Kecheng Xu,M.D.,Lizhi Niu,M.D.,Ph.D.,Weibing He,M.D., Yisong He,M.D.,Jiansheng Zuo,M.D.

ABSTRACT

Objectives.To evaluate the efficacy of sequential use of transarterial chemoembolization (TACE) and percutaneous cryosurgery for unresectable hepatocellular carcinoma(HCC).

Methods. All 420 patients was enrolled in this study. The tumors of all cases were considered to be unresectable or surgical resection was not thought to be feasible because of tumor location or size,or patient comorbidity. TACE was performed according to routine technique. Two to four months after TACE, percutaneous cryosurgery was performed under guidance of ultrasound or CT.

Results.During a mean follow-up of 36±17 months(range 24 to 60 months),129 patients (30.7%) showed no evidence of disease,98 patients (23.3%) are alive with recurrent disease,170 patients (40.5%) have died of disease recurrence or spread, and 23 patients (5.5%) have died other diseases.The overall 1-,2-,3-,4-,and 5-year survival rates are 72%,57.5%,47%,39% and 31%. Comparing the survival rates between TACE-cryosurgery combination and cryo-alone groups,the statistically significant difference was seen for 4 and 5 years after treatment. Disease-free survival at 12 months was 31% for combination therapy and 25% for cryo-alone group (p=0.06), while 60-month disease-specific survival was 26% and 12%, respectively (p=0.002).The local recurrence rate at the ablation area was 17% for all patients, and 11% and 23 % for combination therapy and cryo-alone group,respectively (p=0.04). The overall complication rate was 24%, and there were 21% and 26.2 % of complication rate ,respectively, for combination and cryo-alone groups(p= 0.06).The latter group had more hepatic bleeding (p=0.02), and liver rupture, while the more liver failure occurred in combination therapy group.

Conclusion.

A combined approach involving TACE and perctaneous cryosurgery improves survival. TACE is useful to control tumours burden. Sequential use of TACE and cryosurgery seems to be the best way to improve outcome in unresectable HCC. Key words. hepatocellular carcinoma cryosurgery, percutaneous cryosurgery, transarterial chemoembolization 

Cryosurgery has been used in the past two decades for the treatment of many benign, malignant, and metastatic tumors[1-3]. More specifically, hepatocellular carcinoma (HCC) has been successfully treated either with cryosurgery alone or in combination with resection[4-6].

Transarterial chemoembolization (TACE), by itself, is not associated with improved survival compared with that of an untreated control group[7], however, it is proved to shrink the mass of HCC. It is shown that sequential TACE-resection might improve outcome for patients with large HCC[8]. Therefore , combination of TACE and cryosurgery is expected to yield better therapeutic efficacy and to decrease hemorrhage incidence.

From march 2001 to December 2006,a total of 980 patients with HCC received operative or percutaneous cryosurgery, in whom,660 received TACE before cryosurgery. In this report, 420 patients, who were treated with percutaneous cryosurgery with or without TACE only before 2004, were evaluated.

Patients and Methods

Patients

All 420 patients should be older age 20 years with median of 43 years. There were 310 male and 110 female. The diagnosis of HCC was confirmed by preoperative abdominal computed tomography (CT), liver ultrasonography, and /or whole positron emission tomography (PET).295 cases had an increased serum alpha-fetoprotein(AFP). HCC was proved by biopsy in 286 cases. The tumors of all cases were considered to be unresectable or surgical resection was not thought to be feasible because of tumor location or size,or patient comorbidity. Patients who had Child-Pugh class C with cirrhotic ascites were excluded from this study.

According to therapy modality,420 cased divided into two groups: combination of TACE-cryosurgery group (290 cases) and cryosurgery alone (cryo-alone) group(130 cases).

Table 1 Comparison of features in patients undergoing TACE-cryosurgery vs cryo- alone

Most patients () had three or fewer hepatic turnors, and no patient had more than 5. The median diameter of the cryoablated tumos was 5.5 cm with a range of 2.5 to 15 cm. The majority of patients (74%) had lesions smaller than 5 era. Table I compares the
characteristics of the two patient populations. The combination group tended to have larger tumors and had a greater number of tumors than the cryosurgery alone group(p<0.05).

Technique

TACE was performed in the interventional radiology suite after cross-sectional images were reviewed[9]. A 6 French vascular sheath was placed into the femoral artery, and a 0.035 inch diameter Mickaelson catheter was advanced into the celiac and superior mesenteric arteries. Contrast was injected into the arteries during rapid-sequence radiographic imaging. Arterial branches supplying the
tumor were noted. The venous phase was carefully examined for patency of the portal veins. The vessels were analyzed for the presence of anatomic variation. A 0.018 inch diameter Tracker catheter was advanced through the Mickaelson catheter to the arterial
branches that supply the tumor. Doxorubicin, 50 mg, and Mitomycin, 10 mg, were mixed with Lipiodol (4-15 ml), and the mixture was injected into the arterial branches until hemostasis was achieved. If the tumor had no shrinking, TACE was performed in two stages, 2 weeks apart.

Two to four months after TACE,percutaneous cryosurgery was performed under guidance of ultrasound or CT[10,11].Right lateral intercostals access was often used for probe placement. Selection of cryoprobe was depend upon the tumor size and number. Small lesions were ablated with one or two 2-mm probes. For larger lesions, larger caliber of probes (5-mm or 8-mm) were used. The probes were placed in the centre of the tumor by a modified Seldinger technique under real-time ultrasound guidance. When multiple probes were used the probes were situated in the tumor periphery 1.5–2 cm apart. Once the probe was positioned, freezing was initiated by argon/helium-based cryosurgery system (EndoCare, Inc., Irvine, Calif. USA).Two freeze cycles of 20 minute duration were applied interrupted by 10–15 minutes of helium thaw. Fast freezing, holding the end temperature for some time, and slow thaw performed twice at same location are recommended. The an ice-ball was generated under continual sonographic monitoring until at least I cm beyond the margins of the tumor. Once the probe was removed, the tract was filled with Gelform strips soaked in thrombin.

Follow-up
Postprocedual follow-up consisted of ultrasonography and /or helical CT of the liver, and serial AFP levels every 2-3 months for 1-2 years. A few patients were received positron emission tomography-CT (PET-CT) follow-up.Subsequently, the patients were reassessed every 6 months. Success of tumor ablation (disease-free) is ideally defined by disappearance or no expansion of the lesion ablated on CT follow-up or no metabolic activity on PET-CT. Tumor recurrence or persistence was also defined by using CT. Histology was to be verified eradication or recurrences in a few cases.

Statistical analysis
Actuarial survival was measured from the time of cryosurgery until the time of death or last follow-up. The Kaplan-Meier method was used to calculate survival rate. Values are expressed as mean- standard deviation. Variables were compared using Fisher's exact test (two-sided) or the rank-sum test when appropriate. A P value <0.05 was considered significant. SPSS 9.0 (SPSS, Chicago, Illinois) was used for data analysis.

Results

During a mean follow-up of 36±17 months(range 24 to 60 months),
129 patients (30.7%) showed no evidence of disease,98 patients (23.3%) are alive with recurrent disease,170 patients (40.5%) have died of disease recurrence or spread, and 23 patients (5.5%) have died other diseases ( infection of respiratory system in 5 cases, heart disease in 12 cases, renal failure in 3 cases, and unknown etiology in 3 cases).The overall 1-,2-,3-,4-,and 5-year survival rates are 72%,57.5%,47%,39% and 31%.Comparing the survival rates between TACE-cryosurgery combination and cryo-alone groups,
the statistically significant difference was seen for 4 and 5 years after treatment.(Table 2,Figure 1).

Table 2. Survival and disease status of TACE-cryoablation combination vs.cryo-alone groups

 
Figure 1 Survival rates of patients with HCC

Disease-free survival at 12 months was 31% for combination therapy and 25% for cryo-alone group (p=0.06), while 60-month disease-specific survival was 26% and 12%, respectively (p=0.002).There 18 patients with large HCC ,who underwent combination treatment, have disease-free survival for more than 5 years, and CT picture of the cases are illustrated in figure 2-5.

A	B
C	D

Figure 2 Male,43 years old. Right liver lobe had tumor
mass of 14X9 cm in size and was proved HCC. Figure A-D
sequentially showed the change of mass on CT and lastly
the mass disappearance.Patient has disease-free survival for 64 months.

Figure 3 Male,65 years old. HCC was diagnosed and was
proved by histology.(A)Three months after combination therapy.
(B)Twenty –eight months after combination.The cryoablated mass had cavitiation. No cancer cells were discovered by needle aspiration.

A	B	C

Figure 4 Male,51 years old,had HCC proved by biopsy,underwent combination therapy. Figure A-C showed the evolvement of cryoablated lesion after treatment.

Figure 5 Famale,63 years old,with biopsy-proved HCC.(A)CT showed the lesion in right lobe of the liver.(B)CT on three months after TACE-cryoablation.(C)CT four years after the therapy showed the liquefaction of the lesion and no cancer was discovered by needle aspiration.(D)PET-CT five years after the therapy showed no metabolic activity in the treated lesion.

The local recurrence rate at the ablation area was 17% for all patients, and 11% and 23 % for combination therapy and cryo-alone group,respectively (p=0.04).

Complication

liver rupture,liver failure. thrombocytopenia and clotting dysfunction, acute renal failure with myoglobinuria, pneumonia, as shown in Table 3. The overall complication rate was 24%, and there were 21% and 26.2 % of complication rate ,respectively, for combination and cryo-alone groups(p= 0.06).The latter group had more hepatic bleeding (p=0.02), and liver rupture, while the more liver failure occurred in combination therapy group. Peri-cryosurgery death was only seen 2 patients of cryo-alone group, who died of liver crack and massive hepatic bleeding, respectively.

Table 3 Complication for TACE-cryosurgery combination vs. cryo-alone

Discussion

Cryosurgical ablation, a technique for the in situ ablation of hepatic malignant tissue, has gained acceptance worldwide[12] [1,2].Hepatic cryoablation has been compared to resection in one prospective randomized trial[13,14]. A higher survival rate was seen in the patients treated with cryosurgery than those treated with standard resection (44% vs. 36% at 5 years and 19% vs.8% at 10 years).
However, most reports of hepatic cryosurgery describe its use in the treatment of colorectal liver metastases, and few reports for HCC. This is due to the fact that HCC is a less common disease in the Western country in contrast to the situation in East Asia. It is only a report of the large series that was provided by Zhou et al[15] from China, who successful used cryosurgery in treating 235 patients with HCC with the 1-, 3- and 5-year survival rates of 78%, 54% and 40%, respectively.

In 2005，we have reported the results of percutaneous cryosurgery with or without alcohol injection for 65 patients with unresectable HCC[16]. During follow-up duration of mean 14 months 50.8% were free of tumors, 33.8% alive with tumor recurrence, and 1-year survival rate was 78%.In the present study the overall 1-,2-,3-,4- and 5-year survival rates were 72 %,57%, 47%,39% and 31%, respectively. There were 30.7% and 23.3% of patients, respectively, are alive with and without evidence of disease. Although our survival data are no excelled to that above author’s reports, it would be likely to be remarkable if considering the following factors:(a) our cryosurgery procedure was performed percutaneous, and is a much less invasive for patients as in comparison with surgical cryoablation, (b) the tumor of our patients had more advanced nature and there were as large tumor as more than 10 cm in diameter.

There is reason to believe that the relatively good result is related with the following advantages of TACE for cryosurgery: a possible increase in the rate of tumor ablation as well as reduction in postoperative bleeding.

Clavien et al[17] reported 15 patients with HCC, whose tumor was considered to be unresectable or surgical resection was not thought to be feasible because of tumor location or size, or patient’s comobidity. All but one patient underwent cryosurgery in combination with TACE. The actuarial 5- year survival rate was as high as 79%, which, obviously, is much better compared with previous reports in term of survival of the patients.

In present series, 1-,2-,3,4-,and 5-year survival rates were 71%,61%,52%,49%,and 39%,respectively, in 290 patients who underwent combination of TACE cryosurgery, and 73%, 54%, 42%, 39%, and 23%,respectively,in 130 patients who underwent cryo-alone. The 4- and 5-year survival rates in the combination group were higher than those in cryo-alone group (p=0.04 ),although there were no statistically significant difference of 1-,2-,and 3-year survival rates between both groups. The fact suggests that the addition of TACE results in better long-term outcome.

Cryo-induced tumor cell destruction is influenced by several factors, temperature is critical. Temperatures lower than -40 C are assumed necessary to ensure tumor ablation. Ice-balls larger than the target lesions are thus necessary for complete tumor ablation, because the outer few millimeters of the iceball circumference are at nonlethal temperatures[18-20]. The 1-cm ice-ball extension beyond the tumor borders should be often used as adequate for ablation. According to MRI-estimated three-dimensional temperature distribution in liver cryolesion provided by mala et al [19],the mean value of the distances calculated between the -40 C isotherm and the cryolesion edge is median 4.1 mm and the largest of these distances defined for each cryo-lesion is median 8.1mm. The largest distance defined between the tumoricidal part of the cryolesion and the cryolesion edge may be close to 1-cm for less than 25 cm3 of cryolesion volume, while for lesion larger than 25cm3 the 1-cm rim zone is not likely to ensure temperatures adequate for ablation in the entire volume enclosed by the rim zone. It is shown that tumor size influence the rate of tumor ablation. Lesions larger than 3 cm are more likely associated with a higher recurrence rate than smaller tumors[21].

Therefore,the smaller the tumor, the more effective the cryoablation, and the lower the recurrence rate. TACE is proved to shrink masses of HCC. Obviously, pre-TACE may be expected to increase the efficacy of the cryoablation for HCC. This is of special significance for the large tumor in sight of the main vessels, because that edge zone of the cryolesion would barely be sufficient to ensure the temperature of less than -40C due to blood warming effect[22].

Experimental study showed that selective occlusion of vascular inflow, i.e., ischemia, increases the volume of tissue destruction[23,24]. In clinical practice, additional Pringle maneuver (vascular occlusion) was introduced with the idea of increasing the volume and effectiveness of the cryosurgical procedure.

The major complications of cryosurgery are hemorrhage and liver crack[25,26]. In present series post-cryosurgery hepatic bleeding was seen in 16 cases, in whom 11 cases (8.5%) received cryo-alone and 5 cases (1.7%) received combination therapy group. The most dangerous liver crack was only seen in 2 cases who received cryo-alone. Among 15 patients with HCC receiving cryosurgery reported by Clavian et al, there was only one patient complicated bleeding who just did not undergo pre-cryosurgery TACE. Therefore, it is likely that TACE may reduce the risk of hemorrhage after cryosurgery.Therefore, one advantage of TACE before cryosurgery is possible reduction in post-cryosurgery complication such bleeding and liver crack.

It is anxious for the risk of adverse effects after TACE. Clavien et al[17] reported one patient with Child-Pugh class B cirrhosis who developed liver and renal failure third week after TACE. Present series did not show the risk of liver failure brought about by TACE. Other adverse effects, such as thrombocytopenia and / or clotting dysfunction, acute renal failure with myoglobinuria, were seen in both groups patients without deflection to either therapy. It is specially guarded that there were four patients who developed agranulocytosis which was only seen in combination group and,apparently,was related to higher dose of chemotherapeutic agents in TACE. This complication occurred mostly in the initial stage of our study, and subsequently, was infrequent since we paid a great attention for the buildup of agents infused which were consisted of primary embolization materials and few of chemical drugs.

Above facts suggest TACE before cryosurgery may increase cryoablation efficacy and decrease the adverse effects, especially bleeding complication, and accordingly, raise the survival rate of patients with HCC receiving cryosurgery.

A recent question is whether percutaneous cryosurgery could replace open cryosurgery for treatment of HCC[27]. We have treated selected patients with unresectable HCC using open cryosurgery, which will be analysed in the future. A prospective randomized study between both modes of cryosurgery will ultimately be necessary to determine the value of each mode in treatment of HCC. Nevertheless, for patients with HCC who often have liver cirrhosis and compromised hepatic reserve, percutaneous cryosurgery as a mini-invasive modality should be more proper than open cryosurgery with more invasion. Moreover,
along with developed imaging techniques which are used guidance of cryosurgery and accumulation of clinical experience,the percutaneous mode will be practical for achieving effective ablation for tumor.

TACE before operative resection has been proved to be a good strategy for large HCC. The combination of TACE and percutaneous cryosurgery, therefore, might be applied to treatment of unresectable HCC.

In conclusion,a combined approach involving TACE and perctaneous cryosurgery improves survival. TACE is useful to control tumours burden. Sequential use of TACE and cryosurgery seems to be the best way to improve outcome in unresectable HCC.

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