Rodent Model
2016, Ultrasound in Medicine and Biology
Citation Excerpt :
One approach to address these issues is the development of local, non-invasive ablation therapies. Currently available minimally or non-invasive ablation methods are mostly thermal based, including radiofrequency ablation, microwave therapy, cryoablation, laser ablation and high intensity focused ultrasound (Charnley et al. 1989; Erce and Parks 2003; Head and Dodd 2004; Leslie and Kennedy 2006; Liapi and Geschwind 2007; ter Haar 2001). While these therapies have shown some success, they share inherent limitations due to the heat sink effect from blood flow (Curley 2001; Lu et al. 2003; Marrero and Pelletier 2006; Patterson et al. 1998) as well as the potential for damage to adjacent structures or major biliary radicles.
Hepatocellular carcinoma, or liver cancer, has the fastest growing incidence among cancers in the United States. Current liver ablation methods are thermal-based and share limitations due to the heat sink effect from the blood flow through the highly vascular liver. Recently, our group has investigated histotripsy as a non-invasive liver cancer ablation method. Histotripsy is a non-thermal ultrasonic ablation method that fractionates tissue through the control of acoustic cavitation. Previous experiments in an in vivo porcine model show that histotripsy can create well-confined lesions in the liver through ribcage obstruction without damaging the overlying ribs and other tissues. Histotripsy can also completely fractionate liver tissue surrounding major vessels while preserving the vessels. In this study, we investigate the long-term effects of histotripsy liver ablation in a rodent model. We hypothesize that the fractionated histotripsy lesion will be resorbed by the liver, resulting in effective tissue healing. To test this hypothesis, the livers of 20 healthy rats were treated with histotripsy using an 8-element 1-MHz histotripsy transducer. Rats were euthanized after 0, 3, 7, 14 and 28 days (n = 4). In vivo and post mortem results showed histotripsy lesions were successfully generated through the intact abdomen in all 20 rats. Magnetic resonance imaging found primarily negative contrast on day 0, positive contrast on day 3 and rapid normalization of signal intensity thereafter (i.e., signal amplitude returned to baseline levels seen in healthy liver tissue). Histologically, lesions were completely fractionated into an acellular homogenate. The lesions had a maximum cross-sectional area of 17.2 ± 1.9 mm² and sharp boundaries between the lesion and the healthy surrounding tissue after treatment. As the animals recovered after treatment, the histotripsy tissue homogenate was almost completely replaced by regenerated liver parenchyma, resulting in a small fibrous lesion (<1 mm² maximum cross-section) remaining after 28 d. The results of this study suggest that histotripsy has potential as a non-invasive liver ablation method for effective tissue removal.

View all citing articles on Scopus

: H.W.H. is supported by a grant from Vivant Medical Systems, Inc.

View full text

Thermal ablation for hepatocellular carcinoma

Section snippets

Overview of thermal ablation

RF ablation

Microwave ablation

Laser ablation

Cryoablation

Combined therapy

Conclusion

Am J Gastroenterol

Clin Radiol

Eur J Ultrasound

Minimally invasive treatment of malignant hepatic tumorsat the threshold of a major breakthrough

Radiographics

Image-guided tumor ablationproposal for standardization of terms and reporting criteria

Radiology

Minimally invasive techniques for the treatment of liver tumors

Semin Liver Dis

Radiofrequency tissue ablationeffect of hepatic blood flow occlusion on thermal injuries produced in cirrhotic livers

Ann Surg Oncol

Radiofrequency ablation of hepatic tumors adjacent to the gallbladderfeasibility and safety

AJR Am J Roentgenol

Radiofrequency ablation of hepatic lesions against the dome of the diaphragmfrequency of diaphragmatic injury

Radiofrequency ablationthe experts weigh in

Cancer

Sonographically observed echogenic response during intraoperative radiofrequency ablation of cirrhotic liverspathologic correlation

AJR Am J Roentgenol

Radiofrequency ablation of hepatic tumorsvariability of lesion size using a single ablation device

AJR Am J Roentgenol

Radiofrequency thermal ablationcomputer analysis of the size of the thermal injury created by overlapping ablations

AJR Am J Roentgenol

Percutaneous treatment of small hepatic tumors by an expandable RF needle electrode

AJR Am J Roentgenol

Radiofrequency ablation of unresectable primary and metastatic hepatic malignanciesresults in 123 patients

Ann Surg

Small hepatocellular carcinomatreatment with radio-frequency ablation versus ethanol injection

Radiology

Hepatocellular carcinomaradio-frequency ablation of medium and large lesions

Radiology

Small hepatocellular carcinomatherapeutic effectiveness of percutaneous radio frequency ablation therapy with a LeVeen needle electrode

J Ultrasound Med

Small hepatocellular carcinoma in cirrhosisrandomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection

Radiology

Percutaneous radiofrequency ablation of hepatic tumorsPost-ablation syndrome

AJR Am J Roentgenol