Percutaneous ablative therapy for hepatocellular carcinoma.

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Correspondence to S. K. ACHARYA INTRODUCTION Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and is a highly malignant tumour with a fatal outcome. In about 80% of patients, HCC is associated with underlying chronic liver disease, which has major implications for the prognosis and therapeutic options. The Barcelona Clinic Liver Cancer (BCLC) classification links the stage of HCC with treatment modalities, and suggests that patients with early HCC are suitable for curative treatment. The curative treatment options include surgical resection, liver transplantation and percutaneous ablation. The 5-year survival rate for resection or transplantation is up to 70% in selected patients. Surgical resection is the treatment of choice for HCC in non-cirrhotic patients and offers a realistic chance of cure. Since the majority of patients with HCC have underlying cirrhosis, a large proportion of them are unsuitable for curative resection because of factors such as poor hepatic reserve, multicentric tumours, extrahepatic disease, early vascular invasion and associated co-morbid conditions. Moreover, in about 70% of patients undergoing curative resection, new tumours may arise in the cirrhotic liver that remains. Liver transplantation is regarded as the optimal curative treatment for HCC as it has the dual benefit of simultaneously removing the tumour as well as the underlying diseased liver. However, the procedure has many limitations, such as the possibility of recurrence in the grafted liver and shortage of organs. Moreover, this treatment modality is out of reach for most patients in developing countries where this therapeutic option is available as liver transplantation services are very few and unaffordable. Percutaneous ablation is currently considered the best therapeutic modality for patients with early-stage HCC who are not candidates for surgical intervention. Over the past few decades, several techniques of percutaneous local ablation (PLA) have been developed for the treatment of small HCCs. From the use of chemical ablation to the technology of radiofrequency ablation (RFA), microwave ablation (MWA), laser and cryoablation, PLA is undergoing continuous refinement and has an established role in the management of HCC. We focus on the commonly used ablative methods, the techniques involved, their complications, the local outcome and survival rates. PLA is a simple procedure which is minimally invasive since it targets the tumour and preserves the uninvolved liver parenchyma. It, therefore, does not have the morbidity and mortality associated with liver surgery. Systemic side-effects also do not occur. These procedures require a minimal hospital stay and are cost-effective compared with surgery. They should be recommended in patients with early-stage HCC who are not candidates for surgery. PLA is also being used as a temporizing treatment for patients awaiting liver transplant. Ideal patients for ablation are those in the BCLC A and B stages with Child–Pugh class A/B cirrhosis, a WHO performance status of 0–1, tumour <5 cm (ideal <3 cm), focal nodular lesion, solitary or multiple lesions (<3) without vascular invasion and extrahepatic disease. Contraindications include the presence of extrahepatic metastatic disease, sepsis, severe debilitation, Child–Pugh class C cirrhosis and uncorrectable coagulopathy. Lesions with <1 cm of hepatic parenchyma around or abutting the gallbladder, liver hilum and along the liver surface are relative contraindications and are associated with a higher risk of complications. Ablations in such cases can be considered with caution, using special procedures, and require skilled hands. PLA is usually done under real-time ultrasound guidance, using local anaesthesia. Rarely, CT guidance is required if either the tumour is not localized on US or a proper acoustic window is not available to visualize the tumour. The commonly used percutaneous techniques include intralesional injections of chemical agents that kill tumour cells or the application of an energy source that can cause thermal ablation (such as RFA and MWA) and cryotherapy (Table I).

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