Hepatocellular carcinoma with cirrhosis: are patients with neoplastic main portal vein invasion eligible for percutaneous radiofrequency ablation of both the nodule and the portal venous tumor thrombus?
OBJECTIVE
The purpose of this study was to examine the results of percutaneous radiofrequency ablation of both medium-sized hepatocellular carcinoma (HCC) and the accompanying main portal venous tumor thrombus in patients with cirrhosis.


METHODS
From January 2005 to January 2008, among 1,837 consecutively registered patients with HCC seen at our institution, 412 had HCC and portal venous invasion; 27 of the 412 had a single HCC nodule accompanied by main portal venous tumor thrombus. Thirteen patients (10 men, three women; mean age, 70 years; range, 66-74 years) with 13 HCC nodules 3.7-5 cm in diameter extending into the main portal trunk underwent percutaneous radiofrequency ablation. Fourteen matched patients (10 men, four women; mean age, 69 years; range, 67-73 years) with 14 HCC nodules 3.6-4.8 cm in diameter extending into the main portal trunk refused radiofrequency ablation and composed the control group. Diagnosis of main portal venous tumor thrombus was made with fine-needle biopsy in all cases. Radiofrequency ablation was performed first on the main portal venous tumor thrombus and then on the HCC nodule. Efficacy of radiofrequency was defined as complete necrosis of HCC and complete recanalization of the main portal trunk and its branches. HCC necrosis was evaluated with enhanced CT. Recanalization of portal vessels was analyzed with color Doppler and contrast-enhanced ultrasound. Radiofrequency ablation was performed under ultrasound guidance with a perfused needle electrode.


RESULTS
Complete necrosis of the HCC associated with complete recanalization of the main portal vein and its branches was achieved in 10 patients (efficacy, 77%). In the other three patients, necrosis of the HCC ranged from 70% to 90%, and recanalization of the main portal trunk was not complete. No major complications occurred. In three cases, mild to moderate ascites and increased aspartate aminotransferase and alanine aminotransferase levels were found. The follow-up periods ranged from 3 to 36 months among the treated patients and 2 to 10 months among the untreated patients. The cumulative survival rate was 77% 6, 12, and 36 months after procedure in the treated group and 43% and 0% 6 and 12 months after diagnosis in the untreated group (p < 0.0001). All 10 successfully treated patients were alive and the portal system was patent at the end of the follow-up period. All three untreated patients died of progressive disease within 5 months of diagnosis.


CONCLUSIONS
Radiofrequency ablation can destroy both single intraparenchymal medium-sized HCCs and the accompanying main portal venous tumor thrombus with high efficacy and safety and a low rate of complications.
Giorgio
Antonio
A
Infectious Disease and Interventional Ultrasound Unit, D. Cotugno Hospital, Via Quagliariello 54, 80131 Naples, Italy. assanui1@virgilio.it
Di Sarno
Antonella
A
de Stefano
Giorgio
G
Farella
Nunzia
N
Scognamiglio
Umberto
U
de Stefano
Manuela
M
Giorgio
Valentina
V
D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000601:surgery*; D008297:Male; D009361:Neoplasm Invasiveness; D011169:Portal Vein / Q000601:surgery*; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000209:etiology / Q000601:surgery*