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Local ablation for hepatocellular carcinoma, a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage hepatocellular carcinoma. The lack of organized evidence and expert opinions regarding patient selection, preprocedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-Guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

OBJECTIVE. The purpose of this study is to quantitatively assess perfusion reductions occurring in hepatocellular carcinoma (HCC) during transcatheter arterial chemoembolization (TACE) using 2D perfusion angiography and to evaluate the relationships between various 2D perfusion angiography parameter changes and short-term tumor response. SUBJECTS AND METHODS. This prospective study included 172 patients (144 men and 28 women; mean [± SD] age, 65.4 ± 10.2 years) who underwent TACE for HCC between November 2015 and November 2017. Two-dimensional perfusion angiography was performed before and after TACE. Pre- and postprocedural CT images were also reviewed. Index lesions were defined as all discrete lesions 1.5 cm or larger. The tumor response was assessed using the modified Response Evaluation Criteria in Solid Tumors. Periprocedural 2D perfusion angiography parameters, including the arrival time, time to peak, wash-in rate, width, AUC, and mean transit time, were compared using the Wilcoxon signed rank test. Correlations between 2D perfusion angiography parameter changes and objective tumor response were evaluated using multivariate logistic regression analysis. RESULTS. A total of 187 lesions meeting the inclusion criteria were identified in 172 patients. All analyzed 2D perfusion angiography parameters were significantly different after versus before TACE ( p < 0.001). A significant relationship between periprocedural change in AUC and short-term tumor response was found (odds ratio, 1.535; 95% CI, 1.314-1.793; p < 0.001). CONCLUSION. Two-dimensional perfusion angiography could objectively quantify perfusion reductions and predict short-term tumor response to TACE in patients with HCC.

Purpose: To evaluate the effects of the degree of ethiodized oil accumulation achieved by transarterial chemoembolization followed by radiofrequency (RF) ablation on the treatment efficacy for a single intermediate-sized hepatocellular carcinoma (HCC)., Materials and Methods: A total of 153 consecutive patients who underwent chemoembolization and RF ablation for a single intermediate-sized HCC (2-5 cm) were included. On the basis of the degree of ethiodized oil accumulation in HCC on cone-beam CT images, patients who underwent chemoembolization and RF ablation were classified into 2 groups: compact accumulation (≥ 75%) and noncompact accumulation (< 75%). The rates of cumulative local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between groups., Results: Of the 153 patients, 89 were classified into the compact ethiodized oil accumulation group and 64 in the noncompact ethiodized oil accumulation group. There were no significant differences in patient demographic or HCC characteristics between groups except for the incidence of liver cirrhosis (P = .038) and the tumor margin morphology (P = .008). The cumulative LTP rate was significantly lower in the compact accumulation group than in the noncompact accumulation group (P = .013). There were no significant differences in the incidences of complications, DFS rates (P = .055), or OS rates (P = .184)., Conclusions: The degree of ethiodized oil accumulation does not play a role in decreasing the OS or DFS rate after chemoembolization and RF ablation for intermediate-sized HCC; however, it may contribute to reducing the rate of LTP., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To retrospectively compare long-term outcomes of conventional chemoembolization plus radiofrequency (RF) ablation vs those of surgical resection in patients with a single 3-5-cm hepatocellular carcinoma (HCC)., Materials and Methods: From January 2008 to December 2017, 139 of 623 patients who underwent surgical resection and 60 of 186 patients who underwent chemoembolization/RF ablation in a single center were compared with respect to local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), overall survival (OS), major complications, and hospital stay before and after propensity-score matching., Results: Mean follow-up periods were similar in the chemoembolization/RF ablation and surgical resection groups (41.9 mo vs 48.4 mo). Three (5%) and 17 (28.3%) patients in the chemoembolization/RF ablation group and 12 (8.6%) and 57 (41.0%) patients in the surgical resection group showed LTP and IDR (P = .366 and P =.114, respectively). At 1, 3, and 5 years, respective DFS rates were 88.1%, 65.3%, and 49.0% for chemoembolization/RF ablation and 84.2%, 58.2%, and 46.5% for surgical resection (P = .294). Moreover, respective OS rates were 95.0%, 73.5%, and 54.0% for chemoembolization/RF ablation and 97.1%, 87.4%, and 75.0% for surgical resection (P = .055). After matching (n = 52), therapeutic outcomes remained similar (P = .370, P = .110, P = .230, and P = .760, respectively). Surgical resection was associated with higher complication rates (P = .015) and longer hospital stays (8.4 d ± 3.7 vs 16.9 d ± 7.0; P < .001)., Conclusions: Conventional chemoembolization combined with RF ablation may be feasible for single 3-5-cm HCCs, with comparable therapeutic outcomes vs surgical resection and shorter hospital stays., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Rationale: Radiofrequency ablation (RFA) is a safe and effective local treatment modality with a low complication rate and is commonly used to treat hepatocellular carcinoma (HCC). The clinical outcome of RFA may be closely related to the location, size, and shape of index tumors, and major complications, including hemorrhage, liver abscess, infarction, visceral organ perforation, hemothorax, pneumothorax, tumoral seeding, and hepatic failure. Cardiac tamponade is a rare and serious life-threatening complication associated with RFA. To date, a review of the medical literature reported 5 cases of cardiac tamponade after RFA for HCC. Herein, we report another case of cardiac tamponade after RFA for HCC in a 56-year-old man., Patient Concerns: He had suffered from liver cirrhosis due to alcohol abuse. He had chronic obstructive pulmonary disease. Magnetic resonance imaging showed a 3.0-cm exophytic subcapsular HCC in segment IVa of left hepatic lobe. As the patient was at high risk for surgery because of poor lung function, RFA was selected as the treatment of choice. The index tumor was located in the vicinity of the diaphragm and colon. During RFA procedure, thermal injury to the adjacent diaphragm and colon was minimized by introducing artificial ascites. Bleeding or tumoral seeding was prevented by ablating the electrode track during electrode retraction., Diagnosis: Two hours after RFA, the patient presented with dyspnea, chest discomfort, and low blood pressure (80/60 mm Hg), suggesting cardiac tamponade. Immediate follow-up contrast-enhanced computed tomography image depicted the slightly high attenuated hemopericardium. Transthoracic echocardiography (TTE) showed a moderate amount of pericardial effusion with tamponade and a large hematoma., Interventions: Under fluoroscopy and portable echocardiography guidance, a cardiologist immediately inserted a 7-French pigtail catheter into the pericardial space and collected more than 200 cc of bloody pericardial fluid., Outcomes: After pericardiocentesis, the patient's symptoms and hemodynamic status were dramatically improved. Follow-up TTE showed scanty amount of pericardial effusion and the drainage catheter was removed. The patient was discharged., Lessons: When treating HCC in the left lobe (especially segments II and IVa), attention should be paid to cardiac tamponade. The early diagnosis and immediate treatment of cardiac tamponade may increase the chance of cure.

Rationale: Liver abscesses caused by Clostridium species infection are extremely rare., Patient Concerns: The authors report the first case of a liver abscess due to Clostridium haemolyticum, which occurred after transarterial chemoembolization (TACE) for hepatocellular carcinoma, in a 76-year-old woman who presented with right upper quadrant pain and fever., Diagnoses: Computed tomography of the abdomen after the second TACE showed an air-filled abscess around a compact, lipiodolized lesion in the right hepatic lobe. Pus culture showed the growth of C haemolyticum., Interventions: Broad-spectrum antibiotics, including piperacillin/tazobactam and metronidazole, were administered, and a percutaneous 10-French pigtail catheter for pus drainage and culture was inserted in the liver abscess., Outcomes: Despite administering intensive treatments, she presented with rapid deterioration in mental status, liver function, and infection markers. She was transferred to the local hospital for palliative conservative treatment., Lessons: Clostridia infections, including those involving C haemolyticum, are extremely rare, but should be considered as one of the causative organisms of liver abscess formation after TACE because of its rapid and fatal clinical course.

Rationale: The occurrence of bleeding and hematoma from bone metastasis of hepatocellular carcinoma (HCC) is extremely rare., Patient Concerns: We present a case of scapular metastasis of HCC in a 69-year-old man who presented with acute bleeding and hematoma., Diagnoses: Chest computed tomography showed a large hematoma within the right pectoral muscle of the right upper chest and an exophytic metastatic mass in the right scapula with bony destruction, which caused the intramuscular hematoma. The final diagnosis was scapular metastasis of HCC presenting as acute bleeding and hematoma., Interventions: Selective right subclavian angiography showed a hypervascular metastatic lesion in the right scapula. Subsequently, embolization of the tumoral feeding artery using a microcoil was performed and tumoral bleeding was stopped., Outcomes: The patient was discharged on hospital day 14 without any complications., Lessons: Despite being extremely rare, the possibility of bleeding from bone metastasis of HCC needs to be considered. Transcatheter arterial embolization may be an effective means to treat bleeding from bone metastasis of HCC.

Purpose: To prospectively compare multidetector-row CT (MDCT) and MR imaging (MRI) in the assessment of the ablative margin (AM) and index tumor immediately after radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) and assess whether non-contrast MRI with limited sequences (T1- and T2-weighted imaging only) was superior to a conventional MDCT protocol., Methods: A total of 33 consecutive patients with 42 HCCs were included in this study. Both MDCT and MR images were independently reviewed by two radiologists regarding the ability to visually discriminate between the AM and index tumor, and the AM status within ablation zones. The AM status was classified as AM-plus (AM completely surrounding the tumor), AM-zero (AM was partly discontinuous, without protrusion of the tumor), and AM-minus (AM was partly discontinuous, with protrusion of the tumor). During the follow-up period, the cumulative local tumor progression rates were analyzed using the Kaplan-Meier method and Cox proportional hazards model. To determine the added value of contrast-enhanced MR images, both reviewers separately evaluated the two sets (unenhanced and enhanced) of MR images., Results: Visual discrimination between the AM and index tumor was possible in four (9.5%) and 34 (81%) of the 42 ablation zones using MDCT and MRI, respectively (p < 0.001). Thirty-eight and four cases were classified as AM-plus and AM-zero on MDCT images, respectively, whereas the ablation zones were categorized as AM-plus (n = 32), AM-zero (n = 9), and AM-minus (n = 1) when examining the MR images. The cumulative incidence of local tumor progression was significantly lower in cases with AM-plus on MRI (p = 0.007). Contrast-enhanced MRI had no added value for the assessment of the AM and index tumor., Conclusion: MRI was superior to MDCT for the differential assessment of the AM and index tumor immediately after RF ablation for HCC. Non-contrast MRI was also superior to the conventional MDCT protocol.

Purpose: To compare therapeutic outcomes of radiofrequency (RF) ablation combined with transcatheter arterial chemoembolization vs surgical resection (SR) for single 2-3 cm hepatocellular carcinoma (HCC)., Materials and Methods: Seventy patients underwent combined chemoembolization/RF ablation therapy and 84 underwent SR. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), and overall survival (OS) rates, as well as major complications and duration of hospital stay, were compared between groups before and after propensity-score matching., Results: LTP and IDR had developed in 9 (12.9%) and 24 (34.3%) patients in the combined treatment group and in 7 (8.3%) and 24 (28.6%) patients in the SR group (P = .262 and P = .252, respectively). The 1-, 3-, 4-, and 5-year DFS rates were similar between groups (82.6%, 53.2%, 53.2%, and 37.6%, respectively, vs 84.5%, 63.6%, 59.2%, and 52.1%, respectively; P = .278), and 1-, 3-, 4-, and 5-year OS rates were also comparable (94.2%, 81.2%, 74.1%, and 59.4%, respectively, vs 95.2%, 86.3%, 84.0%, and 80.3%, respectively; P = .081). After matching (n = 98), LTP, IDR, DFS, and OS rates were still similar (P = .725, P = .826, P = .484, and P = .578, respectively). Major complication rate was not significantly different (2.9% vs. 6.0%; P = .596); however, after matching, major complication rate was higher in SR group (2.0% vs. 6.1%; P < .001). Hospital stays were significantly longer in the SR group (16.6 ± 6.7 d vs 8.5 ± 4.1 d; P < .001)., Conclusions: Before and after matching, there were no significant differences in long-term therapeutic outcomes between combined chemoembolization/RF ablation and SR groups. Therefore, combined chemoembolization/RF ablation therapy may be an alternative treatment for single 2-3 cm HCCs., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)

Ultrasound-guided percutaneous radiofrequency (RF) ablation has become one of the most promising local cancer therapies for both resectable and nonresectable hepatic tumors. Although RF ablation is a safe and effective technique for the treatment of liver tumors, the outcome of treatment can be closely related to the location and shape of the tumors. There may be difficulties with RF ablation of tumors that are adjacent to large vessels or extrahepatic heat-vulnerable organs and tumors in the caudate lobe, possibly resulting in major complications or treatment failure. Thus, a number of strategies have been developed to overcome these challenges, which include artificial ascites, needle track ablation, fusion imaging guidance, parallel targeting, bypass targeting, etc. Operators need to use the right strategy in the right situation to avoid the possibility of complications and incomplete thermal tissue destruction; with the right strategy, RF ablation can be performed successfully, even for hepatic tumors in high-risk locations. This article offers technical strategies that can be used to effectively perform RF ablation as well as to minimize possible complications related to the procedure with representative cases and schematic illustrations.

Objective: To compare gadoxetic acid injection rates of 0.5 mL/s and 1 mL/s for hepatic arterial-phase magnetic resonance (MR) imaging., Materials and Methods: In this prospective study, 101 consecutive patients with suspected focal liver lesions were included and randomly divided into two groups. Each group underwent dynamic liver MR imaging using a 3.0-T scanner after an intravenous injection of gadoxetic acid at rates of either 0.5 mL/s (n = 50) or 1 mL/s (n = 51). Arterial phase images were analyzed after blinding the injection rates. The signal-to-noise ratios (SNRs) of the liver, aorta, portal vein, hepatic vein, spleen, and pancreas were measured. The contrast-to-noise ratios (CNRs) of the hepatocellular carcinomas (HCC) were calculated. Finally, two experienced radiologists were independently asked to identify, if any, HCCs in the liver on the images and score the image quality in terms of the presence of artifacts and the proper enhancement of the liver, aorta, portal vein, hepatic vein, hepatic artery, spleen, pancreas, and kidney., Results: The SNRs were not significantly different between the groups (p = 0.233-0.965). The CNRs of the HCCs were not significantly different (p = 0.597). The sensitivity for HCC detection and the image quality scores were not significantly different between the two injection rates (p = 0.082-1.000)., Conclusion: Image quality and sensitivity for hepatic HCCs of arterial-phase gadoxetic acid-enhanced MR were not significantly improved by reducing the contrast injection rate to 0.5 mL/s compared with 1 mL/s.

Objective: To compare the effectiveness of radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) with surgical resection in patients with a single hepatocellular carcinoma (HCC) ranging from 2 to 5 cm., Materials and Methods: The study participants were enrolled over a period of 29 months and were comprised of 37 patients in a combined therapy group and 47 patients in a surgical resection group. RFA was performed the day after TACE, and surgical resection was performed by open laparotomy. The two groups were compared with respect to the length of hospital stay, rates of major complication, and rates of recurrence-free and overall survival., Results: Major complications occurred more frequently in the surgical resection group (14.9%) than in the combined therapy group (2.7%). However, there was no statistical significance (p = 0.059). The rates of recurrence-free survival at 1, 2, 3 and 4 years were similar between the combined therapy group (89.2%, 75.2%, 69.4% and 69.4%, respectively) and the surgical resection group (81.8%, 68.5%, 68.5% and 65%, respectively) (p = 0.7962, log-rank test). The overall survival rates at 1, 2, 3 and 4 years were also similar between groups (97.3%, 86.5%, 78.4% and 78.4%, respectively, in the combined therapy group, and 95.7%, 89.4%, 84.3% and 80.3%, respectively, in the surgical resection group) (p = 0.6321, log-rank test)., Conclusion: When compared with surgical resection for the treatment of a single HCC ranging from 2 to 5 cm, RFA combined with TACE shows similar results in terms of recurrence-free and overall survival rates.

Purpose: To assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency (RF) ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on computed tomography (CT) or magnetic resonance (MR) imaging., Materials and Methods: Patients referred for planning US for percutaneous RF ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. The study enrolled 898 patients (684 men and 214 women, age range 32-86 years). HCCs that were invisible on planning US were compared with visible HCCs with respect to tumor size, distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha fetoprotein (AFP) level, body mass index (BMI), previous treatments for HCC, previous chemoembolization treatments for HCC, institutions, and experience of radiologists., Results: Among 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each P < .05)., Conclusions: Smaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of invisible tumors on planning US., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effectiveness of ultrasound-guided radiofrequency (RF) ablation in patients with incompletely treated hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) and to evaluate possible prognostic factors for this therapy., Subjects and Methods: Thirty nine patients with incompletely treated single HCC (≤ 5 cm) after TACE were treated with RF ablation. All patients were evaluated for complete tumor ablation rate, local recurrence-free rate, overall survival rate, and complications. Local recurrence-free rate and overall survival rate were calculated using the Kaplan-Meier method. The possible prognostic factors of local recurrence-free rate and survival rate were analyzed using Cox proportional-hazards regression model., Results: The complete tumor ablation rate was 92.3%. Local recurrence-free rates for 1-, 2-, 3-, and 5-years were 81.7%, 63.1%, 53.6%, and 35.7%, respectively. One-, 2-, 3-, and 5-year overall survival rates were 96.9%, 82.9%, 67.8%, and 48.4%, respectively. Among prognostic factors included in the analysis, only tumor diameter (≤ 2 cm versus > 2 cm) was statistically significant in terms of predicting local recurrence. Complications were observed in two patients, one with liver abscess and the other with portal venous thrombosis., Conclusion: Ultrasound-guided RF ablation could be effective and safe in treating incompletely treated HCC after TACE. The diameter of HCC was a significant prognostic factor for local recurrence.

Objective: To evaluate whether the histopathological differentiation and the expression of vascular endothelial growth factor (VEGF) of hepatocellular carcinoma (HCC) do show correlation with the apparent diffusion coefficient (ADC) value on diffusion-weighted imaging (DWI)., Materials and Methods: Twenty-seven HCCs from 27 patients who had undergone preoperative liver MRI (1.5T) and surgical resection were retrospectively reviewed. DWI was obtained with a single-shot, echo-planar imaging sequence in the axial plane (b values: 0 and 1,000 sec/mm(2)). On DWIs, the ADC value of the HCCs was measured by one radiologist, who was kept 'blinded' to the histological findings. Histopathologically, the differentiation was classified into well (n = 9), moderate (n = 9) and poor (n = 9). The expression of VEGF was semiquantitatively graded as grade 0 (n = 8), grade 1 (n = 9) and grade 2 (n = 10). We analyzed whether the histopathological differentiation and the expression of VEGF of the HCC showed correlation with the ADC value on DWI., Results: The mean ADC value of the poorly-differentiated HCCs (0.9 +/- 0.13x10(-3) mm(2)/s) was lower than those of the well-differentiated HCCs (1.2 +/- 0.22x10(-3) mm(2)/s) (p = 0.031) and moderately-differentiated HCCs (1.1 +/- 0.01x10(-3) mm(2)/s) (p = 0.013). There was a significant correlation between the differentiation and the ADC value of the HCCs (r = -0.51, p = 0.012). The mean ADC of the HCCs with a VEGF expression grade of 0, 1 and 2 was 1.1 +/- 0.17, 1.1 +/- 0.21 and 1.1 +/- 0.18x10(-3) mm(2)/s, respectively. The VEGF expression did not show correlation with the ADC value of the HCCs (r = 0.07, p = 0.74)., Conclusion: The histopathological differentiation of HCC shows inverse correlation with the ADC value. Therefore, DWI with ADC measurement may be a valuable tool for noninvasively predicting the differentiation of HCC.