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ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 378-383

Comparison of percutaneous microwave ablation and surgical resection for hepatocellular carcinoma in the caudate lobe


1 Medical School of Chinese PLA; Department of Interventional Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
2 Department of Medical Administration, the 305th Hospital of Chinese PLA, Beijing, China
3 Department of Interventional Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China

Date of Submission05-Jul-2021
Date of Acceptance03-Jan-2022
Date of Web Publication20-May-2022

Correspondence Address:
Xiaoling Yu
Department of Interventional Ultrasound, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.jcrt_1067_21

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 > Abstract 


Background: This study aims to compare the clinical efficacy and safety between ultrasound (US)-guided percutaneous microwave ablation (MWA) assisted with a three-dimensional (3D) visualization preoperative planning system and surgical resection (SR) for hepatocellular carcinoma (HCC) in the caudate lobe.
Materials and Methods: Forty-nine patients diagnosed with caudate lobe HCC, who underwent US-guided percutaneous MWA (29 patients) or SR (20 patients), were enrolled between November 2005 and December 2018. Follow-up was performed at 1, 3, 6, 12, 18, 24, and 36 months after ablation or resection. The follow-up endpoint was recurrence or patient death. Overall survival (OS) and progression-free survival (PFS) were the primary outcomes, whereas local tumor progression (LTP), intrahepatic recurrence, and extrahepatic metastasis were the secondary ones.
Results: The mean age of the two groups was 61.4 ± 9.1 (MWA) and 53.1 ± 6.8 (SR), respectively, with a significant difference (P < 0.01). There were no significant differences in OS (69.0% in the MWA group and 75.0% in the SR group) and PFS (62.1% in the MWA group and 35.3% in the SR group). LTP, intrahepatic recurrence, and extrahepatic recurrence were 6.9% (2/29), 31.0% (9/29), and 20.7% (6/29) in the MWA group and 5.0% (1/20), 60.0% (12/20), and 5.0% (1/20) in the SR group. The MWA group was more cost-effective and required less hospitalization time. No major complications were observed.
Conclusions: US-guided percutaneous MWA for HCC in the caudate lobe assisted with a 3D visualization preoperative planning system is an optional treatment with less expenses and shorter hospitalization than SR.

Keywords: Hepatocellular carcinoma in the caudate lobe, microwave ablation, preoperative treatment planning, surgical resection, three-dimensional visualization


How to cite this article:
Qi E, Zhang S, Li X, Cheng Z, Han Z, Yu J, Liang P, Yu X. Comparison of percutaneous microwave ablation and surgical resection for hepatocellular carcinoma in the caudate lobe. J Can Res Ther 2022;18:378-83

How to cite this URL:
Qi E, Zhang S, Li X, Cheng Z, Han Z, Yu J, Liang P, Yu X. Comparison of percutaneous microwave ablation and surgical resection for hepatocellular carcinoma in the caudate lobe. J Can Res Ther [serial online] 2022 [cited 2022 Oct 1];18:378-83. Available from: https://www.cancerjournal.net/text.asp?2022/18/2/378/345520




 > Introduction Top


Thermal ablation, a therapeutic method of the “TATI” (transcatheter arterial chemoembolization, ablation, tyrosine kinase inhibitors, and immunotherapy) modality,[1] is a curative method for liver cancer.[2],[3] Nevertheless, ablation for hepatocellular carcinoma (HCC) in the caudate lobe is technically difficult and potentially dangerous because of the proximity of the major vessels to the caudate lobe.[4],[5] The application of three-dimensional (3D) visualization preoperative planning has shown that it could improve clinical efficacy.[6]

This study is to compare the efficacy and safety of ultrasound (US)-guided percutaneous microwave ablation (MWA) for HCC in the caudate lobe assisted with a 3D visualization preoperative planning system and surgical resection (SR).


 > Materials and Methods Top


Patients

Forty-nine patients who underwent US-guided percutaneous MWA with the aid of a 3D visualization preoperative planning system (n = 29) or (SR, n = 20) between November 2005 and December 2018 were enrolled in this study. [Table 1] shows the characteristics of the enrolled patients. All the patients in the MWA group met the following eligibility criteria:[1] unsuitable for resection due to surgical contraindications,[2] unwillingness to undergo surgery,[3] three or fewer concomitant tumors in the liver, and[4] no extrahepatic metastasis or malignant portal vein or inferior vena cava (IVC) thrombosis. HCC diagnosis was based on at least two different contrast-enhanced imaging modalities or US-guided percutaneous biopsy.[7] Patients' data in the SR group were retrospectively consulted. This investigation was approved by the institutional ethics committee of the Chinese PLA General Hospital. Written informed consent was obtained from all patients.
Table 1: Patient and tumor characteristics

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Establishment of preoperative planning

Our team independently developed a 3D visualized preoperative planning software, which could achieve the following functions: liver segmentation, tumors, intrahepatic ducts, simulation of thermal fields, visualization of needle insertion path planning, and quantitative calculation.[6],[8] Contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) scanning was performed before MWA for each patient. The patients' DICOM format contrast-enhanced CT or MRI data were imported into the 3D visualization preoperative planning system for 3D reconstruction. Tumors were segmented in a semiautomatic manner using the open-source program Medical Imaging Interaction Toolkit (http://www.mitk.net/download_mitk1.html). According to our previous studies,[9],[10] the thermal modeling of MWA was established on the basis of the Pennes continuum model. The tumor volume, stereo relationship between tumor and surrounding organs, antennas parameters (number, insertion pathway and angle, and energy), and thermal field distribution were precisely demonstrated in 3D visualization preoperative treatment planning.

MWA preoperative planning abided to the following principles:[1] covering the entire tumor plus a predefined 5 mm peritumoral ablative margin in cases where the safe margin could be achieved and covering the entire tumor without a predefined ablative margin in cases where a safe margin could not be achieved for caudate lobe HCC adjacent to vessels or the gastrointestinal tract (GIT),[2] minimizing the number of ablation sessions,[3] minimizing the number of electrode insertions, and[4] avoiding thermal damage to any critical organ.

Microwave ablation with preoperative planning

US-guided MWA was performed under unconscious intravenous anesthesia (propofol, 6–12 mg/kg/h; ketamine, 1–2 mg/kg) in the operating room. All ablations were performed by two experienced radiologists under US guidance according to the result of 3D visualization preoperative planning. Contrast-enhanced US-guided ablation with SonoVue (Bracco, Milan, Italy) was performed when tumors were unclear on the conventional US. The microwave equipment (KY-2000, Kangyou Medical, China) comprised three independent microwave generators, three flexible coaxial cables, and three water pumping machines, which could drive three cool-tip needle antennas (15Gauge in diameter with cool shaft). The generator was capable of producing 1–100 W of power at 2450 MHz. During the therapy, we monitored the hyperechoic area of the ablated zone under US and/or thermal monitoring to decide the treatment endpoint. When withdrawing the antennas, the needle tracks were routinely cauterized to avoid tumor seeding or bleeding. We checked whether hemorrhage had occurred through color Doppler US following the extraction of the antennas. Within 3 days after MWA, contrast-enhanced imaging was performed in each patient to evaluate ablation efficacy. If residual tumor was detected, additional MWA treatment was performed.

Ancillary treatment techniques

One or two 21Gauge PTC (percutaneous transhepatic cholangiography) needles were inserted into the marginal tumor tissue near the IVC or hepatic hilum (HH) under US guidance. A small dose of dehydrated, sterile 99% ethanol was slowly injected into the marginal tumor tissue during the MWA procedure to enhance thermal efficacy.

The hydrodissection technique and the thermal monitoring procedure were performed to avoid thermal damage when tumors were adjacent to the GIT. The former method is achieved by inserting a 16Gauge intravenous catheter (BD Angiocath; Sandy, UT, USA) into the abdominal cavity between the edge of the liver and the adjacent GIT under US guidance while infusing sufficient normal saline to separate the lesion from the GIT. Drip infusion was continued during the MWA procedure to keep the distance between the target lesion and adjacent GIT more than 0.5 cm. By contrast, the thermal monitoring procedure was performed during treatment to prevent thermal damage to adjacent organs or tumor tissues, such as the gallbladder and GIT. One or two 21Gauge thermal monitoring needles (Kangyou Medical, China) were placed into the marginal tissue of the tumor under US guidance, and real-time temperature monitoring was carried out to protect the surrounding tissues or organs from heat damage. According to our experimental process and clinical experience, the threshold temperature for ablation therapy was set at 60°C. MWA immediately stopped when the temperature reached 60°C, and it was activated again after the temperature decreased to 50°C.

Therapeutic efficacy assessment and follow-up

Therapeutic efficacy was assessed through contrast-enhanced imaging after treatment. The effectiveness of this technique was defined as the “complete ablation” of the macroscopic tumor proved by imaging modalities at 1-month postablation. Local tumor progression (LTP) was defined as the incompletely treated viable tumor that continued to grow or a new tumor (or “daughter” or “satellite” tumors) growing at the original site during follow-up. The follow-up period was calculated from the beginning of the MW ablation or SR in all patients. Contrast-enhanced images were repeated at 1-and 3-month intervals within 1 year and then at 6-month interval after MWA or SR. Complications were defined according to the SIR reporting standards for image-guided tumor ablation.

Statistical analysis

Data analysis was performed using the SPSS 25.0 for windows (SPSS Inc., Chicago, IL, USA), and the continuous data were expressed as means ± standard deviations.


 > Results Top


The mean maximum tumor diameters for the MWA and SR groups were 2.6 ± 1.3 cm (range: 1.1–6.5 cm) and 3.0 ± 0.8 cm (range: 1.5–4.0 cm), respectively. The mean age for the MWA and SR groups was 61 ± 9 (range: 42–81 years) and 53 ± 7 (range: 43–65 years), respectively. The median follow-up for the MWA and SR group was 30 months (range: 4–136 months) and 42.5 months (range: 15–99 months), respectively. MWA was successfully performed for all tumors in the MWA group. One MWA session was performed in 23 patients, two sessions were performed in five patients, and three sessions were performed in one patient within 3 days due to residual tumors. All 29 patients achieved complete ablation on the 1-month imaging follow-up. The technical effectiveness rate was 100% [Figure 1]. Among the 29 patients, percutaneous ethanol injection (PEI) was performed in 12 patients during MWA to guarantee ablative accuracy and tolerability. A thermal monitoring procedure was performed in four patients with tumors adjacent to the GIT. Furthermore, hydrodissection was performed successfully in nine patients with tumors near the GIT.
Figure 1: Images of a 62 year old patient with hepatocellular carcinoma in the caudate lobe. (a) Preoperative magnetic resonance imaging showed that the tumor was located in the Spiegelian lobe (arrows). (b) Threedimensional visualization images showed the spatial relationship between the tumor and its surrounding structure in multiangle. (c) The preoperative planning was achieved using a threedimensional visualization preoperative planning system, and two needles were needed to cover the tumor completely (arrows). (d) Microwave ablation was performed according to the threedimensional visualization of the preoperative planning. (e) Contrastenhanced magnetic resonance imaging showed complete tumor necrosis at 1 month after microwave ablation (arrows). (f) Threedimensional visualization postoperative evaluation showed that the ablation area (red) covered the tumor completely (arrow)

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During a median follow-up of 30 months (range: 4–136 months) in the MWA group and 46.5 months (range: 15–99 months) in the SR group, no significant differences were observed in overall survival and progression-free survival between the two groups [Figure 2]. LTP was found in two of the 29 patients (6.9%) in the MWA group and in one of the 20 patients (5.0%) in the SR group. Intrahepatic recurrence and extrahepatic recurrence were, respectively, 31.0% (9/29) and 20.7% (6/29) in the MWA group and 60.0% (12/20) and 5.0% (1/20) in the SR group.
Figure 2: There were no significant differences between the microwave ablation and surgical resection groups concerning the overall survival and progression-free survival, although the survival curve revealed a relatively higher overall survival trend and lower progression-free survival in the surgical resection group

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Neither major (SIR classifications C–E) nor minor complications (SIR classifications A and B), such as intractable hemorrhage, liver abscess, bile-duct injury, and tumor seeding, were observed in this study. Nevertheless, the MWA was more cost-effective and required less hospitalization time compared to [Table 2].
Table 2: Hospitalization parameters

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 > Discussion Top


HCC in the caudate lobe is located deeply between the HH and the IVC, underlining the challenging nature of the subsequent treatment. SR is considered the main treatment for HCC in the caudate lobe, although it has a higher surgical risk and recurrence rate when compared with conventional hepatectomy of noncaudate lobe masses.[11]

As for MWA, in addition, the diameter of the tumor should be smaller than or equal to 3 cm according to the MWA guidelines.[12] However, there were seven patients in the MWA group whose tumors were larger than 3 cm because of their advanced age, serious underlying diseases, or greater reluctance to resection. Interestingly, a similar prognosis was observed in both groups in this study, a finding which reflects the advantage of applying various auxiliary techniques.

Preoperative planning is a key step for the thermal ablation of tumors. Conventionally, radiologists usually apply their spatial awareness and experience to reconstruct 3D imaging data into 3D images for preoperative treatment planning. Nevertheless, under this perspective, different physicians are bound to generate different planning results, which may be misinterpreted by inexperienced radiologists, and thus lead to treatment failure or to the development of major complications. 3D visualization preoperative planning could objectively display the location and the relationship between the tumor and its surrounding tissues, predict the time-temperature profile during ablation, and improve both the ablation technique and the ablation success rate.[13],[14],[15],[16] The main aspect of preoperative planning is to select a reasonable puncture path and subsequently establish an effective thermal field so that the tumors can be completely ablated without any damage to the surrounding tissues or organs. 3D visualization preoperative treatment planning can quantitatively calculate the tumor volume and the distance between the tumor and the surrounding vital structures and thus provide an accurate simulation of the 3D thermal field and planning of the puncture pathway.[6],[13] Consequently, this is a significant improvement when compared with the conventional US-guided MWA for HCC. Thus, the application of a 3D visualization preoperative planning in US-guided percutaneous MWA for HCC in the caudate lobe may improve clinical efficacy.

The previous reports have suggested two approaches for percutaneous MWA for HCC in the caudate lobe, namely, the right and the anterior approaches.[17],[18] In this study, the right approach was used for all tumors, especially for tumors located at the paracaval portion and the caudate process. By contrast and even though the anterior approach under US guidance through the left lobe of the liver has a high risk of lethal puncture injury to the blood vessels or bile ducts, this method was used for tumors in the Spiegelian lobe when the right approach was not available according to the 3D visualization preoperative planning results. Because of the special anatomy of the caudate lobe, a safe margin is hard to achieve for thermal ablation to prevent future tumor recurrence. In our study, the principles of thermal ablation were as follows: (1) a composite of spherical thermal fields should cover the entire tumor plus a predefined ablative margin when a safe margin could be achieved, (2) and the thermal fields should just cover the entire tumor without a predefined ablative margin when a safe margin could not be achieved for caudate lobe HCCs adjacent to vessels or GIT.

Shibata et al. reported that PEI could achieve complete tumor ablation of HCC in the caudate lobe with more treatment sessions compared with radiofrequency ablation (RFA), one of the thermal ablation modalities.[19] RFA or MWA combined with PEI have been reported to be more effective than RFA or MWA alone, with a higher complete necrosis rate and similar complication rate for tumors in high-risk locations.[20],[21] Thus, PEI combined with MWA was adopted according to 3D visualization preoperative planning for the region near the vessel for which it was difficult to cover the entire tumor with the microwave thermal field alone. PEI was performed in 12 patients with a little dose of ethanol during MWA to guarantee ablation accuracy and tolerability in this study.

The application of the hydrodissection technique and thermal monitoring technology could both ensure the success of ablation therapy and prevent the incidence of complications caused by thermal damage.[22],[23] Consequently, neither major nor minor complications were observed in this study.

Significantly, the mean age in the MWA group was larger than that in the SR group. Elderly patients had lower operative tolerance, and thus, they preferred MWA. Moreover, cost-effectiveness and shorter hospitalization rates render MWA as an alternative curative method for patients unsuitable for resection.

There are three limitations in our study. First, the present study was a preliminary retrospective one with small sample size; thus, a further study, such as a randomized controlled study, and a larger sample size may be needed. Second, the heat sink effect was not considered in the 3D visualization preoperative treatment planning system. Moreover, we did not use the navigation device to ensure the placement of the antenna would be consistent and exact with the predefined plan. Third, this was a single-center study; a multicenter study would be more convincing.


 > Conclusions Top


US-guided percutaneous MWA for HCC in the caudate lobe assisted with a 3D visualization preoperative treatment planning system was found to be safe and effective in comparison with SR.

Acknowledgment

This study was funded by the National Key R&D Program of China (2017YFC01), the National Scientific Foundation Committee of China (grant numbers 81871375, 81801723, 81471683, 82172027, 82171940).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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