RPS 109 - Liver malignancies: HCC and metastases

Purpose:

To evaluate the efficacy, advantages, and limitations of the ultrasound fusion imaging (US-FI) technique in percutaneous ablation of focal hepatic malignant tumours and to assess the change in the timing of the procedures performed under US-FI guidance.

Methods and materials:

16 consecutive patients with 33 focal hepatic malignant tumours (27 hepatocellular carcinomas, 6 metastases) were prospectively enrolled between January and May 2019 and treated with percutaneous radiofrequency ablation or ethanol injection under US-FI guidance. Procedures were performed by two expert radiologists who answered several scored questions (from 1 to 10) of a survey about US-FI technique at the end of every procedure. The times of the procedure with and without US-FI were monitored and compared. The mean qualitative and quantitative parameters of the tumour were evaluated by CT/MRI before and after the procedures.

Results:

US-FI was judged more useful, the less conspicuous the lesion was in B-mode (p<0.001), increasing operator confidence in 88.2% of cases. US-FI changed the perception of lesion size in 70.5% of cases, correcting the choice of needle path in 76.5% of the procedures. The synchronization process is more precise when the lesion diameter is larger (p=0.047). The mean time of the procedures was 17min and 50s and the total duration of the procedure did not influence the radiologists' judgment about the utility of US-FI (p>0.05). The complete ablation of lesions was achieved in 67% of tumours. No post-procedural complication was observed.

Conclusion:

US-FI significantly increases the confidence of operators, enhancing the conspicuity of the target lesion and permitting to plan the needle path more precisely. The technique does not significantly prolong the total time of the procedure.

Limitations:

Interoperator variability.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the effectiveness and safety of DSM-TACE using irinotecan, oxaliplatin, and adriblastine loaded with absorbable microspheres (50 micron in size) for the treatment of colorectal, gastro-oesophagal breast cancer, NET and GIST liver metastases in a salvage setting of patients refractory to or not able to tolerate chemotherapy.

Methods and materials:

A total of 39 DSM-TACE were performed in 29 patients (mean 2.4/patient, range 1-3). The interval between treatments ranged from 4 to 6 weeks (mean 5.0 weeks, median 4 weeks). TACE was done with lobar delivery (22 via the right hepatic artery, 17 via the left hepatic artery). Microcatheters 2.7 Fr in diameter were used for all treatments (Progreat Terumo, JAP). C-arm CT was performed during arterial test injections (flow 2 cc/sec, volume 24 cc, delay 4s, scan 8s,) before TACE in 31 procedures to confirm the appropriate catheter position.

Results:

All patients had upper abdominal pain and nausea lasting for 1-3 days after TACE. The pain was graded severe in 32%, moderate in 40%, and mild in 28% of procedures. Nausea was graded ECOG 3 in 12%, ECOG 2 in 43%, and ECOG 1 in 45%.

At 3 months, the complete absence of tumour enhancement during CT was seen in 9 patients and necrosis comprising about 50% of tumour volume in 16 patients.

Conclusion:

TACE using DSM-TACE is safe and effective in patients with liver metastases who had been treated with systemic chemotherapy before. The median time to progression was 5 months, however, all patients showed intrahepatic tumour progression during follow-up (median follow-up 9 months).

Limitations:

No potential bias.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Post-radiofrequency ablation (RFA) evaluation of liver tumours are currently based on visual inspection of computed tomography (CT) images. This study aimed to investigate the correlation between CT number shift and temperature change in order to create CT thermal maps for objective assessment of ablation margins.

Methods and materials:

RFA was conducted on ex-vivo bovine livers (n=40) with constant temperature monitoring via embedded fibre-optic sensors at various locations within the ablation volume. CT scans were performed at 3-minute intervals throughout the ablation and cooling process. CT numbers were obtained from points that corresponded to the locations of the temperature sensors. The correlation between CT number shift and temperature change was analysed using SPSS and MATLAB software. CT thermal maps for the real-time monitoring of tissue temperature were then developed and tested on patients undergoing hepatic RFA.

Results:

A negative linear correlation was found between CT number shift (y) and temperature change (x): y =-4.99-1.16x (r=0.84). CT number decreased as tissue temperature increased during ablation and vice versa during the cooling period at a rate of 1.16 HU/°C. In clinical settings, the CT thermal maps were feasible in the intra-ablation scans but demonstrated poor results in delayed post-ablation scans.

Conclusion:

There was a strong correlation between CT number shift and tissue temperature during RFA. Using the equation developed from this study and the aid of thermal map algorithms, it is possible to estimate tissue temperature based on CT number shift during real-time CT-guided RFA. This approach would improve the objective evaluation of ablation margins.

Limitations:

The small number of human subjects with RFA images suitable for thermal map testing.

Ethics committee approval

University of Malaya Medical Centre MREC ID No:20161025-4414.

Funding:

University of Malaya Postgraduate Research Fund (PO057-2015B).

Purpose:

To show the road we took to introduce percutaneous ablative therapy for tumours in Croatia, which was practically non-existing until 2017, to now having a growing demand by oncologists and surgeons after treating our first 150 patients.

Methods and materials:

This is a retrospective analysis of 150 patients treated with percutaneous CT-guided microwave ablation from January 2017-October 2019. We treated 78 kidney tumours, 42 liver tumours (including 34 CRC metastasis and 8 HCC), 9 bone tumours, and 22 lung tumours (including 14 metastases and 8 lung cancers).

We used HS Amica, Emprint, and Eco ablation devices, with internally cooled ablation probes, usually 14 or 16G, with high energy output.

Results:

Best results were achieved with kidney cancer ablation, with only 3 cases of residual tumour after the initial treatment, which were additionally treated with second MWA. Our secondary efficacy is 100% until now. There was only one case of severe bleeding after ablation which was treated with embolisation in the angio suite.

We had the highest rate of recurrence with CRC liver metastases, where 18 patients showed residual tumour tissue. In 12 cases, there were adittional new metastases found in the follow-up period. There were 2 cases of significant complications with biliary tree injury and colon injury that were treated surgicaly.

Conclusion:

Percutaneous CT-guided microwave ablation has a growing role in the therapy of liver, kidney, lung, and bone tumours in Croatia, and with our good results in the first 150 patients since 2017, there is a higher awareness about the role of interventional radiology in cancer treatment.

Limitations:

A retrospective observational study.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the role of IVIM imaging in the response evaluation of HCC after TACE.

Methods and materials:

15 patients underwent TACE with 40-60 mg epirubicin from April 2018-Oct 2019. MRI-DWI with IVIM and T1 dynamic CEMR imaging was done in 3T GE machine before TACE procedure and at 6 weeks and 12 weeks after TACE. Response evaluation was analysed by comparing IVIM parameters (like D*,f, and ADC) before and after TACE procedure and also with dynamic CEMR imaging.

Results:

IVIM parameters after TACE showed a decrease in values when compared to pre-TACE values. Decreased IVIM values correlated well with nonenhancing and minimal enhancing regions. Before TACE, mean D*, f, and ADC values were 25x10-4 +/- 5x10-4 mm2/s, 12+/- 6%, and 750x10-6 +/- 150x10-6 mm2/s, respectively. After TACE, mean D*, f, and ADC values were 15x10-4 +/- 5x10-4 mm2/s, 5 +/- 2% and 1500x10-6 +/- 150x10-6 mm2/s, respectively

Conclusion:

IVIM is useful to evaluate tumour response and may obviate the need for contrast usage in some situations.

Limitations:

Small sample size and lack of pathological validation of the MRI results.

Ethics committee approval

Approved by Ethics committee of SCTIMST, Trivandrum, Kerala, India.

Funding:

Funding received from the STIMST institute.

Purpose:

To assess and compare the effectiveness and safety of HCC patients with PVT and without PVT, after Y-90 Transarterial radioembolisation (TARE).

Methods and materials:

From November 2005-November 2012, Y-90 resin-based TARE was performed in an IRB-approved prospective protocol, on 89 patients with unresectable HCC. 33/89 patients had PVT, the remaining 56 were resistant-to-cTACE or underwent TARE as a downstaging therapy. All patients were studied with multi-detector computed tomography (MDCT), angiography, 99mTc-MAA-scintigraphy, and a liver biopsy. The gastroduodenal artery was embolised in most cases. Proton-pump inhibitors were administered to prevent gastritis and ulcers. A χ2 test with Yates correction and log-rank test were used to compare the two proportions and Kaplan-Meier survival curves, respectively.

Results:

The average activity administered was 1.7 ± 0.4 GBq. After the treatment, CTCAE grade 2 adverse events occurred in 46% (41/89) patients. In particular, fever and abdominal pain were found in 25 and 16 patients, respectively. No major side-effect was observed. According to the mRECIST criteria, partial response or complete response was found in 70% of patient three months after the treatment and in 90.5% nine months after the treatment. No significant difference was found in the survival of patients with PVT compared to those without PVT (p=0.672). Complete regression of PVT was observed in almost half of the patients (13/27, 48.1%).

Conclusion:

Portal vein invasion does not affect survival in advanced-stage HCC-patients undergoing TARE using Y-90 resin-based microspheres. The Y90 procedure is associated with a regression of portal vein tumour thrombus.

Limitations:

A single-centre, retrospective study.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the feasibility, safety, and efficacy of combined single-step therapy in patients with an unresectable single large (>3 cm) hepatocellular carcinoma (HCC) with balloon-occluded microwave ablation (BO-MWA) plus transcatheter arterial balloon-occluded chemoembolisation (BO-TACE).

Methods and materials:

10 consecutive child-A patients (mean age: 69.7±9y, range: 62-78y) with an unresectable single large HCC (>3 cm) (mean size: 5.6±0.43 cm-range: 4.2-8 cm) were enrolled in our pilot study. The schedule consisted of percutaneous microwave ablation of the lesion during occlusion of the hepatic artery supplying the tumour (BO-MWA), followed by TACE under the occlusion of feeding arteries by a micro-balloon catheter (BO-TACE). Adverse events and intra and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of m-RECIST criteria.

Results:

Technical success was obtained in all procedures. No major complications occurred. A mean necrotic area of 6.2±1.03 cm was obtained, with a complete response of 80% obtained at 1-month follow-up, with 2 partial responses (less than 30% of residual tumour). All lesions smaller than 5 cm in size were completely necrotic.

Conclusion:

Our preliminary experience seems to demonstrate that BO-MWA plus BO-TACE could be a safe and effective combined therapy for unresectable large HCC lesions, allowing a high rate of local response also in lesion exceeding 5 cm in size.

Limitations:

A small number of cases.

Ethics committee approval

Written informed consent was obtained.

Funding:

No funding was received for this work.

Purpose:

To compare microwave ablation (MWA) with laser-induced thermotherapy (LITT) in the treatment of hepatocellular carcinoma (HCC) regarding local tumour control, survival rate, and complications.

Methods and materials:

Of 277 patients, 231 patients (177 males, 54 females; mean:65.8 years) were treated with MWA and 46 patients (36 males, 10 females; mean:67.1 years) with LITT. All ablations were evaluated for the location of the lesion, diameter, volume, post-ablation volume, device, power, duration of therapy, and local tumour control.

Results:

The mean tumour diameter and volume were 21.13 mm and 4.8 cm³ in the MWA group and 24.33 mm and 5.4 cm³ in the LITT group. The mean post-ablation volume was 30 cm³ in the MWA group and 47.6 cm³ in the LITT group. The local recurrence rate was 4.3% (10/231) in the MWA group and 2.2% (1/46) in the LITT group. The complete remission rate was 23.8% (55/231) in the MWA group and 34.8% (16/46) in the LITT group. The rate of newly developed HCC lesions was 71.9% (166/231) in the MWA group and 63% (29/46) in the LITT group. The complication rate was 4.32% in the MWA group versus 13% (6/46) in LITT. Survival time was 922 days in the MWA group versus 1,293 days in the LITT group, with a significant difference in the survival time (p=0.002).

Conclusion:

MWA and LITT are both effective for the local treatment of HCC. LITT patients had an overall longer survival time than MWA patients with a higher rate of complications.

Limitations:

A retrospective study design.

Ethics committee approval

Approved by the Institutional Review Board.

Funding:

No funding was received for this work.

Purpose:

To compare the efficacy and safety of radiofrequency ablation (RFA) and repeat resection as the first-line treatment in recurrent HCC.

Methods and materials:

This retrospective study analysed 290 patients who underwent RFA (n=199) or repeat resection (n=91) between January 2006 and December 2016 for locally recurrent HCC (≤5 cm) following primary resection. We compared overall survival (OS), progression-free survival (PFS), and complications between the two treatment groups for the total cohort and the propensity score matched (PSM) cohort.

Results:

The 1, 3, and 5-year OS (90.7%, 69.04%, 55.6% versus 87.7%, 62.9%, 38.1%, p=0.11) and PFS (56.5%, 27.9%, 14.6% versus 50.2%, 21.9%, 19.2%, p=0.80) were similar in the RFA group and the repeat resection group. However, RFA was superior to repeat resection in the complication rate and hospital stay (p≤0.001). We observed similar findings in the PSM cohort of 50 pairs of patients and when OS and PFS were measured from the time of the primary resection. The OS of the RFA group was significantly better than the repeat resection group among those with 2 or 3 recurrent tumour nodules in both the total cohort (p=0.009) and the PSM cohort (p=0.038).

Conclusion:

RFA has the same efficacy as repeat resection in recurrent HCC patients, but with fewer complications. RFA is more efficient and safer than repeat resection in patients with 2 or 3 recurrent tumour nodules.

Limitations:

Our study is limited by the noninterventional nonrandomised study design, but we used the propensity score matching method.

Ethics committee approval

The study was approved by Shandong Provincial Hospital review board with a waiver of patient informed consent.

Funding:

This work was supported by Shandong Provincial Medical Health Technology Development Projects (No. 2017WS472).

Purpose:

To investigate the correlation between radiomic features of the surrounding liver parenchyma and local tumour progression (LTP) after ablative treatments of colorectal liver metastases (CLM). No pertinent data concerning the role of radiomics in this setting are present in the literature.

Methods and materials:

39 CT-based radiomic features were extracted from 37 CLM in 35 consecutive patients who underwent image-guided thermal ablation. Patients with preprocedural CT acquired earlier than 30 days before the procedure were excluded. Ablation margins, size of the lesion, chemotherapy regimens, and technology (radiofrequency or microwave) were also evaluated.

CT images of CLM were manually segmented on portal phase acquisitions (ITKsnap software, version 3.6.0). Subsequently, a volume including 1 cm in width of surrounding liver parenchyma was automatically generated. Radiomic features were extrapolated using in-house software developed in C++ with ITK libraries. Statistical analysis was performed using a Mann-Whitney U test and Pearson test. ROC curves and AUC were also evaluated.

Results:

1st percentile (p=0.023; AUC=0.738) and 10st percentile (p=0.043; AUC=0.713) had a direct correlation with LTP in all pre-treatment lesions. In the 24 lesions with ablation margins ≥5 mm (LTP in 7/24 cases, 29.2%), 7 features (1st percentile, contrast, entropy, diffEntropy, infCorr1, dissimilarity, and SRE) and 6 features (including correlation, energy, homogeneity, infCorr2, diffVariance, and maxGLCM), respectively showed a direct and an indirect correlation with LTP (p<0.005).

Conclusion:

CT radiomic features of the surrounding liver parenchyma of CLM with LTP significantly differ from ablated CLM without LTP, especially in the case of adequate safety margins (≥5 mm). These preliminary findings suggest a role for radiomic features as predicting factors of the outcome of CLM ablation.

Limitations:

The limited number of patients.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the role of best supportive care (BSC) versus systemic chemotherapy versus regional chemoembolisation (TACE) in patients with unresectable cholangiocarcinoma (CCC). The treatment performed was documented and the survival of the patients with unresectable CCC treated at a tertiary referral centre was analysed.

Methods and materials:

In 220 consecutive patients with CCC, systemic chemotherapy, using cisplatin and gemcitabine, and TACE using mitomycin, cisplatin, and lipiodol, was performed. Survival curves were calculated according to the Kaplan-Meier method and the log-rank test was applied for survival analysis.

Results:

Any palliative treatment was beneficial for patients with unresectable CCC when compared to BSC alone; the median OS with BSC was 10 weeks (BSC vs. TACE p=0.017, HR=0.36; BSC vs. TACE/chemotherapy p<0.001, HR=0.24; BSC vs. chemotherapy p<0.001, HR=0.31). A combination of TACE and chemotherapy prolonged overall survival as compared to TACE alone (105 weeks vs. 43 weeks, p=0.045).

Conclusion:

The majority of patients with biliary tract cancer are diagnosed with intrahepatic CCC and have a poor prognosis with advanced stage CCC. Multimodal treatment in palliative patients significantly prolongs survival.

Limitations:

A retrospective study design.

Ethics committee approval

Approval by the Institutional Review Board.

Funding:

No funding was received for this work.

Purpose:

To evaluate the local tumour progression (LTP) and overall survival (OS) in patients with neuroendocrine liver metastases (NLMs) who have undergone percutaneous thermal ablation.

Methods and materials:

The retrospective two-centre study was conducted on 36 patients (67 lesions) with NLM who were treated with percutaneous thermal ablation and subsequent intra-arterial therapy, if necessary. Uni/multivariate analyses were performed using logistic regression and Cox-regression models.

Results:

The midgut was the most frequent primary tumour site (34.3%) followed by the pancreas (21%).

100% of the secondary hepatic lesions were ablated completely at the first cross-sectional imaging control and only 6% showed LTP (4/67).

The median OS was calculated as 11.26 years and the midgut (site of origin) was shown as the main independent predictor of OS (HR: 7.39, p=0.001). Furthermore, patients with non-functional NETs had a reduced OS compared to functional NET (HR: 0.027, p=0.027). No immediate post-procedural complications were found.

Conclusion:

Percutaneous thermal ablation procedures appear feasible and safe in the treatment of well-differentiated NLMs and allow an effective local tumour control with a low LTP rate. However, furthur study is required to show if radiologic procedures themself might really improve the relatively high OS.

Limitations:

A relatively small series.

Ethics committee approval

Ethics committee approval obtained.

Funding:

No funding was received for this work.