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Percutaneous Ablation of Hepatocellular
Carcinoma: Current Status
Justin P. McWilliams, MD, Shota Yamamoto, BS, Steven S. Raman, MD, Christopher T. Loh, MD,
Edward W. Lee, MD, David M. Liu, MD, and Stephen T. Kee, MD
Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous
ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative
candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modal-
ities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound
ablation. A review of these modalities, including technical success, survival rates, and complications, will be
presented, as well as considerations for treatment planning and follow-up.
J Vasc Interv Radiol 2010; 21:S204–S213
Abbreviations: HCC ⫽hepatocellular carcinoma, PEI ⫽percutaneous ethanol injection, RF ⫽radiofrequency
HEPATOCELLULAR carcinoma (HCC)
is now the fifth most common cancer,
and the third leading cause of cancer
death worldwide (1). Although hepatic
resection remains a first-line treatment,
approximately 80% of patients are not
candidates as a result of poor hepatic
reserve, tumor location, or tumor bur-
den (2), and eventual tumor recurrence
is the rule (3). Orthotopic liver trans-
plantation offers high rates of disease-
free remission (4), but is limited by strin-
gent selection criteria, cost, and donor
availability (5). Overall 5-year survival
rates for HCC remain lower than 10% in
Europe and the United States (6).
During the past few decades, several
minimally invasive ablation techniques
have been developed to prolong the “sur-
vivability” of unresectable HCC. Percuta-
neous ethanol injection was introduced as
the seminal ablation technique for HCC in
the 1980s. In 1990, the first use of percuta-
neous radiofrequency (RF) ablation for
HCC was published (7), followed by per-
cutaneous microwave (MW) ablation in
1994 (8). More recently, cold-based and
extracorporeal techniques have also been
introduced (Fig). Ablation can offer po-
tentially curative treatment for small (⬍3
cm) and medium-sized (3–5 cm) HCC,
can salvage cases of tumor recurrence,
and can “bridge” patients to orthotopic
liver transplantation by prolonging sur-
vivability and decreasing tumor burden
(9–12).
In this review, we discuss the percuta-
neous ablative therapies for local control
of HCC, with a focus on survival data,
recurrence rates, and complications.
TREATMENT PLANNING
The use of biomarkers and surveil-
lance imaging with ultrasound (US), com-
puted tomography (CT), and magnetic
resonance (MR) imaging has facilitated
the early detection of HCC (12). Mul-
tiphase contrast-enhanced CT or MR im-
aging of the liver should be performed in
all patients to define the size and number
of tumors, their location, and their rela-
tionship to vital structures.
At our institution, treatment decisions
for hepatocellular carcinoma are made in
the setting of a multidisciplinary tumor
board, including representatives from on-
cology, hepatology, abdominal and inter-
ventional radiology, surgery, and radia-
tion oncology. Percutaneous ablation is
the preferred mode of treatment for non-
surgical candidates with one or several
tumors up to 3 cm, or up to 5 cm in select
situations. Once referred for ablative ther-
apy, all patients are seen in clinic with the
interventionist, at which time a history
and physical is performed, the risks and
benefits of the procedure are discussed,
and visibility of the tumor on ultrasound
is confirmed.
Durable success of ablation, and re-
sultant improved survival, depends on
complete ablation of the tumor (13,14).
The likelihood of complete ablation de-
creases with increasing tumor size (14–
16), and multiplicity of tumors com-
pounds this consideration. Transarterial
chemoembolization, systemic chemo-
therapy, or symptomatic treatment can
be considered if the tumor burden is
deemed excessive or unsafe for ablation.
The approach to the tumor should
avoid crossing other organs, large vessels,
and major bile ducts. With the use of US,
From the Departments of Interventional Radiology
(J.P.M., C.T.L., D.M.L., S.T.K.) and Radiological Sci-
ences (S.Y., E.W.L.), University of California Los
Angeles Medical Center, 757 Westwood Plaza, Suite
2125C, Los Angeles, CA 90095; Department of Radi-
ology, Faculty of Medicine (D.M.L.), University of
British Columbia; and Department of Radiology,
Interventional Radiology Section (D.M.L.), Van-
couver General Hospital, Vancouver, British Co-
lumbia, Canada. Received October 7, 2009; final
revision received October 28, 2009; accepted No-
vember 7, 2009. Address correspondence to J.P.M.;
E-mail: jumcwilliams@mednet.ucla.edu
None of the authors have identified a conflict of
interest.
© SIR, 2010
DOI: 10.1016/j.jvir.2009.11.025
S204
some obliquity can usually be found that
will allow safe placement of the ablation
probe. CT-ultrasound fusion imaging,
which matches a preprocedural volumet-
ric CT to real-time ultrasound images, can
aid probe placement in difficult cases (17).
Positioning of the active tip near the large
and small bowel, bile ducts, stomach, gall-
bladder, and diaphragm can cause collat-
eral damage and limits percutaneous ab-
lation in approximately 6–9% of cases
(18,19).
In such cases, adjunctive use of dex-
trose solution (20), carbon dioxide
(21), or balloon interposition (22) can
separate and protect vital organs.
Thermocouples can be used to moni-
tor temperatures adjacent to sensitive
structures (23). For lesions adjacent to
main bile ducts, the placement of a
nasobiliary stent with instillation of
chilled saline can protect the ducts
from thermal damage (24). These tech-
niques allow the vast majority of abla-
tions to be safely and effectively per-
formed using percutaneous technique.
HCC TREATMENT
MODALITIES
Percutaneous Ethanol Injection
One of the first methods devised to
ablate liver tumors involved percutane-
ous ethanol injection (PEI). Several non-
randomized trials in the 1990s (25–27)
confirmed that PEI can safely achieve
complete necrosis of small HCCs, with
5-year survival rates of 32%–38%. How-
ever, the technique suffered from the need
for multiple treatment sessions, uncer-
tainty of the ablation zone, and a high
local progression rate of 17%–38% (28,29).
Several randomized controlled trials
compared PEI versus RF ablation in the
treatment of small HCC (30–32). These
trials demonstrated an approximately
20% advantage for RF ablation versus PEI
in overall survival at 3–4 years, mainly as
a result of a much lower incidence of local
tumor recurrence in the RF ablation
group. Also, approximately threefold
fewer treatment sessions were required
for RF ablation compared with PEI. Two
recent metaanalyses comparing RF abla-
tion versus PEI echoed these sentiments,
declaring RF ablation superior to PEI in
the treatment of small HCC (33,34).
PEI maintains the advantage of al-
lowing treatment of tumors near sensi-
tive organs and tissues, and avoids the
problem of the “heat-sink” effect adja-
cent to vessels. The applicability of PEI
in other situations is limited. Given the
superiority of RF ablation to PEI for the
treatment of HCC, this review will focus
on thermal ablation.
RF Ablation
RF ablation uses rapidly alternating
RF current to induce frictional heat
around an electrode, producing cell
death by coagulation necrosis. Small
electrode diameter, good ablation area
size, and effective marketing have com-
bined to make RF ablation a popular
technique. RF ablation also benefits
from the “oven effect”; heat retention is
improved in lesions surrounded by cir-
rhotic tissue (35). Complete ablation
rates for small to medium HCC exceed
80% in a single treatment session, and
exceed 90% with two sessions; 5-year
survival rates in the largest studies are
40%–58% (14,18,19,36–39). Local pro-
gression after complete ablation is un-
commonly observed (1%–12%). RF abla-
tion studies are summarized in Table 1
(18,19,36–38).
The most commonly used RF abla-
tion devices in contemporary practice
are monopolar internally cooled
electrodes, such as the Cool-Tip de-
vice (Covidien, Mansfield, Massa-
chusetts), and monopolar multitined
expandable electrodes, such as the
LeVeen (Boston Scientific, Natick, Mas-
sachusetts) or RITA (Angiodynamics,
Queensbury, New York) devices. Two
studies have been performed compar-
ing the effectiveness of the two electrode
types in the treatment of small HCC
(40,41); neither study found any differ-
ence in immediate treatment success,
complication rate, local progression, or
overall survival between the treatment
groups (40,41).
Cohort studies of RF ablation have
shown low rates of major complications,
ranging from 0.9% to 5.0%. (37,42). Peri-
toneal hemorrhage, bile duct injury, ab-
scess, and intestinal perforation were
the most notable adverse outcomes.
Tumor seeding is occasionally re-
ported, particularly with subcapsular
tumors, but rarely occurs when careful
attention is given to technique (indi-
rect tumor puncture, gradual increase
in power deposition, and thermocoag-
ulation of the needle track) (43).
RF ablation does have some disad-
vantages. The majority of ablation oc-
curs through thermal conduction, which
can be limited by tissue desiccation and
charring (44). RF ablation is susceptible
to a heat-sink effect from flowing blood,
which may result in sublethal tempera-
tures adjacent to vessels larger than 3
mm in size (45–48). As a result of elec-
Figure. Representative percutaneous ablation devices. Clockwise from top left: Cool-Tip
internally cooled RF electrode, LeVeen expandable RF electrodes, Evident 915-MHz
cooled-shaft percutaneous MW antenna, and Perc-24 cryoprobe (Endocare, Irvine, Cali-
fornia). (Available in color online at www.jvir.org.)
McWilliams et al •S205
Volume 21 Number 8S
tromagnetic interference, only one RF
electrode can be activated at one time,
which can lengthen procedure time in
medium and large lesions. Finally, the
grounding pads required for RF abla-
tion can occasionally cause skin burns.
These limitations have invited interest
in alternative ablation modalities de-
scribed in the subsequent sections.
Microwave Ablation
Microwave (MW) ablation uses high-
frequency electromagnetic energy to ag-
itate water molecules, producing frictional
heat and resultant coagulation necrosis.
Although both modalities function by
tissue heating, MW ablation has several
advantages versus RF ablation. MW ab-
lation has a much broader zone of active
heating, leading to higher temperatures
within the targeted zone in a shorter
treatment time. The active heating of
MW ablation is less affected by the heat-
sink effect, improving tumor necrosis
adjacent to vessels (49). Multiple anten-
nae can be simultaneously activated
with MW ablation, potentially allowing
more rapid treatment of large or multi-
focal tumors (50). Grounding pads are
not required.
Three cohort studies of percutaneous
MW ablation in a mix of small to large
HCC demonstrated a complete ablation
rate of 89%–94%, local progression rate
of 6%–8%, and 5-year survival rate of
51%–57%, despite a predominance of
patients with Child class B disease (51–
53). These results compare favorably
with the results of RF ablation (Table 2)
(51–53).
One randomized controlled trial (54)
compared MW ablation versus RF abla-
tion for small HCC in 72 well matched
patients. The complete ablation rates
were similar (89% for MW and 96% for
RF). Long-term survival was not re-
ported.
The only comparative survival data
for MW versus RF ablation with percu-
taneous technique come from retrospec-
tive, unmatched case series. One such
series showed no difference in complete
ablation rate or survival between the
two techniques in HCC averaging 2.6
cm in size, despite worse underlying
liver disease and more tumor multiplic-
ity in the MW ablation group (55). In
contrast, a second unmatched series
in small HCC showed better survival in
the RF ablation group (71% vs 49% at 3
years), largely due to higher complica-
tion and local recurrence rates with MW
ablation (56).
The range of complications encoun-
tered with MW ablation are the same as
with RF ablation, including hemor-
rhage, abscess, biliary tract injury, and
tumor seeding. The rate of major com-
plication in most series varies from 0%
to 8%, similar to RF ablation.
The above-quoted studies of percuta-
neous MW ablation come from Asia, us-
ing a previous-generation 2450-MHz
microwave system. A new generation of
cooled-shaft 2450-MHz antennae prom-
ise ablation volumes similar to the lat-
est-generation RF ablation electrodes
Table 1
Percutaneous RF Ablation in de novo HCC among Cohort Studies with at Least 100 Patients and 5-year Survival Data
(18,19,36–38)
Study, Year
No. of
Pts.
Child Class
(A/B/C)
Tumor Size
(cm) Complete
Ablation
(%)
No. of
Sessions
Survival
(%) Local
Recurrence
(%)
Major
Complications
(%)Mean Range 3 y 5 y
Lencioni et al, 2005 (18) 187 144/43/0 2.8 1.5–5.0 90 1.2† 71 48 10 2
N’Kontchou et al,
2005 (36)
235 205/30/0 2.9 1.1–5.0 94 1.2† 60 40 12 0.9
Tateishi et al, 2005 (37) 319* 221/94/4 2.6 0.8–9.7 93 1–2 78 54 2 4
Raut et al, 2005 (38) 140 59/46/35 3.0 NR 97 1 74 58 3 5
Livraghi et al, 2008 (19) 218 218/0/0 NR ⱕ2 98 1.1† 76 55 1 2
Note.—NR ⫽not reported.
* A total of 137 of these patients received transarterial embolization before RF ablation. Tumor size, technical success rate, local
recurrence rate, and major complication rate are composite data from de novo and recurrent HCC in this series.
† Mean.
Table 2
Details of Percutaneous Microwave Ablation in HCC among Cohort Studies with at Least 50 Patients (51–53)
Study, Year
No. of
Pts.
Child Class
(A/B/C)
Tumor Size (cm) Complete
Ablation
(%)
Survival
(%) Local
Recurrence
(%)
Major
Complications
(%)Mean Range 3 y 5 y
Dong et al, 2003 (51) 234 24/207/3 4.1 1.2–8.0 89* 66 57 7% 0%
Liang et al, 2005 (52) 288 54/214/20 3.8 1.2–8.0 NR 72 51 8% NR
Lu et al, 2001 (53) 50 16/30/4 2.7 0.8–6.4 94† 73 — 6% 0%
Note.—NR ⫽not reported.
* One session.
† Two sessions.
S206 •Percutaneous Ablation of HCC August 2010 JVIR
and should decrease the need for mul-
tiple treatment sessions (57). The 915-
MHz cooled-shaft microwave system
available in the United States (Evident,
Covidien, Mansfield, Massachusetts)
has been validated with intraoperative
use (58), but has not yet been studied for
percutaneous application. Further re-
search using these cooled-shaft anten-
nae is awaited.
MW ablation possesses several po-
tential advantages versus RF ablation,
but these have not yet equated to supe-
riority in real-world application. None-
theless, most studies suggest equivalent
outcomes to those of RF ablation in
small and medium HCC. Continued ad-
vances in antenna design likely herald a
larger role for MW ablation in the fu-
ture.
Cryoablation
Cryoablation is based on the cyclic
application of extremely low tempera-
tures in the targeted tissue, causing cell
death by ice crystal formation. The grad-
ual downsizing of cryoprobes has fu-
eled interest in percutaneous use, which
offers several potential advantages ver-
sus RF ablation. First, multiple cryo-
probes can be used simultaneously to
generate a large ice ball (59). Second, the
size and shape of the developing ice ball
can be readily visualized using intrapro-
cedural CT (60), MR imaging (61,62), or
US (63). Third, in contrast to heat-based
ablation, percutaneous cryoablation is a
relatively painless procedure (64).
To our knowledge, only one study
has reported long-term survival data for
percutaneous cryoablation (65). A total
of 130 patients with medium to large
HCC (mean, 4.6 cm) were treated as a
control group within a study comparing
cryoablation plus chemoembolization
versus cryoablation alone. There was a
large proportion of patients with Child
class B disease and patients with multi-
focal tumors. Local progression rate was
24%, and 5-year survival rate was 23%.
The complication rate was high (31%),
including two perioperative deaths.
Two small studies have made use of
the latest-generation 17-gauge cryo-
probes for percutaneous ablation of
HCC. A preliminary study in four pa-
tients with small HCC achieved com-
plete ablation in all cases without major
complication (60). Short-term follow-up
(6 months) yielded one local and one
distant recurrence, but no mortality. A
second study that used MR guidance in
15 patients with small or medium-sized
HCC (61) achieved complete ablation in
88% of cases, with a local progression
rate of 20%. Overall survival was 79% at
3 years.
Comparative studies with other abla-
tive technologies are scarce. In one
study, percutaneous cryoablation was
compared with RF ablation in 36 well
matched patients with HCCs smaller
than 5 cm (66). Treatment success was
similar (80% for cryoablation vs 86% for
RF ablation). Local progression seemed
more common for cryoablation than for
RF ablation (38% vs 17%), but 1-year
survival was similar (66% vs 61%).
Complication rates and length of hospi-
tal stay were comparable.
Percutaneous cryoablation faces sev-
eral disadvantages. The ablation zone of
individual probes is generally smaller
than seen with RF ablation, and is not
aided by an oven effect. The zone of
complete lethality lies a variable dis-
tance inside the edge of the ice ball—
4–10 mm or more—meaning a large
amount of surrounding hepatic paren-
chyma must be frozen to ensure a satis-
factory treatment margin (67,68). Cryo-
ablation can suffer a “cold-sink” effect
from adjacent vessels (47). Finally, there
is a concern for high complication risk
with cryoablation, including hemor-
rhage, cold injury to adjacent organs,
biliary fistula, cryoshock, and hepatic
parenchymal fracture (69). A prospec-
tive trial of intraoperative cryo-
ablation versus RF ablation for liver ma-
lignancies (70) showed a much higher
complication rate for cryoablation (41%
vs 3%).
Though cryoablation has some po-
tential advantages over RF ablation, the
higher complication rates and the lack
of proven efficacy benefit versus other
techniques have caused some authors to
question its use in HCC (71). Further ex-
perience with the new, smaller cryo-
probes may change this mindset.
High-intensity Focused US Ablation
High-intensity focused US concen-
trates an external source of US energy to
a target tissue inside the body, produc-
ing coagulation necrosis. The prime ad-
vantage of high-intensity focused US
compared with other techniques is its
noninvasiveness; no instruments need
to be placed.
Three cohort studies have examined
the use of high-intensity focused US in
patients with large unresectable HCC
(72–74). After one or two treatment ses-
sions lasting 4–5.5 hours each, the com-
plete ablation rate was 28%–69%. Over-
all survival rates were 50%–76% at 1
year; in the one study that reported it,
5-year survival rate was 32% (73). Minor
skin burns occurred in 13%–25% of pa-
tients, but major complications were
rare. Overlying ribs can obstruct the
treatment path, requiring partial rib resec-
tion in as many as 18% of patients. Be-
cause high-intensity focused US is tar-
geted from outside the body, general
anesthesia is usually required to control
patient breathing and prevent movement.
High-intensity focused US is a fasci-
nating modality, but in its current itera-
tion, the time- and labor-intensiveness
of the technique will likely be prohibitive
for widespread acceptance. There are also
a paucity of survival data. At present,
high-intensity focused US is not approved
for HCC ablation by the United States
Food and Drug Administration.
PERCUTANEOUS ABLATION
VERSUS SURGICAL
RESECTION
Two randomized controlled trials
(75,76) have been performed to compare
the outcomes of percutaneous thermal
ablation versus surgical resection in
small to medium-sized HCC. Both dem-
onstrated no difference in overall or dis-
ease-free survival at 3–4 years. Three
well matched retrospective studies (77–
79) have also been performed in patients
who were candidates for either resec-
tion or RF ablation, and all three dem-
onstrated no significant differences in
overall or disease-free survival. Compli-
cation rates were higher in the operative
groups (11%–56%, including a 4% oper-
ative mortality rate) compared with the
RF ablation groups (1%–10%). Most
publications claiming better survival for
hepatic resection are unmatched retro-
spective studies, in which the severity of
liver disease clearly favors the surgical
arm (80–82).
A single retrospective cohort study
(83) compared percutaneous MW abla-
tion versus surgical resection for solitary
small to medium-sized HCC in 194 well
matched patients. The 5-year disease-
free survival rates were similar between
surgery (26%) and MW ablation (33%)
groups.
Emerging evidence suggests that
McWilliams et al •S207
Volume 21 Number 8S
percutaneous RF ablation or MW abla-
tion may offer equivalent survival to
surgical resection in patients with de
novo HCC as large as 5 cm in size
(Table 3)(75–83). Percutaneous ablation
also demonstrates lower rates of post-
treatment morbidity, decreased hospital
stay, and lower cost compared with tra-
ditional resection (84). At present, there
are no studies comparing percutaneous
cryoablation or high-intensity focused
US ablation versus surgical resection.
PERCUTANEOUS ABLATION
FOR RECURRENT HCC
Although surgical resection is the
gold standard treatment for HCC, the
5-year recurrence rate is 70%–85% (85–
87), reflecting the underlying carcino-
genesis of the cirrhotic liver. Repeat
hepatectomy is the accepted treatment
for recurrence, with a 5-year survival
rate of 40%–52%, but most patients are
not candidates as a result of impaired
liver function or excessive tumor burden
(86,88–91). Chemoembolization and PEI
have been studied as treatment alterna-
tives for recurrence after surgery, but
5-year survival rates have been discour-
aging (0%–21% and 0%, respectively)
(92–95).
Percutaneous ablation for recurrent
HCC has shown similar outcomes to re-
peat resection. In one study, 345 patients
received RF ablation for recurrent HCC
after surgery, chemoembolization, or
ablation; a 5-year survival rate of 38%
was achieved (37). Three smaller studies
of thermal (RF or MW) ablation for post-
surgical recurrence showed 5-year sur-
vival rates of 18%–52% (96–98). The
only comparative study (99) showed no
difference in 5-year survival between RF
ablation (37%) and repeat resection
(41%) in small recurrent HCC. These
positive results are supported by a
study (100) that found that 5-year sur-
vival of hepatectomy patients is signifi-
cantly improved (from 39% to 58%)
when percutaneous ablation is available
to treat recurrence. Interestingly, RF ab-
lation produces more survival benefit
for late recurrence (ie, ⬎1 year after
resection) than for earlier recurrence,
likely related to aggressiveness of dis-
ease (101). These studies are summa-
rized in Table 4 (37,96–99,101). Percuta-
neous cryoablation and high-intensity
focused US ablation have not been spe-
cifically studied for recurrent HCC.
PERCUTANEOUS ABLATION
FOR LARGE HCC
Given its success in small and me-
dium-sized HCC, interest has grown in
the use of percutaneous ablation for
large (⬎5 cm) HCC. One study (102)
examined the use of MW or RF ablation
in a subgroup of 20 patients with HCC
measuring 5–7 cm, including recurrent
and multifocal tumors and a high propor-
tion of patients with Child class B dis-
ease. Complete ablation was achieved in
80%, usually in a single session, and the
rate of local progression was 31%. The
5-year survival rate was 17%, regardless
of ablation method. Complete ablation
was not achieved in tumors larger than
7 cm.
Two studies of RF ablation examined
treatment success in large HCC (16,103).
Complete ablation rates of 24% and 62%
were reported in tumors measuring
5–9.5 cm and 5–7 cm, respectively. Com-
plication rates were acceptable at 2%–
10%, but one death was reported.
Clearly, conventional RF ablation is
limited in the treatment of large lesions.
This is mainly because of the potential
for error with multiple needle reposi-
tionings, resulting in incomplete abla-
tion. Several new RF ablation technolo-
gies, including perfusion electrodes and
bipolar devices, promise to produce
larger ablation zones, facilitating treat-
ment of large HCCs (104–106). Using
three bipolar electrodes, an 81% com-
plete ablation rate has been achieved in
HCCs measuring 5.0– 8.5 cm, without
Table 3
Details of Comparative Studies of Percutaneous Ablation versus Surgical Resection (75–83)
Study Study Type Treatment No. of Pts. Child Class (A/B/C)
Chen et al, 2006 (75) RCT RF ablation 71 71/0/0
Surgery 88 88/0/0
Lu et al, 2006 (76) RCT RF or MW ablation 51 N/A
Surgery 54 N/A
Hong et al, 2005 (77) Cohort RF ablation 55 55/0/0
Surgery 93 93/0/0
Lupo et al, 2007 (78) Cohort RF ablation 60 44/16/0
Surgery 42 28/14/0
Montorsi et al, 2005 (79) Cohort RF ablation 58 40/18
Surgery 40 32/8
Guglielmi et al, 2008 (80) Unmatched cohort RF ablation 109 64/45/0
Surgery 91 69/22/0
Vivarelli et al, 2004 (81) Unmatched cohort RF ablation 79 43/36/0
Surgery 79 70/9/0
Ueno et al, 2009 (82) Unmatched cohort RF ablation* 155 89/63/3
Surgery 123 94/6/0
Wang et al, 2008 (83) Cohort MW ablation 114 71/40/3
Surgery 80 52/28/0
Note.—NA ⫽not available; NR ⫽not reported; RCT ⫽randomized controlled trial.
* A total of 45 of the RF ablations were performed intraoperatively.
S208 •Percutaneous Ablation of HCC August 2010 JVIR
major complication and usually in a sin-
gle treatment session (107). The local
progression rate was 14%, and the
2-year survival rate was 56%. No long-
term or comparative data yet exist.
The use of conventional MW ablation
in large HCC is marked by higher recur-
rence rates and lower survival than in
small and medium-sized HCC (51,52).
However, complete ablation rates of
90% have recently been achieved in
large HCC with the use of adjacent in-
ternally cooled electrodes with one or
two treatment sessions (108). Only one
case of local progression was detected,
and the complication rate was 12%. A
second group (109), which used a simi-
lar device in a mixture of primary and
secondary liver cancer, demonstrated
similar results, including effective ablation
of seven masses larger than 10 cm in size.
They reported a 92% 1-year survival rate
and a complication rate of 10%.
Cryoablation is limited when it
Tumor Size (cm) Survival (%)
Complications (%) ConclusionMean Range 1 y 3 y 5 y
NR ⬍5 96 71 — 4 No survival difference
NR ⬍59373— 56
NR ⬍5 94 87 — 8 No survival difference
NR ⬍59186— 11
2.4 ⬍4 100 73 — NR No survival difference
2.5 ⬍49884— NR
3.6 3.0–5.0 96 53 32 10 No survival difference
4.0 3.0–5.0 91 57 43 17
NR ⬍5 85 61 — NR No survival difference
NR ⬍58473— NR
NR ⬍6 83 42 20 10 Surgery better for Child class A patients and patients
with single tumor ⬎3cmNR ⬍6846448 36
NR NR 78 33 — NR Surgery better for Child class A patients with single
tumorNR NR 83 65 — NR
2.0 ⬍5 98 92 63 1 Surgery better for Child class A patients with single
tumor; RF better for patients with multifocal tumors2.7 ⬍5999280 NR
2.9 1.1–4.9 73 54 33 0 No survival difference
3.0 1.2–4.8 68 60 26 0
Table 4
Percutaneous Ablation for Recurrent HCC (37,96–99,101)
Study Treatment
No. of
Pts.
Child Class
(A/B/C)
Tumor Size Complete
Ablation
(%)
Survival (%) Local
Progression
(%)
Major
Complications
(%)Mean Range 1 y 3 y 5 y
Tateishi et al,
2005 (37)
RF ablation 345* 225/111/9 2.6 0.8–9.7 93 92 62 38 2 4
Choi et al, 2007 (98) RF ablation 102 77/10/0 2.0 0.8–5.0 93 94 66 52 8 5
Ren et al, 2008 (99) RF ablation 68 NA NA ⱕ3NA956537NA NA
Yang et al,
2006 (101)
Early recurrence
group
RF ablation 20 9/9/1 3.9 2.0–6.6 93 56 10 — 10 0
Late recurrence
group
RF ablation 21 12/9/1 3.7 2.0–6.1 94 89 72 — 9 5
Lu et al, 2005 (96) RForMW
ablation
72 48/22/2 2.4 0.9–7.0 96 75 43 18 14 4
Itamoto et al,
2001 (97)
MW ablation 15 NA NA NA NA 100 67 — 50 NA
Note.—NA ⫽not available.
* A total of 145 of these patients received transarterial embolization before RF ablation. Tumor size, technical success rate, local
recurrence rate, and major complication rate are composite data from de novo and recurrent HCC in this series.
McWilliams et al •S209
Volume 21 Number 8S
comes to treating large HCC. Because of
the small ablation size per cryoprobe,
many probes must be placed; this is
compounded by the fact that the lethal
isotherm in large ice balls lies farther
inside the rim than in small ice balls (68).
Also, the risk of hepatic parenchymal
fracture and cryoshock increases with
volume of treatment (110). These con-
cerns have been confirmed in vivo; a
high complication rate was encountered
and the 5-year survival rate was 0%
among patients with large HCCs treated
by cryoablation in a recent study (65).
The use of high-intensity focused US
ablation in large HCCs was described
earlier. It seems safe and moderately
effective in preliminary trials, though
treatment times can be prohibitively
long.
Given the bleak alternatives for non-
operative candidates with large HCCs,
thermal ablation offers significant prom-
ise. The treatment of large HCCs may
finally provide the setting in which the
latest-generation MW ablation devices
can realize their potential advantages
versus RF ablation. However, constant
advances in RF electrode design make
this a dynamic comparison.
TREATMENT FOLLOW-UP
After ablation, contrast-enhanced mul-
tiphase CT or MRI is performed within 1
month to determine technical success;
complete ablation appears as hypoat-
tenuation without enhancement. There-
after, many groups monitor for recur-
rence using
␣
-fetoprotein levels and US
at 3–6-month intervals, with CT or MR
imaging performed for any suspicious
findings; other groups perform CT or
MR imaging at each follow-up regard-
less of suspicion. At our institution,
cross-sectional imaging, labs, and clinic
visit with the interventionist are per-
formed concurrently, at one month fol-
lowing the ablation procedure and ev-
ery three months thereafter up to a year.
If the patient remains free of disease,
routine surveillance is then resumed.
CONCLUSION
Percutaneous RF and MW ablation
are effective treatment modalities for de
novo and recurrent HCCs as large as 5
cm, with high technical success rates
and 5-year survival rates similar to
those associated with hepatic resection.
Complications are rare and morbidity
rates are low. Recurrent or new sites of
disease are frequent, but can usually be
treated with repeat ablation. In larger
HCC, recent advances in RF and MW
probe design are making percutaneous
therapy increasingly feasible. Cryoabla-
tion and high-intensity focused US ab-
lation hold some promise, but are lim-
ited by higher complication rates (with
cryoablation) or excessive procedure
times (with high-intensity focused US
ablation). Prospective, comparative tri-
als are needed to determine the optimal
treatment modality for individual pa-
tient situations.
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