Intra-Procedural CT/MR-Ultrasound Fusion Imaging Helps to Improve Outcomes of Thermal Ablation for Hepatocellular Carcinoma: Results in 502 Nodules

Abstract

Purpose The aim was to assess the value of intra-procedural CT/MR-ultrasound (CT/MR-US) fusion imaging in the management of thermal ablation for hepatocellular carcinoma (HCC).

Materials and Methods This retrospective study was approved by the institutional review board. From May 2010 to October 2016, 543 HCC nodules in 440 patients (387 men and 53 women; age range: 25–84 years) that met the Milan Criteria were treated by percutaneous thermal ablation using intra-procedural CT/MR-US fusion imaging. The HCC nodules were divided into subgroups and compared (≤ 3 cm and > 3 cm, or high-risk and low-risk location, or inconspicuous and conspicuous, respectively). Technique efficacy and major complication were calculated. Cumulative local tumor progression (LTP), tumor-free and overall survival rates were estimated with the Kaplan-Meier method.

Results CT/MR-US fusion imaging was successfully registered in 419 patients with 502 nodules. The technique efficacy rate of thermal ablation was 99.4 %. The major complication rate was 1.9 %. The cumulative LTP rates were 3.2 %, 5.6 % and 7.2 % at 1, 3, and 5 years, respectively. There were no significant differences for the comparisons of cumulative LTP rates between different subgroups (P = 0.541, 0.314, 0.329). The cumulative tumor-free survival rates were 74.8 %, 54.0 % and 37.5 % at 1, 3, and 5 years, respectively. The cumulative overall survival rates were 97.8 %, 87.1 % and 81.7 % at 1, 3, and 5 years, respectively.

Conclusion Intra-procedural CT/MR-ultrasound fusion imaging is a useful technique for percutaneous liver thermal ablation. It could help to achieve satisfying survival outcomes for HCC patients who meet the Milan Criteria.

Zusammenfassung

Zweck Das Ziel war es, den Wert der intraprozeduralen CT/MR-Ultraschall-Fusionsbildgebung (CT/MR-US) bei der Behandlung durch thermische Ablation bei hepatozellulärem Karzinom (HCC) zu beurteilen.

Materialien und Methoden Diese retrospektive Studie wurde vom Ethikkomitee des Instituts genehmigt. Von Mai 2010 bis Oktober 2016 wurden 543 HCC-Herde bei 440 Patienten (387 Männer und 53 Frauen; Altersgruppe: 25–84 Jahre), die die Mailand-Kriterien erfüllten, durch perkutane thermische Ablation mit intraprozeduraler CT/MR-US-Fusionsbildgebung behandelt. Die HCC-Herde wurden in Untergruppen eingeteilt und verglichen (≤ 3 cm und > 3 cm oder Hoch- und Niedrigrisiko-Lokalisation bzw. unauffällig und auffällig). Die Wirksamkeit der Technik und schwere Komplikationen wurden ermittelt. Die Raten für die kumulative lokale Tumorprogression (LTP), das rezidivfreie Überleben und das Gesamtüberleben wurden mit der Kaplan-Meier-Methode geschätzt.

Ergebnisse Die CT/MR-US-Fusionsbildgebung wurde bei 419 Patienten mit 502 Herden erfolgreich aufgenommen. Die Effizienzrate der Technik bei der thermischen Ablation betrug 99,4 %. Die Rate für schwere Komplikationen betrug 1,9 %. Die kumulativen LTP-Raten betrugen 3,2 % nach 1 Jahr, 5,6 % nach 3 Jahren bzw. 7,2 % nach 5 Jahren. Es gab keine signifikanten Unterschiede beim Vergleich der kumulativen LTP-Raten in den verschiedenen Untergruppen (p = 0,541, 0,314, 0,329). Das kumulative rezidivfreie Überleben betrug 74,8 % nach 1 Jahr, 54,0 % nach 3 Jahren und 37,5 % nach 5 Jahren. Das kumulative Gesamtüberleben betrug 97,8 % nach 1 Jahr, 87,1 % nach 3 Jahren und 81,7 % nach 5 Jahren.

Schlussfolgerung Die intraprozedurale CT/MR-US-Fusionsbildgebung ist eine nützliche Technik für die perkutane thermische Leberablation und könnte dazu beitragen, ein zufriedenstellendes Überlebens-Outcome für HCC-Patienten zu erzielen, die die Mailand-Kriterien erfüllen.

Key words

ultrasound - fusion imaging - hepatocellular carcinoma - thermal ablation - survival outcome

• References

• 1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. Ca A Cancer J Clin 2016; 66: 7
• 2 European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018; 69: 182-236
• 3 Bruix J, Sherman M. Management of hepatocellular carcinoma: An update. Hepatology 2011; 10: 761-780
• 4 Wells SA, Hinshaw JL, Lubner MG. et al. Liver Ablation: Best Practice. Radiol Clin North Am 2015; 53: 933-971
• 5 Lee MW, Rhim H, Cha DI. et al. Planning US for percutaneous radiofrequency ablation of small hepatocellular carcinomas (1–3 cm): value of fusion imaging with conventional US and CT/MR images. J Vasc Interv Radiol 2013; 24: 958-965
• 6 Konopke R, Bunk A, Kersting S. The role of contrast-enhanced ultrasound for focal liver lesion detection: an overview. Ultrasound Med Biol 2007; 33: 1515-1526
• 7 Kim YS, Rhim H, Cho OK. et al. Intrahepatic recurrence after percutaneous radiofrequency ablation of hepatocellular carcinoma: analysis of the pattern and risk factors. Eur J Radiol 2006; 59: 432-441
• 8 Ikeda K, Osaki Y, Nakanishi H. et al. Recent progress in radiofrequency ablation therapy for hepatocellular carcinoma. Oncology 2014; 87: 73-77
• 9 Khajanchee YS, Streeter D, Swanstrom LL. et al. A mathematical model for preoperative planning of radiofrequency ablation of hepatic tumors. Surg Endosc 2004; 18: 696-701
• 10 Minami Y, Kudo M. Ultrasound fusion imaging of hepatocellular carcinoma: a review of current evidence. Dig Dis 2014; 32: 690-695
• 11 Abi-Jaoudeh N, Kruecker J, Kadoury S. et al. Multimodality image fusion-guided procedures: technique, accuracy, and applications. Cardiovasc Interv Radiol 2012; 35: 986-998
• 12 Calandri M, Mauri G, Yevich S. et al. Fusion Imaging and Virtual Navigation to Guide Percutaneous Thermal Ablation of Hepatocellular Carcinoma: A Review of the Literature. Cardiovasc Intervent Radiol 2019; 42: 639-647
• 13 Bo XW, Xu HX, Wang D. et al. Fusion imaging of contrast-enhanced ultrasound and contrast-enhanced CT or MRI before radiofrequency ablation for liver cancers. Br J Radiol 2016; 89: 20160379
• 14 Ahn SJ, Lee JM, Lee DH. et al. Real-time US-CT/MR Fusion Imaging for Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma. J Hepatol 2016; 66: 374-354
• 15 Song KD, Lee MW, Rhim H. et al. Percutaneous US/MRI Fusion-guided Radiofrequency Ablation for Recurrent Subcentimeter Hepatocellular Carcinoma: Technical Feasibility and Therapeutic Outcomes. Radiology 2018; 288: 878-886
• 16 Mauri G, Cova L, De Beni S. et al. Real-time US-CT/MRI image fusion for guidance of thermal ablation of liver tumors undetectable with US: results in 295 cases. Cardiovasc Interv Radiol 2015; 38: 143-151
• 17 Zhong-Zhen S, Kai L, Rong-Qin Z. et al. A feasibility study for determining ablative margin with 3D-CEUS-CT/MR image fusion after radiofrequency ablation of hepatocellular carcinoma. Ultraschall der Medizin 2012; 33: 250-255
• 18 Li K, Su ZZ, Xu EJ. et al. Improvement of ablative margins by the intraoperative use of CEUS-CT/MR image fusion in hepatocellular carcinoma. BMC Cancer 2016; 16: 1-9
• 19 Li K, Su Z, Xu E. et al. Evaluation of the ablation margin of hepatocellular carcinoma using CEUS-CT/MR image fusion in a phantom model and in patients. BMC Cancer 2017; 17: 61
• 20 Kim Y, Lim HK, Rhim H. et al. Ten-year outcomes of percutaneous radiofrequency ablation as first-line therapy of early hepatocellular carcinoma : Analysis of prognostic factors. J Hepatol 2013; 58: 89-97
• 21 Huang J, Yan L, Cheng Z. et al. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Ann Surg 2010; 252: 903-912
• 22 Teratani T, Yoshida H, Shiina S. et al. Radiofrequency ablation for hepatocellular carcinoma in so-called high-risk locations. Hepatology 2006; 43: 1101-1108
• 23 Ahmed M, Solbiati L, Brace CL. et al. Image-guided tumor ablation: standardization of terminology and reporting criteria – a 10-year update. Radiology 2014; 273: 241-260
• 24 Rossi S, Ravetta V, Rosa L. et al. Repeated radiofrequency ablation for management of patients with cirrhosis with small hepatocellular carcinomas: a long-term cohort study. Hepatology 2011; 53: 136-147
• 25 Shiina S, Tateishi R, Arano T. et al. Radiofrequency Ablation for Hepatocellular Carcinoma: 10-Year Outcome and Prognostic Factors. Am J Gastroenterol 2012; 107: 569-577
• 26 Lee DH, Lee JM, Lee JY. et al. Radiofrequency ablation of hepatocellular carcinoma as first-line treatment: long-term results and prognostic factors in 162 patients with cirrhosis. Radiology 2014; 270: 900-909
• 27 Tateishi R, Shiina S, Teratani T. et al. Percutaneous radiofrequency ablation for hepatocellular carcinoma. An analysis of 1000 cases. Cancer 2005; 103: 1201-1209
• 28 Yu J, Yu X, Han Z. et al. Letter: Percutaneous cooled-probe microwave versus radiofrequency ablation in early-stage hepatocellular carcinoma: a phase III randomised controlled trial. Gut 2016; 66: 1172-1173
• 29 Makuuchi M. Remodeling the surgical approach to hepatocellular carcinoma. Hepatogastroenterology 2002; 49: 36-40
• 30 Kudo M. Radiofrequency ablation for hepatocellular carcinoma: updated review in 2010. Oncology 2010; 78: 113-124