Abstract
Purpose
This study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.
Methods and materials
This pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5–6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). 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 the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.
Results
No major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5–5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5–1.3cm).
Conclusions
TACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.
Riassunto
Obiettivo
Valutare nei pazienti affetti da epatocarcinoma multinodulare unilobare non resecabile, con almeno una lesione con diametro >3 cm, la fattibilità, la sicurezza e l’efficacia di una nuova terapia combinata con RFA durante occlusione arteriosa con catetere per PTA (BO-RFA) seguita da TACE della lesione principale e TACE delle restanti lesioni, in un’unica seduta. Endpoint secondario del nostro studio è stata la comparazione degli effetti iniziali in termini di necrosi tumorale delle lesioni trattate con questa nuova terapia combinata con quelli ottenuti in una popolazione di confronto trattata nel nostro centro nell’anno precedente con sola TACE.
Materiali e metodi
Il nostro studio pilota è stato approvato dal comitato etico e dall’autorità competente, e per tutti i pazienti è stato ottenuto un consenso informato scritto. Dieci pazienti consecutivi affetti da HCC multinodulare (2–6 noduli) unilobare, non resecabile e con una lesione target di diametro >3 cm di diametro (range 3,5–6 cm), non suscettibile di trattamenti di tipo curativo, sono stati arruolati nel nostro studio pilota monocentrico multidisciplinare. Il piano di trattamento è stato: RFA (ago con punta esposta da 3 cm) della lesione target durante occlusione endovascolare dell’arteria epatica afferente al tumore con catetere per PTA seguita da una TACE selettiva della stessa, più una TACE lobare per il trattamento delle altre lesioni (450 mg di carboplatino più lipiodol associato a embolizzazione temporanea con spongostan). Gli eventi avversi, cosÌ come le complicanze intra- e periprocedurali sono stati valutati clinicamente. L’efficacia locale in fase precoce è stata valutata mediante TC multifasica eseguita a un mese dalla procedura, sulla base dei criteri m-RECIST; separatamente è stata, inoltre, effettuata una valutazione delle lesioni target in termini di enhancement, diametro dell’area necrotica e presenza e distribuzione di lipiodol.
Risultati
Non si sono verificate complicanze maggiori. Il successo tecnico complessivo, definito come la completa devascolarizzazione di tutti i noduli in fase arteriosa, è stato ottenuto in 7/10 pazienti con 3 risposte parziali (persistenza di piccoli noduli ipervascolarizzati). Considerando solo le lesioni target, il successo tecnico è stato raggiunto in tutti i pazienti, con la presenza di un’area priva di enhancement nella zona corrispondente al precedente nodulo di HCC (diametro necrotico 3,5–5 cm), con un accumulo periferico di lipiodol circonferenziale (margine di sicurezza), di almeno 0,5 cm (0,5–1,3 cm).
Conclusioni
Il trattamento combinato con BO-RFA seguita da TACE, in un approccio single-step, sembra essere una terapia sicura ed efficace per il trattamento dell’HCC avanzato non resecabile, permettendo di ottenere un alto tasso di risposta locale completa anche in lesioni di grandi dimensioni.
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Iezzi, R., Cesario, V., Siciliani, L. et al. Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE). Radiol med 118, 555–569 (2013). https://doi.org/10.1007/s11547-012-0914-7
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DOI: https://doi.org/10.1007/s11547-012-0914-7