Comparison of the therapeutic efficacy of microwave ablation and radio - frequency ablation for hepatoccelular carcinomas

Nội dung text: Comparison of the therapeutic efficacy of microwave ablation and radio - frequency ablation for hepatoccelular carcinomas

1. Journal of military pharmaco-medicine n o2-2018 COMPARISON OF THE THERAPEUTIC EFFICACY OF MICROWAVE ABLATION AND RADIO-FREQUENCY ABLATION FOR HEPATOCCELULAR CARCINOMAS Vo Hoi Trung Truc*; Tran Viet Tu** SUMMARY Objectives: Comparison of the therapeutic efficacy of percutaneous microwave ablation (MWA) and radio frequency ablation (RFA) for treatment of hepatocellular carcinomas (HCC). Subjects and method: 136 patients with HCC were divided into two groups. 66 patients with 71 tumors were treated with MWA and 70 with 74 tumors were treated with RFA. Results: The complete response rate of MWA and RFA were 95.7% and 97.3%, respectively. No significant differences in the complete response rate between modalities (MWA and RFA) and tumor sizes (< 3 cm and ≥ 3 cm). The disease-free survival (DFS) rates at 1 and 2 years in the MWA group were 68.2% and 43.9% with a mean DFS period of 17.4 ± 9.2 months. Those at 1 and 2 years in the RFA group were 65.7% and 41.4%, respectively with a mean DFS period of 16.8 ± 8.7 months . No significant difference in the DFS rates (p = 0.76 and 0.767 ) and DFS period (p = 0.446) between 2 groups. Platelet, age and AFP were identified independent prognostic factors for DFS by using Cox’s proportional hazards model. Conclusion: MWA has the similar efficacy to RFA in treating HCCs. Platelet, age and AFP were prognostic factors for DFS. * Keywords: Hepatocellular carcinoma; Microwave ablation; Radio frequency ablation. INTRODUCTION Therefore, we did this research in order Liver cancer in men is the fifth most to: Compare the local ablation effects of frequently diagnosed cancer worldwide percutaneous MWA and RFA in the but the second most frequent cause of treatment of HCC cancer death. In women, it is the seventh most commonly cancer and the sixth SUBJECTS AND METHODS leading cause of cancer death [3]. Local 1. Subjects. ablation therapies have been recognized 136 patients were diagnosed with as radical, minimally invasive ones for HCCs and treated in the Liver Tumor early HCCs. Among a variety of these, Department, Choray Hospital between RFA is the most common thermal ablation modality worldwide. MWA was first June, 2012 and December, 2013. They deployed in Choray Hospital in June 2012 were divided into two groups: MWA group and should be proven its efficacy in (66 patients with 71 tumors) and RFA destroying liver tumors in Vietnam. group (70 patients with 74 tumors). * Choray Hospital ** 103 Military Hospital Corresponding author: Vo Hoi Trung Truc (bstruc200667@gmail.com) Date received: 20/11/2017 Date accepted: 22/01/2018 134
2. Journal of military pharmaco-medicine n o2-2018 * Inclusion criteria: The pathological enhancement within the ablation area or finding is HCC, liver tumors (one or two the target tumor [1]. All patients with nodules of 5 cm or smaller in size), Child- incomplete ablation were further treated Pugh A or B, prothrombin time more than by complementary ablations. All patients 50% and platelet count more than were regularly followed up every 2 - 3 3 50.000/mm , unresectable HCC or patients’ months during the follow-up. refusal to undergo surgery, patients agree Continuous variables were reported as to participate in the study. mean ± standard deviation. Differences in * Exclusion criteria: Patients with PST categorical variables and continuous > 2, venous thrombosis (portal vein, hepatic variables between the groups were vein, lower vena cava), bile duct dilation, analyzed with the Chi-square test or distant metastasis or invasion of adjacent Fisher’s exact test and with student’s organs. t-test, respectively, using the Stata 2. Methods. version 13.0 software. The Wilcoxon A total of 136 eligible patients were signed-rank test is used when comparing enrolled in this prospective cohort study. two matched samples. DFS curve was Under the guidance of real-time ultrasound, evaluated using Kaplan-Meier curve and the antenna of the microwave system compared using the log-rank test. To AveCure (Medwaves, USA) or the electrode identify the prognostic factors for DFS, 12 of Valley-lab Cool-tip™ RF Ablation System variables were used, including ablation (Covidien, USA) was percutaneously probed modality (MWA/RFA), age (< 60, ≥ 60), into the tumors. A RFA was applied for 5 - sex (male, female), albumin (< 3.5; ≥ 3.5 12 mins and a MWA for 7.5 - 10 mins until mg%), bilirubine (< 2, ≥ 2 mg%), platelet whole tumor was ablated completely with (< 100, ≥ 100), prothrombin time (< 16, a safety margin of 5 - 10 mm. Patients ≥ 16), AFP level (< 200, ≥ 200), tumor were discharged one day after procedures. differentiation (1, 2, 3), tumor size (< 3, A contrast-enhanced CT-scan was ≥ 3 cm), tumor number (1, 2), BCLC (0, A, performed 1 month after ablation. The B). Variables with p values less than 0.05 local efficacy was evaluated. Complete in the univariate analysis were entered ablation was defined as that the ablated into a Cox proportional hazards model for area completely covers the target tumor. multivariate analysis. A p-value less than Incomplete ablation was defined as any 0.05 was considered statistically significant. 135
3. Journal of military pharmaco-medicine n o2-2018 RESULTS 1. Patients’ baseline characteristics. Table 1: Characteristics of patients. MWA group (n1 = 66) RFA group (n1 = 70) p Sex Male/female 55/11 62/8 0.379 Age Mean ± SD 60.8 ± 10.9 62.1 ± 10.7 0.408 Platelet (G/L) Mean ± SD 154.3 ± 68.5 172.2 ± 68.1 0.129 Fibrinogen (g/L) Mean ± SD 2.8 ± 1.3 2.8 ± 0.7 0.958 Prothrombin time (sec) Mean ± SD 13.8 ± 2.2 14.2 ± 1.8 0.312 APTT (sec) Mean ± SD 31.5 ± 4.3 31.9 ± 5.1 0.615 AST(U/L) Median (IQR) 61 (46 - 94) 60(45 - 87) 0.459 ALT(U/L) Median (IQR) 48 (37 - 88) 45(28 - 70) 0.729 Bilirubine (mg/dL) Median (IQR) 0.9 (0.6 - 1.2) 0.8(0.6 - 1.1) 0.221 Albumin blood (g/dL) Mean ± SD 4.2 ± 0.6 4.2 ± 0.5 0.629 Tumor differentiation 1/2/3 21/44/1 20/49/1 0.854 Child-Pugh A/B 60/6 63/7 1.00 BCLC 0/A/B 3/59/4 5/63/2 0.579 PST 0/1 62/4 66/4 1.00 The number of nodules 1/2 61/5 66/4 0.739 Median follow-up time Median (IQR) 24.7 (14 - 25.7) 24.4 (15.7 - 25.4) 0.806 (n1: Total number of patients) There was no significant difference in clinical backgrounds between the two groups. 2. Ablation effectiveness. Table 2: AFP changing after treatments. AFP level MWA group (n1 = 66) RFA group (n1 = 70) Before the procedure Median (IQR) 11.8 (6.0 - 39.7) 11.2 (5.8 - 28.9) After the procedure Median (IQR) 7.5 (4.6 - 19.4) 8,1 (3.6 - 13.3) p < 0.001 < 0.001 AFP levels after treatment decreased significantly in both two groups. 136
4. Journal of military pharmaco-medicine n o2-2018 Table 3: Technique effectiveness. MWA group (n2 = 71) p RFA group (n2 = 74) 3 3/27/41 0.534 5/33/36 Nodule size (cm) Mean ± SD 3.3 ± 1 0.573 3.2 ± 1 1/ ≥ 2 57/14 0.504 56/18 Sessions for one nodule Mean ± SD 1.2 ± 0,4 0.220 1.3 ± 0.6 Overall 95.8% 97.3% Complete response Nodule ≤ 3 cm 97% 97.5% Nodule > 3 cm 94.6% 97.1% (n2: Total number of nodules) No significant differences in nodule sizes and the number of ablation sessions for the target nodule were observed between the MWA and the RFA groups. The CA rate in the tumor treated with MWA was the same as one in the tumors treated with RFA. 3. Disease free survival. Table 4: DFS and rate. MWA group (n1 = 66) RFA group (n1 = 70) p Disease free 1-year survival 68.2% 65.7% 0.76 Disease free 2-year survival 43.9% 41.4% 0.767 Mean DFS 17.4 ± 9.2 (months) 16,8 ± 8.7 (months) 0.724 No significant differences in the DFS rates and DFS period between two groups. 4. Prognostic factors. Table 5: Prognostic factors of complete response. Multiple linear regression Odds ratio p-value 95%CI Ablation modality (MWA/RFA) 1.5 0.64 0.2 9.6 Nodule size ( ≤ 3 cm, > 3 cm) 0.6 0.64 0.1 4 No significant differences in the complete response rate between modalities (MWA and RFA) and tumor sizes (< 3 cm and ≥ 3 cm). 137
5. Journal of military pharmaco-medicine n o2-2018 Table 6: Prognostic factors of DFS. Multivariate analysis Hazard ratio p-value 95%CI Age(< 60, ≥ 60) 0,6 0.021 0,4 0,9 Platelet (< 100, ≥ 100) 0.4 0.002 0.2 0.7 AFP level (< 200, ≥ 200) 1.5 0.013 1.1 1.9 Variables were analyzed: ablation modality (MWA/RFA), sex (male, female), age ( 3.5 mg%), bilirubine ( ≤ 2, > 2 cm), platelet (< 100, ≥ 100), prothrombin time (< 16, ≥ 16), AFP level (< 200, ≥ 200), tumor differentiation (1, 2, 3), nodule size (< 3, ≥ 3 cm), nodule number (1, 2), BCLC (0, A, B) Age, platelet count and AFP were independent prognostic factors of DFS. DISCUSSION difference was not significant (p = 0.301) There was no significant difference in [2]. Lu et al documented the complete clinical backgrounds between the two response rate achieved using MWA group groups. AFP levels after treatment decreased was 94.9%. Complete response rates were significantly in both two groups. 98.6% in tumors ≤ 3 cm versus 83.3% in tumors > 3 cm (p = 0.01) [8]. Wang et al 1. Technique effectiveness of MWA. found that patients with tumor > 5 cm Complete response confirmed at 1 month were less likely to gain complete ablation after treatment is very important. It is one at first microwave ablation and more of the main criteria to evaluate the efficacy likely to suffer from incomplete ablation of ablation. The complete response rate after two sessions of MWA compared with of MWA group was 95.8%. This rate is not those with tumor ≤ 5 cm. However, tumor different from many other studies. Liu et al number and location have no significant realized that 85.7% of tumors in the impact on technique effectiveness [6]. 915 MHz MW group and 73.7% of tumors in the 2,450 MHz MW group achieved 2. The therapeutic efficacy of MWA complete ablation [4]. Xu et al found that versus RFA. the complete response was 94.6%. Theoretically, MWA outperforms RFA In our study, there was no difference in some areas, such as faster ablation between the complete response rate in time, bigger coagulation volume, higher nodules ≤ 3 cm and the one in nodules tumor temperature and being less affected > 3 cm (p = 0.64) [7]. Hetta et al showed by the heat-sink effect of local blood vessels. that MW ablation success was higher with However, we found that the CR rates using nodules ≤ 3 cm (98.3%) in comparison to MWA and RFA were 95.8% and 97.3%, nodules > 3 cm (92.5%). However, the respectively. There was no difference 138
6. Journal of military pharmaco-medicine n o2-2018 between the two groups (p = 0.64). Lu et respectively, with a mean DFS period of al found that the complete response rates 15.5 months. The DFS rates at 1, 2, 3 were 94.9% using MWA versus 93.1% years in the RFA group were 37.2%, using RFA (p = 0.75) [8]. Zhang et al 20.7%, 15.5%, respectively, with a mean reported the complete response rate was DFS period of 16.5 months (p = 0.53) in achieved in 86.7% of tumors treated with comparison with the MWA group [8]. MWA and 83.4% of the treated those with Zhang et al showed that the 1-, 3-, 5-year RFA, with no significant difference between DFS rates were 62.3%, 33.8%, 20.8%, the two groups (p = 0.957) [9]. Xu et al respectively, for the MWA group and found that the complete response rate in 70.5%, 42.3%, 34.2%, respectively for the MW and RF ablation was 94.6% and RF ablation group. There was no significant difference between these two groups 89.7%, respectively (p > 0.05) [7]. (p = 0.123) [9]. Vogl et al reported that the 3. Disease free survival. progression-free survival rate at 1 and According to our study, the 1-year and 2 years were much higher than ours. In 2-year DFS rates in the MWA group were the Vogl et al’s study, the progression- 68.2% and 43.9%, respectively with a free survival rate for patients treated with mean DFS period of 17.4 ± 9.2 months. MWA of 1, 2, 3 years were 97.2%, 94.5%, The 1-year and 2-year DFS rates in the 91.7 and treated with RFA were 96.9%, RFA group were 65.7% and 41.4% with a 93.8%, and 90.6%, respectively (p = 0.98) mean DFS period of 16.8 ± 8.7 months. [5]. The difference was not significant There was no difference in disease free 1- between the two groups (p = 0.98) [5]. We year survival (0.76), disease free 2-year confirmed that the prognostic factors of survival (p = 0.767) and mean DFS period DFS were age (< 60, ≥ 60), platelet (p = 0.724) between the two groups. The (< 100, ≥ 100) and AFP level (< 200, outcome in our study is better than that in ≥ 200). Wang et al identified levels of AFP the Lu et al’s study. Lu et al showed that and GGT as independent prognostic the DFS rates at 1, 2, 3 years in the factors of recurrence-free survival in MWA group were 45.9%, 26.9%, 26.9%, patients receiving MWA [6]. 139
7. Journal of military pharmaco-medicine n o2-2018 CONCLUSION R.A, Lee F.T Jr, Livraghi T, McGahan J.P, Rhim H, Silverman S.G. Image-guided tumor Findings in this study revealed that the ablation: Proposal for atandardization of terms complete response rates of MWA and and reporting criteria. Radiology. 2003, 228 RFA were 95.8% and 97.9%, respectively. (2), pp.335-345. There was no difference between the two 2. Hetta O.M, Shebrya N.H, Amin S.K. groups (p = 0.64). There was no difference Ultrasound-guided microwave ablation of between the complete response rate in hepatocellular carcinoma: Initial institutional nodules ≤ 3 cm and the one in nodules experience. The Egyptian Journal of Radiology > 3 cm (p = 0.64). The 1-year and 2-year and Nuclear Medicine. 2011, 42 (3-4), pp. DFS rates in the MWA group were 68.2% 343-349. and 43.9% with a mean DFS period of 3. Jemal A, Bray F., Center M.M et al. 17.4 ± 9.2 months. The 1-year and 2-year Global cancer statistics. CA: a Cancer Journal DFS rates in the RFA group were 65.7% for Clinicians. 2011, 61 (2), pp.69-90. and 41.4% with a mean DFS period of 16.8 ± 8.7 months. There was no difference 4. Liu F.Y, Yu X.L, Liang P et al. in disease free 1-year survival (0.76), Comparison of percutaneous 915 MHz microwave ablation and 2,450 MHz disease free 2-year survival (p = 0.767). microwave ablation in large hepatocellular We confirmed that age (< 60, ≥ 60), carcinoma. J Hyperthermia. 2010, 26 (5), platelet (< 100, ≥ 100) and AFP level pp.448-455. (< 200, ≥ 200) were the prognostic factors of DFS after ablations. 5. Vogl T.J, Farshid P, Naguib N.N et al. Ablation therapy of hepatocellular carcinoma: REFERANCES a comparative study between radiofrequency 1. Goldberg S.N, Charboneau J.W, D.G. r, and microwave ablation. Abdom Imaging. Dupuy D.E, Gervais D.A, Gillams A.R, Kane 2015, 40 (6), pp.1829-1837. 140
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