|Year : 2019 | Volume
| Issue : 3 | Page : 261-267
Microwave ablation versus hepatic resection in management of hepatocellular carcinoma
Mohammed Hussien1, Sahar Hassany2, Mohamed El Kassas3, Ahmed M Ali4, Ehab F. A. Moustafa2, Osman A. H. Osman2
1 Department of Hepatology, Gastroenterology and Infectious Disease, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
2 Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
3 Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo, Egypt
4 Department of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
|Date of Submission||14-Mar-2018|
|Date of Acceptance||27-Apr-2018|
|Date of Web Publication||23-Sep-2019|
Department of Hepatology, Gastroenterology and Infectious Disease, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Postal Code: 33511
Source of Support: None, Conflict of Interest: None
Management of early hepatocellular carcinoma (HCC) in cirrhotic patients is still a challenge. Hepatic resection remains the best curative treatment, but more complications with a risk of HCC recurrence in cirrhotic patients make it less favorable. Few studies have recently started to evaluate microwave ablation (MWA) as a method of HCC eradication in cirrhotic patient and compare it by other ablative methods. The aim of this study was to evaluate patient with HCC before and after both MWA and hepatic resection.
Patients and methods
A prospective study was performed in Assiut University Hospital in collaboration with National Hepatology and Tropical Medicine Research Institute in Cairo. We recruited 40 patients; all of them had radiology-proved HCC with lesion up to 5 cm and amenable for MWA or surgical resection.
There is a statistically significant difference between Child score after hepatic resection in comparison with the mean Child score for patients who underwent MWA (before ablation was 6.1 ± 0.7 and after ablation was 6.1 ± 1.0, but was 5.5 ± 0.6 and was 7.2 ± 1.4 after hepatic resection). There is marked decrease of α-fetoprotein after hepatic resection (as the mean level before resection was 172.73 and after liver resection was 10.95). Fewer complications were recorded after MWA in comparison with that after hepatic resection.
Hepatic resection is superior to MWA in HCC eradication as no residual activity. MWA is better than hepatic resection in maintaining the Child score, as it was more affected in patients who underwent hepatic resection than those who underwent MWA.
Keywords: child Score post microwave ablation and hepatic resection, Hepatic resection, management of early HCC, Microwave Ablation
|How to cite this article:|
Hussien M, Hassany S, El Kassas M, Ali AM, Moustafa EF, Osman OA. Microwave ablation versus hepatic resection in management of hepatocellular carcinoma. J Curr Med Res Pract 2019;4:261-7
|How to cite this URL:|
Hussien M, Hassany S, El Kassas M, Ali AM, Moustafa EF, Osman OA. Microwave ablation versus hepatic resection in management of hepatocellular carcinoma. J Curr Med Res Pract [serial online] 2019 [cited 2020 Mar 28];4:261-7. Available from: http://www.jcmrp.eg.net/text.asp?2019/4/3/261/267675
| Introduction|| |
Hepatocellular carcinoma (HCC) is the most common primary neoplasm of the liver with a significant cause of morbidity and mortality and carries an unfavorable prognosis with aggressive behavior and a high recurrence rate . It is the third leading cause of cancer deaths worldwide, with more than 500 000 people affected. The incidence of HCC is highest in Asia and Africa, where the endemic high prevalence of hepatitis B and hepatitis C strongly predisposes to the development of chronic liver disease and subsequent development of HCC . Egypt is confronted with a huge number of hepatitis C virus (HCV) infections, which distinguishes it from the rest of North Africa. It has the highest prevalence of HCV in the world, and up to 90% of HCC cases in the Egyptian population were owing to HCV. So, HCC represents an important public health problem in Egypt and is the third among male cancers . The mainstay of screening and diagnosis of HCC is liver imaging, which classify into the following: routine noninvasive studies such as ultrasound (US), computed tomography (CT), and MRI, and more specialized invasive techniques including CT during hepatic arteriography and CT arterial portography . Hepatic resection is the treatment of choice for early HCC in noncirrhotic patients and offers the best curative rate with a 5-year survival of 41–74%. The resectability of the tumor is dependent on the tumor size, location, underlying liver function, and whether or not the remaining liver volume will allow for resection without increasing post resection morbidity and mortality. However, unfortunately this option is feasible in only 5% of the cases in western countries . Microwaves offer several advantages over other ablation therapy, including faster heating over a larger volume, less susceptibility to 'heat sinks' or local perfusion compared with Radiofrequency (RF), and the ability to create much larger ablation zones. Few studies have recently started to evaluate microwave ablation (MWA) as a method of HCC eradication in cirrhotic patient and compare it with other ablative methods ,,,,. The aim of this study was to evaluate patient with HCC before and after both MWA and hepatic resection in short-term evaluation. This study is considered as the first study in Egypt to evaluate MWA versus hepatic resection in management of HCC by assessment of the patients before intervention and after intervention in short-term follow-up.
| Patients and Methods|| |
This is a prospective study performed between December 2014 and August 2016 in Assuit University Hospital for the patients candidate for hepatic resection and National Institute of Tropical Medicine and Hepatology in Cairo for the patients candidate for MWA.
A total of 46 patients with liver cirrhosis and HCC who fulfilled the inclusion criteria were enrolled in the study and MWA was done for 20 cases and hepatic resection for 20 patients (according to the multidisciplinary team decision). Of the 46 patients, follow-up was done for 40 cases only because four cases were missed on follow-up and two cases refused to continue in the study. So 40 (nine females and 31 males) cases were enrolled and followed up and statistical analysis was done for them. A total of 32 cases were diagnosed by typical arterial enhancement of the tumor followed by a washout pattern in the images in the portal venous phase or the equilibrium phase on dynamic spiral CT imaging and only eight needed further confirmation by dynamic MRI with diffusion.
The patient selection for microwave or hepatic resection was carried out by a multidisciplinary team which consists of hepatologists, interventional radiologists, transplant surgeons, oncologists and residents.
Inclusion criteria of the patients were radiology-proved cases of HCC, and the patients with lesion up to 5 cm and amenable for MWA or surgical resection, with the Child score A and early B (score not > 7).
Exclusion criteria of the patients were advanced HCC or with focal lesion not amenable for resection or MWA, patients who refused follow-up and evaluation, failure to obtain consent, pregnant patients to avoid potential risks to the patient and/or fetus, and patients with implanted electronic devices such as implantable pacemakers that may be adversely affected by microwave power output.
All included patients were subjected to full history taking and full clinical examination, including complete blood count, liver function tests, urea and creatinine, international normalization ratio (INR), prothrombin time and concentration, hepatitis B surface antigen, HCV antibody, serum α-fetoprotein (AFP), abdominal ultrasonography, abdominal CT, and dynamic MRI with diffusion when needed.
Microwave ablation technique
Patients were treated under sedation with intravenous administration of fentanyl and propofol, in spontaneous breathing with oxygen mask support.
The technique uses microwave energy that induces an ultra-high speed, 915 or 2.450 MHz (2.45 GHz), alternating electric field, which causes water molecule rotation and the creation of heat. This results in thermal coagulation and localized tissue necrosis. In MWA, we use a single microwave antenna connected to a generator inserted directly into the tumor or tissue to be ablated; energy from the antenna generates friction and heat.
The size and the shape of the hyperechoic zone caused by gas microbubbles appearing in the ablated zone during MWA procedure were monitored by US to assess the completeness of therapy.
Treatment was stopped when the entire target was completely hyperechoic and the determined time and power according to the size of the lesion reached.
Hepatic resection was done on the basis of the segmental anatomy of the liver, which can be delineated using intraoperative ultrasound during operation. The delineation of a proper transaction plane is important not only for adequate tumor-free margin in resection of liver tumors but also to avoid inadvertent injuries to major intrahepatic vessels or bile duct pedicles.
Follow-up after the intervention
Evaluation criteria in hepatocellular carcinoma 4 weeks after the initiation of therapy
Reassessment of the patient includes complete clinical examination, including complete blood count, liver function tests, urea and creatinine, INR and serum AFP level. Abdominal ultrasound and triphasic CT examination of the abdomen were done to evaluate WHO performance status, Child score, and BCLC classification.
Ethics and consents
The survey was approved by the faculty's ethics committee and permission was obtained from all departments who assured that confidentiality would be maintained and ethical principles would be followed. Before initiation of the study, a background about the study and its reason was explained to the patients, the targeted population was encouraged to participate without any undue pressure, and written informed consent was obtained.
Statistical package for the social sciences (SPSS) software (SPSS Inc., Chicago, Illinois, USA) version 16 for Windows 7 (Microsoft Corp., Redmond, Washington, USA) was used for analysis.
Wilcoxon's test and paired Student's t-test were used to compare paired data, whereas χ2-test, Fisher's exact test and Mann–Whitney U-test were used to compare unpaired data.
| Results|| |
During the period of the study, a total of 40 patients previously diagnosed as having HCC by characteristic radiologic findings, such as typical arterial enhancement of the tumor followed by a washout pattern in the images in the portal venous phase or the equilibrium phase on dynamic spiral CT imaging or contrast-enhanced MRI were enrolled in the study. So 40 (nine females and 31 males) cases were enrolled and followed up and statistical analysis was done for them. The mean age was 58.1 ± 7.7 years for patients who underwent MWA and 57.8 ± 4.3 years for patient who underwent hepatic resection [Table 1]). The descriptions data of the patients according to their age, sex and type of hepatitis infection are shown in [Table 1].
Patients underwent MWA had a mean Child score of 6.1 ± 0.7 and after ablation 6.1 ± 1.0, but was 5.5 ± 0.6 before hepatic resection and 7.2 ± 1.4 after resection [Table 2].
|Table 2: Child scoring before and after both microwave ablation and hepatic resection|
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[Table 3] shows the mean HCC size in patients who underwent MWA was 3.15 ± 1.15 and was 3.82 ± 0.84 cm in patients who underwent hepatic resection. Overall, 75% of patients underwent MWA were in right lobe and 80% for those underwent hepatic resection.
There is a high statistically significant difference in hemoglobin level in patients who underwent hepatic resection at P value 0.000 but not in patients who underwent MWA, as shown in [Table 4]. Serum albumin was 3.34 ± 0.63 g/dl after MWA and 2.83 ± 0.75 g/dl after hepatic resection [Figure 1]. INR was 1.25 ± 0.23 after MWA and was 1.22 ± 0.19 after hepatic resection. Changes in prothrombin concentration after both microwave and hepatic resection in comparison with preintervention level are shown in [Figure 2]. The AFP level after MWA was 130 ± 268.84 and was 10 ± 6.73 after hepatic resection, as shown in [Figure 3].
|Table 4: Comparison between blood picture values in the studied patients underwent both microwave and hepatic resection|
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|Figure 1: Variation in level of albumin after both microwave and hepatic resection in comparison to preintervention level.|
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|Figure 2: Changes in prothrombin concentration after both microwave and hepatic resection in comparison to preintervention level.|
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|Figure 3: Changes in the level of a-fetoprotein before and after intervention.|
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There is a statistically significant difference in total protein before and after hepatic resection, with P value 0.030, and also in serum albumin, with P value 0.025 and direct bilirubin, with P value 0.014 but not in MWA [Table 5]. The difference in albumin level preintervention and postintervention is shown in [Figure 1].
|Table 5: Comparison between liver function values in the studied patient underwent both microwave and hepatic resection|
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Complications that occurred after 4 weeks of follow-up after MWA and hepatic resection are categorized as occurrence of recurrence in one case of 40 cases (in the patients who underwent hepatic resection), residual activity in two cases of the 40 cases (only in patients who underwent MWA), appearance of new lesion in six cases of the 40 cases (five cases in patients who underwent MWA and one case in patients who underwent hepatic resection), hepatic encephalopathy in two cases (in the patients who underwent hepatic resection), plural effusion in five cases (three cases in patients who underwent MWA and two cases in patients underwent hepatic resection), ascites in14 cases of the 40 cases (four cases in patients underwent MWA and 10 cases in patients who underwent hepatic resection), and skin laceration in one case (only in a patients who underwent MWA) [Figure 4].
| Discussion|| |
The choice of appropriate decision to treatment of early HCC in cirrhotic patients is still challenge. Hepatic resection remains the best curative treatment but, the pre-existing liver damage and possible tumor multifocality in addition to portal hypertension and reduced functional capacity of the cirrhotic liver significantly increase the perioperative risk and increase postoperative decompensation, with the risk of development of another HCC in the cirrhotic liver again. The MWA offers several advantages, including faster heating over a larger volume, less susceptibility to 'heat sinks' or local perfusion compared with RF, and permits the simultaneous treatment of multiple lesions with multiple electrodes that can produce larger ablation volumes .
Our study showed that the patients who underwent MWA had a mean Child score of before ablation 6.1 ± 0.7 and after ablation 6.1 ± 1.0, but was before hepatic resection 5.5 ± 0.6 and 7.2 ± 1.4 after resection. This is concordant with Kauffmann and his colleagues who also showed that postoperative liver cell failure remains the most dreadful complication,  and it is the major source of morbidity and mortality after hepatic resection and the precise evaluation of liver condition is one of the key point to select patients undergoing liver resection in the intent to reduce postoperative morbidity and mortality .
We noticed that 90% of the patients with HCC were males and only 10% were females and this is concordant with Yu et al.  who mentioned that HCC is more prevalent in men than in women, which may be at least in part explained by the differences in exposure to risk factors. However, sex hormones and other X-linked genetic factors may also be important. It has been speculated that estrogens and androgens could modulate hepatocarcinogenesis and explain the higher incidence of HCC in men . The prevalence of HCV in Egypt is much more increased . This study showed that most of HCC cases attributed to HCV, as 95% of HCC had HCV antibody and only 5% had hepatitis B surface antigen positive. Schütte and his group also showed that the rise in the incidence of HCC was directly related to the increase in the prevalence of HCV infection .
This study detected that there is decrease in the level of albumin in comparison with its preresection level and increase in the total leukocytic count in spite of this, there is no difference in serum albumin level or leukocytic count after MWA (as the serum albumin was 3.34 ± 0.63 g/dl after MWA and 2.83 ± 0.75 g/dl after hepatic resection, and the mean white blood count level was 5.16 ± 1.51 109/l after MWA and 12.71 ± 9.03 109/l after hepatic resection). Haridas et al. , Neumayer et al. , and Gibbs et al. showed that hypoalbuminemia is a well-known marker of liver cell failure, has been associated with higher incidences of sepsis and postoperative infection after hepatic resection.
In our study the mean prothrombin concentration was 74.79 ± 16.15% after MWA and was 63.7 ± 16.47% after hepatic resection and this was concordant with De Pietri et al.  and Bezeaud et al.  who noted that a postoperative derangement in conventional markers of coagulation such as INR, prothrombin time, prothrombin concentration and platelet count are common after liver resection, but our results are discordant regarding platelets level as there is no difference between the level before and after hepatic resection and also no difference between MWA or hepatic resection as P value is 0.157. This difference from other study may be owing to the extent of hepatic resection which may be affecting the thrombopoietin synthesis.
This study showed that there is high statistical significant difference between the level of AFP before and after hepatic resection (as the mean level before resection was 172.73 ng/dl and after liver resection is 10.95 ng/dl). Moreover, there is statistically significant difference in the AFP level between patients who underwent hepatic resection and those underwent MWA as P value is 0.035, although that there is no statistical difference in the levels before both interventions as P value is 0.602. Toro et al.  also mentioned that the AFP level is useful in the diagnosis of recurrence and predicting prognosis in patients with HCC who have undergone hepatic resection or other loco regional therapy as it markedly decreased after complete eradication of HCC.
In our study we noticed that the mean time needed for complete ablation to HCC less than 5 cm was 80.5 s and the mean power was 58 W. Poggi et al.  mentioned that MWA is a very fast procedure, but the time of energy application differed according to the diameter of the nodules. A mean time of ablation of only 63 s was sufficient to obtain an adequate ablation.
In our study, there was 10% recurrence rate after hepatic resection after 1 month. We suggested that early recurrence may be owing to micro metastases in the remaining liver parenchyma rather than inadequate surgical resection. Regimbeau et al. , Belghiti et al. , Fong et al., Farges et al., Poon et al. , Imamura et al.  confirmed that the rate of recurrence following resection of HCC is ~80% at 5 years.
We noticed that residual activity occurred only in patients who underwent MWA (in 10% of cases), Liang et al. mentioned that incomplete ablation after microwave occurred in 5.9% of cases.
Appearance of new lesion occurred in 25% of cases that underwent MWA in this study. Liang et al.  showed that new lesion occurred in the same segment but apart from the original sites in 9%. New lesion was found in different segments of the liver in 12%. Appearance of new lesion occur in 5% of cases who underwent hepatic resection. This difference between MWA and hepatic resection may be attributed to the superiority of hepatic resection in radical removal of the tumor which decreases the incidence of micro metastases.
Results from our study recorded fewer complications than that recorded by other studies, as we found that ascites occurred in 20%, plural effusion in 15%, and skin lacerations in 5% of patients underwent MWA. Liang et al.  noted that complications associated with MWA were generally related to the antenna application and include abscesses, bleeding, bile duct injury, burns, thoracic complications and bowel injury.
We noticed that patients who underwent hepatic resection had minor complications than that recoded by other studies. We categorized complications after hepatic resection as recurrence in 5% (but no residual activity had been detected at all), appearance of new lesion only in 5% of patients, hepatic encephalopathy in 10% of patients, pleural effusion in 10% patients, and ascites in 50% of patients. Jin et al.  mentioned that complications after of hepatic resection include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, sub phrenic infection, urinary tract infection, intraperitoneal hemorrhage, bile leakage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, and hepatic failure. Huang et al.  and Sato et al.  mentioned that the bleeding is the most feared technical complication and may be grounds for urgent reoperation, Liver failure poses a significant hazard to patients with underlying liver cirrhosis and complications after MWA are less common than those after hepatectomy. The amount of intraoperative blood loss was smaller and the length of hospital stay was shorter. This may demonstrate low invasiveness of MWA. We concluded that hepatic resection is superior to MWA in HCC eradication. Child score is more affected in patients who underwent hepatic resection than those underwent MWA. However, postprocedure complications more common in resection.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]