Expert Review of Anticancer Therapy
ISSN: 1473-7140 (Print) 1744-8328 (Online) Journal homepage: http://www.tandfonline.com/loi/iery20
Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal? Giuseppe Cabibbo, Michela Antonucci, Rodolfo Sacco & Elio Sciarrino To cite this article: Giuseppe Cabibbo, Michela Antonucci, Rodolfo Sacco & Elio Sciarrino (2015) Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal?, Expert Review of Anticancer Therapy, 15:2, 147-150 To link to this article: http://dx.doi.org/10.1586/14737140.2015.1001374
Published online: 06 Jan 2015.
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Date: 14 November 2015, At: 19:50
Editorial
Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal? Expert Rev. Anticancer Ther. 15(2), 147–150 (2015)
Downloaded by [University of Florida] at 19:50 14 November 2015
Giuseppe Cabibbo Author for correspondence: Section of Gastroenterology, DI.BI.M.I.S., University of Palermo, Palermo, Italy Tel.: +39 091 655 2280 Fax: +39 091 655 2156 [email protected]
Michela Antonucci Section of Radiology, Di.Bi.Me.F. University of Palermo, Palermo, Italy
Rodolfo Sacco Gastroenterology and Metabolic Diseases Unit, Pisa University Hospital, Pisa, Italy
Elio Sciarrino Private Practice, Palermo, Italy and Past in Medicine, V. Cervello Hospital, Palermo, Italy
Ultrasound-guided techniques play a key role in the clinical management of hepatocellular carcinoma. Among these, percutaneous ethanol injection (PEI) was the first technique to be proposed for the treatment of nodular-type hepatocellular carcinoma: the role of PEI was first discussed during the European Association for the Study of the Liver conference held in Barcelona in 2000, 15 years ago. Since then, other techniques have been introduced and radiofrequency ablation now represents the most widely used percutaneous technique. PEI and radiofrequency ablation are widely used in clinical practice. However, only scant progresses in the application of these techniques have been performed over the past 15 years, and percutaneous approaches are often only marginally discussed and studied. Here, we discuss the most relevant clinical issues regarding PEI and radiofrequency ablation that have emerged in the past years.
Hepatocellular carcinoma (HCC) is a challenging malignancy of global importance that is associated with a dismal prognosis [1]. The management of HCC, both in early and advanced stages of disease, requires a multidisciplinary approach with the driving role of the hepatologist, as cirrhosis underlies HCC in most patients [2,3]. Image-guided tumor ablation has a key role in the clinical management of HCC [4]. In particular, ultrasound has become the standard method for directing therapeutics tools to achieve HCC ablation. This term refers to the direct application of chemical or thermal therapies to the tumor to eradicate it or cause a substantial tumor destruction [4]. Minimally invasive percutaneous treatments are considered the most effective treatment alternatives for patients with early HCC, optimal residual liver function and not eligible for surgical resection or transplantation. Percutaneous ethanol injection (PEI) was the first technique to be proposed for the treatment of nodular-type HCC, and consists of the injection of absolute ethanol directly into the HCC lesions. The
role of PEI was defined during the European Association for the Study of the Liver conference held in Barcelona in 2000, 15 years ago [5]. Since then, other techniques have been introduced and radiofrequency ablation (RFA) – which allows a more complete tumor resection with less treatment sessions when compared with PEI – now represents the most widely used percutaneous technique [4,6] PEI and RFA are widely used in clinical practice. However, only scant progresses in the application of these techniques have been made over the past 15 years, and percutaneous approaches are often only marginally discussed and studied [7]. We discuss here the most relevant clinical issues regarding PEI and RFA that have emerged in the past years. Selection of study endpoints
In oncology, the actual endpoint of treatment of any study should be overall survival (OS). This endpoint, in fact, is unambiguous and does not suffer from interpretation bias. However, also radiological assessment of treatment response represents an important evaluation parameter,
KEYWORDS: HCC . PEI . RFA
informahealthcare.com
10.1586/14737140.2015.1001374
2015 Informa UK Ltd
ISSN 1473-7140
147
Editorial
Cabibbo, Antonucci, Sacco & Sciarrino
Downloaded by [University of Florida] at 19:50 14 November 2015
and may be used as a surrogate marker for the assessment of efficacy. Radiological assessment is a crucial aspect in cancer therapy, and plays a critical role in clinical management and decision making [8]. Whether clinical response should represent an endpoint in patients treated with percutaneous therapies is still debated. However, a recent study specifically designed to identify prognostic factors of survival in HCC patients treated with RFA showed that OS is significantly dependent on the achievement of a complete radiological response according to EASL criteria [9]. Therefore, we believe that complete response may be considered a relevant surrogate endpoint that should be assessed by multiphasic CT or MR scan in all patients who undergo RFA or, potentially, other locoregional therapies.
analysis of about 8500 patients, with a 10-year perspective, showed that in patients with very early HCC and Child–Pugh class A, RFA provides similar life-expectancy and qualityadjusted life-year at a lower cost compared with resection [17]. When analyzed in more detail, for single larger HCC nodules (3–5 cm), resection resulted in better life-expectancy and was more cost-effective than RFA; on the other hand, in patients with two or three nodules £3 cm, life-expectancy and qualityadjusted life-year were similar, but again cost-effectiveness was more favorable for RFA. In this latter setting, the main advantage of surgical resection therefore seems to lie in the opportunity to pathologically assess the risk of early recurrence. If a patient is not eligible for transplant, resection will not offer a better survival than RFA and therefore the latter becomes the first-line option.
PEI versus RFA
PEI and RFA have been directly compared in a number of studies, some of which were analyzed in meta-analyses published some years ago [10–12]. Overall, the two methods showed a similar efficacy in the treatment of small HCC nodules (
ISSN: 1473-7140 (Print) 1744-8328 (Online) Journal homepage: http://www.tandfonline.com/loi/iery20
Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal? Giuseppe Cabibbo, Michela Antonucci, Rodolfo Sacco & Elio Sciarrino To cite this article: Giuseppe Cabibbo, Michela Antonucci, Rodolfo Sacco & Elio Sciarrino (2015) Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal?, Expert Review of Anticancer Therapy, 15:2, 147-150 To link to this article: http://dx.doi.org/10.1586/14737140.2015.1001374
Published online: 06 Jan 2015.
Submit your article to this journal
Article views: 48
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iery20 Download by: [University of Florida]
Date: 14 November 2015, At: 19:50
Editorial
Ultrasound-guided ablation for hepatocellular carcinoma: time for a reappraisal? Expert Rev. Anticancer Ther. 15(2), 147–150 (2015)
Downloaded by [University of Florida] at 19:50 14 November 2015
Giuseppe Cabibbo Author for correspondence: Section of Gastroenterology, DI.BI.M.I.S., University of Palermo, Palermo, Italy Tel.: +39 091 655 2280 Fax: +39 091 655 2156 [email protected]
Michela Antonucci Section of Radiology, Di.Bi.Me.F. University of Palermo, Palermo, Italy
Rodolfo Sacco Gastroenterology and Metabolic Diseases Unit, Pisa University Hospital, Pisa, Italy
Elio Sciarrino Private Practice, Palermo, Italy and Past in Medicine, V. Cervello Hospital, Palermo, Italy
Ultrasound-guided techniques play a key role in the clinical management of hepatocellular carcinoma. Among these, percutaneous ethanol injection (PEI) was the first technique to be proposed for the treatment of nodular-type hepatocellular carcinoma: the role of PEI was first discussed during the European Association for the Study of the Liver conference held in Barcelona in 2000, 15 years ago. Since then, other techniques have been introduced and radiofrequency ablation now represents the most widely used percutaneous technique. PEI and radiofrequency ablation are widely used in clinical practice. However, only scant progresses in the application of these techniques have been performed over the past 15 years, and percutaneous approaches are often only marginally discussed and studied. Here, we discuss the most relevant clinical issues regarding PEI and radiofrequency ablation that have emerged in the past years.
Hepatocellular carcinoma (HCC) is a challenging malignancy of global importance that is associated with a dismal prognosis [1]. The management of HCC, both in early and advanced stages of disease, requires a multidisciplinary approach with the driving role of the hepatologist, as cirrhosis underlies HCC in most patients [2,3]. Image-guided tumor ablation has a key role in the clinical management of HCC [4]. In particular, ultrasound has become the standard method for directing therapeutics tools to achieve HCC ablation. This term refers to the direct application of chemical or thermal therapies to the tumor to eradicate it or cause a substantial tumor destruction [4]. Minimally invasive percutaneous treatments are considered the most effective treatment alternatives for patients with early HCC, optimal residual liver function and not eligible for surgical resection or transplantation. Percutaneous ethanol injection (PEI) was the first technique to be proposed for the treatment of nodular-type HCC, and consists of the injection of absolute ethanol directly into the HCC lesions. The
role of PEI was defined during the European Association for the Study of the Liver conference held in Barcelona in 2000, 15 years ago [5]. Since then, other techniques have been introduced and radiofrequency ablation (RFA) – which allows a more complete tumor resection with less treatment sessions when compared with PEI – now represents the most widely used percutaneous technique [4,6] PEI and RFA are widely used in clinical practice. However, only scant progresses in the application of these techniques have been made over the past 15 years, and percutaneous approaches are often only marginally discussed and studied [7]. We discuss here the most relevant clinical issues regarding PEI and RFA that have emerged in the past years. Selection of study endpoints
In oncology, the actual endpoint of treatment of any study should be overall survival (OS). This endpoint, in fact, is unambiguous and does not suffer from interpretation bias. However, also radiological assessment of treatment response represents an important evaluation parameter,
KEYWORDS: HCC . PEI . RFA
informahealthcare.com
10.1586/14737140.2015.1001374
2015 Informa UK Ltd
ISSN 1473-7140
147
Editorial
Cabibbo, Antonucci, Sacco & Sciarrino
Downloaded by [University of Florida] at 19:50 14 November 2015
and may be used as a surrogate marker for the assessment of efficacy. Radiological assessment is a crucial aspect in cancer therapy, and plays a critical role in clinical management and decision making [8]. Whether clinical response should represent an endpoint in patients treated with percutaneous therapies is still debated. However, a recent study specifically designed to identify prognostic factors of survival in HCC patients treated with RFA showed that OS is significantly dependent on the achievement of a complete radiological response according to EASL criteria [9]. Therefore, we believe that complete response may be considered a relevant surrogate endpoint that should be assessed by multiphasic CT or MR scan in all patients who undergo RFA or, potentially, other locoregional therapies.
analysis of about 8500 patients, with a 10-year perspective, showed that in patients with very early HCC and Child–Pugh class A, RFA provides similar life-expectancy and qualityadjusted life-year at a lower cost compared with resection [17]. When analyzed in more detail, for single larger HCC nodules (3–5 cm), resection resulted in better life-expectancy and was more cost-effective than RFA; on the other hand, in patients with two or three nodules £3 cm, life-expectancy and qualityadjusted life-year were similar, but again cost-effectiveness was more favorable for RFA. In this latter setting, the main advantage of surgical resection therefore seems to lie in the opportunity to pathologically assess the risk of early recurrence. If a patient is not eligible for transplant, resection will not offer a better survival than RFA and therefore the latter becomes the first-line option.
PEI versus RFA
PEI and RFA have been directly compared in a number of studies, some of which were analyzed in meta-analyses published some years ago [10–12]. Overall, the two methods showed a similar efficacy in the treatment of small HCC nodules (
