1. 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 Fondation
Policlinico Hospital – Milan - Italy
General Surgery & Liver Transplant Unit*
Interv. Radiology Unit**
2. Aim of our experience
To assess the finalhistological pattern afterRFA and
DEB-TACE performed as “Bridge Treatment” for HCC
before Liver Transplantation.
3. HCC Bridge Treatment before Liver Transplantation
According to BCLCA Guidelines
CurativeTreatments
• 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
4. 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
5. 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 61
in BCLCA A1-A4 selected for LT
Sex 24M,6F
Age 55.6 (57±3.8)
Patients selected for the 30 (49.2%)
“Bridge Treatment”
RFA 18 pts
DEB-TACE 10 pts
Patients excluded 2 pts (both treatments)
6. 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
7. Baseline Characteristics of the Patients
Enrolled in the Study
Pts Characteristics DEB-TACE RFA
10 pts 18 pts
Child-Pugh
A 6 12
B 4 6
HCC size 30±12.2 mm 30±15.0 mm
N° 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. **
Ethiology
HBV 0 1
HCV 5 10
ETH 1 2
Mixed 4 5
8. 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
9. 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 treatment
CT-scan Complete 91% 88% 0.941
Necrosis (3 months)
Complete 82% 78% 0.963
PathologicalRespo
nse
PartialPathological 18% 22% n.s.
Response
11. 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
12. … improve is to change!
…be perfect is to change often!
Sir Winston Churchill (1874-1965)
Thank you very much indeed for your attention!!
