Radiofrequency ablation plus drug-eluting beads transcatheter arterial chemoembolization for the treatment of single large hepatocellular carcinoma

Abstract

Background

Our aim was to evaluate the effectiveness of the single-step combined therapy with radiofrequency ablation and drug-eluting beads transarterial chemoembolization in single hepatocellular carcinoma (HCC) larger than 3 cm. Secondary aim was to compare the results with those obtained in a matched population treated with drug-eluting beads transarterial chemoembolization alone.

Methods

40 consecutive cirrhotic patients with single HCC were prospectively enrolled and treated. Twenty-three patients had tumours between 3 and 5 cm (Group A), and 17 larger than 5 cm (Group B). Twenty cirrhotic patients with single HCC treated only with chemoembolization formed the control group.

Results

Complete response at 1 month was achieved in 32/40 tumours (80%). During follow-up, complete response was maintained in 25 patients (25/40, 62.5%), and this rate was higher in Group A (69.6% vs 53%, p = 0.008). The group treated with combined therapy showed a significantly lower 2-year recurrence (48.1% vs 78.2%, p < 0.001) and significantly higher survival (91.1% vs 60.6%, p = 0.004) than the group treated with chemoembolization alone.

Conclusions

Balloon-occluded-radiofrequency ablation plus drug-eluting beads transarterial chemoembolization is an effective treatment of HCC larger than 3 cm not amenable to surgical resection, providing better results than transarterial chemoembolization alone. The best results are achieved in tumours up to 5 cm.

Introduction

Despite the implementation of screening programmes for early diagnosis, about half of the cirrhotic patients still present with single large hepatocellular carcinomas (HCC) at diagnosis, and only 30% of them benefit from curative therapies [1], [2], [3], [4]. Resection may provide excellent long-term results in these patients [5]. However, in patients who are not good surgical candidates, radiofrequency ablation (RFA) is not a good treatment option as the better results are achieved in tumours up to 3 cm large [6]; furthermore, studies performed on explanted livers obtained from patients treated with RFA before transplantation show that the rate of complete necrosis ranges between 13% and 43% in tumours larger than 3 cm [7]. On the other hand, despite transarterial chemoembolization (TACE) is the current standard of care for patients with large HCC not amenable to surgery, a sustained complete response (CR) is achieved in only 27–35% of cases [8]. An improvement in TACE technique has been attained after the introduction of drug-eluting beads (DEB-TACE): these particles are able to bind and then elute doxorubicin in a predictable manner, thus allowing a more standardized approach and less drug-related toxicity [9]. However, even though DEB-TACE induces extensive tumour necrosis in more than 70% of tumours, less than 20% of the patients achieve a CR [10], [11], [12]. The main goal of the research in this field should be to increase the number of patients with single HCC larger than 3 cm suitable for non-surgical curative treatment; for these patients, a reasonable approach is to combine therapies with possible synergistic effects. Recent studies show that combined therapy with RFA and TACE could be more effective than TACE or RFA alone in local disease control and survival improvement, but it is not clear how the lesion's size affects the follow-up response [13], [14], [15].

Therefore, the primary aim of this study was to evaluate the effectiveness of the single-step combined therapy with RFA and DEB-TACE in single HCC ≥3 cm. The secondary aim was to compare the results with those obtained in a matched population treated with DEB-TACE alone.