WCIO 2011 – June 9 – 12 , New York Is RFA still the standard of treatment for patients with HCC awaiting liver transplantation? RM Lauro*, A Nicolini** IRCCS Cà Granda FondationPoliclinico Hospital – Milan - Italy General Surgery & Liver Transplant Unit* Interv. Radiology Unit**
Aim of our experienceTo assess the finalhistological pattern afterRFA andDEB-TACE performed as “Bridge Treatment” for HCCbefore Liver Transplantation.
HCC Bridge Treatment before Liver Transplantation According to BCLCA GuidelinesCurativeTreatments• Surgery in very early (O) and early stage (A) (Laparaoscopy)• PEI (early stage)• Thermoablation (RFA) in early stage• Other Ablation procedures, even though not yet approved with the need of further investigations (MW, CrioAbl, Laser-LITT etc..) (early stage)• TACE in intermediate stage Palliative Treatment Namiki Izumi, J of Gastroenterol & Hepatol 26 (2011) Suppl. 1 ; 115-122 J Bruix and M Sherman, Hepatology 2011; 53 N.3: 1020-1022 Belghiti J, Lencioni R et al., Ann Surg Oncol 2008; 15: 993-1000 Bharat et al, Am J Coll Surg 2006; pp. 411-420 Xian-Jie Shi et al.,Hepatobiliary Pancreat Dis Int. 2011; 10: 143-150 T Livraghi et al., Scandinavian Journal of Surgery 2011; 100: 22–29
TACE• In recent years TACE procedures have been improved• The recent introduction of microsphere loaded with Epirubicin or Doxorubicin (DEB-TACE) has improved TACE efficacy, extending tumor necrosis Varela M et al., J Hepatol 2007; 46: 474-481 Malagari K et al., Abdom Imaging 2008; 33: 512-519 Nicolini A et al., Dig Liver Dis 2009; 41: 143-149 Nicolini A et al., JVIR 2010; 21: 327-332 Mike SL Liem et al., World J Gastroenterol 2005;11(29):4465-4471 A G Singal & J A Marrero, Current Opinion in Gastroenterology 2010,26:189–195
Methods January 2005 – December 2010 Based on a Clinical Basis , we have investigated a significant group of patients within the “Milano Criteria”.Patients with HCC 61in BCLCA A1-A4 selected for LTSex 24M,6FAge 55.6 (57±3.8)Patients selected for the 30 (49.2%)“Bridge Treatment”RFA 18 ptsDEB-TACE 10 ptsPatients excluded 2 pts (both treatments)
Methods• According to BCLC guidelines all patients were considered for RFA.• Only patients with at least a lesion in critical sites or more than 30 mm in diameter not treatable with RFA , were cured using DEB-TACE• The pathological specimen of the native unhealthy liver was analyzed by the pathologists
Baseline Characteristics of the Patients Enrolled in the Study Pts Characteristics DEB-TACE RFA 10 pts 18 ptsChild-PughA 6 12B 4 6HCC size 30±12.2 mm 30±15.0 mmN° of HCC Nodules Lap. 13 pts , Perc. 5 pts-1 N 7 (70%)*** 1 (6%)-2 N 1 (10%) 11 (61%)-3 N 2 (20%) 6 (33%) Lap. **EthiologyHBV 0 1HCV 5 10ETH 1 2Mixed 4 5
N. of Nodules DEB-TACE RFA 10 pts 18 pts 1N ***7 pts (70%) 1 pts (6%) - Critical Sites -Close to main vessels -Size > 30 mm -Less Invasive impact before LT 2N 1 pts (10%) 11 pts (61%) 3N 2 pts (20%) **6 pts (33%) Third nodule always detected as occasional finding >>Laparoscopic US
Results Treatment RFA DEB-TACE p< N° of Pts 18 10 N° of Treatments 1.30 (1-3) 1.5 (1-3) n.s.WT to LT after the 12.8 (1-24 M) 8.0 (3-18 M) n.s. 1st treatmentCT-scan Complete 91% 88% 0.941Necrosis (3 months) Complete 82% 78% 0.963PathologicalRespo nsePartialPathological 18% 22% n.s. Response
Question?DEB-TACE :Is it only for Palliative Treatment? TopicofDiscussion
Conclusion• Our results suggests that RFA and DEB-TACE have similar results• Both RFA and DEB-TACE are good therapeutic approaches to limit HCC progression in stable LT candidates.• DEB-TACE has a better cost/benefit ratio (less invasive, lower costs, excellent efficacy)• DEB-TACE in expert hands, might be also considered as “Curative Treatment” very soon.• A wider comparison of the two procedures seems warranted in the light of Clinical Effectiveness Research
… improve is to change! …be perfect is to change often! Sir Winston Churchill (1874-1965)Thank you very much indeed for your attention!!