This article evaluates the role of radiofrequency ablation (RFA) in the management of hepatocellular carcinoma (HCC) in patients with hepatitis B-associated cirrhosis. RFA has emerged as a favored therapeutic approach due to its low recurrence rates and applicability in patients unfit for surgical resection. The case report details a patient with a 30 mm lesion, which was effectively treated with RFA under ultrasound guidance, resulting in a significant reduction in size and absence of complications at six-month follow-up. The findings highlight the importance of individualized treatment approaches, interdisciplinary collaboration, and the use of advanced imaging techniques in monitoring therapeutic outcomes

Kondakova, Miryana

Leonidova, Mariya

Yosifova, Natalia

English

Varna Medical University Press: Journals

98Proceedings - Symposium “Alumni Club and Friends” - April, 5-6, 2024CT ASSESSMENT OF DIAGNOSTIC FINDINGS IN PATIENTS WITH HEPATOCELLULAR CARCINOMA (HCC)Natalia Yosifova1, Mariya Leonidova2,3, Miryana Kondakova2,31Student, Faculty of Medicine, Medical University of Varna, Bulgaria2Department of Imaging Diagnostics, Interventional Radiology, Faculty of Medicine, Medical University of Varna, Bulgaria3Department of Diagnostic Imaging, St, Marina University Hospital,  Medical University of Varna, BulgariaABSTRACTThis article evaluates the role of radiofrequency ablation (RFA) in the management of hepatocellular carcinoma (HCC) in patients with hepatitis B-associated cirrhosis. RFA has emerged as a favored therapeutic approach due to its low recurrence rates and applicability in patients unfit for surgical resection. The case report details a patient with a 30 mm lesion, which was effectively treated with RFA under ultrasound guidance, resulting in a significant reduction in size and absence of complications at six-month follow-up. The findings highlight the importance of individualized treatment approaches, interdisciplinary collaboration, and the use of advanced imaging techniques in monitoring therapeutic outcomes. Keywords: radiofrequency ablation (RFA), hepatocellular carcinoma (HCC), imaging diagnostics, thermal ablationINTRODUCTIONOver time, thermal ablation has gained a reputa-tion as a reliable therapeutic method for treating pri-mary or metastatic liver lesions, with a very low rate of local recurrence (1,2,3,6,7). Radiofrequency abla-tion (RFA) and microwave ablation are the most com-monly used modalities, with postprocedural clinical verification of the results. The main advantage of the RFA technique is its applicability in treating unre-sectable tumor formations or in patients with comor-bidities (1,2,4). Preprocedural imaging diagnostics allow for precise planning of the volume and exact localization of the lesion (1,9). The desired thermal denaturation of proteins results in coagulative necro-sis of the ablation zone, leading to tissue destruction. The primary goal is to achieve smooth, clear borders, comparable to the lesion’s resection state, while min-imizing the involvement of surrounding tissue.According to the Barcelona Clinic Liver Can-cer (BCLC) staging system, RFA is the method of choice for patients with comorbidities in stages 0 and A (6,8). Furthermore, thermal ablation can also be combined with chemotherapy for lesions larger than 3 cm (1,2,4,6,7,10). Technological advancements and recent research have led to an expansion of the crite-ria for ablation in recent years. Today, the RFA meth-od often surpasses BCLC guidelines and other crite-ria when making final decisions in interdisciplinary teams (2,5). An individualized approach to patient pathology helps overcome “relative” and “absolute” contraindications, improving survival rates, partic-ularly when palliative techniques are applied prior to the RFA procedure.PRESENTATION OF THE CASE REPORT:We present a patient with known hepatitis B-asso-ciated cirrhosis and hepatocellular carcinoma (HCC), diagnosed by CT. The first diagnostic CT images show post-contrast enhancement of a well-demarcat-ed lesion in the left lobe, measuring 30 mm in the ar-terial phase (Fig. 1 and 2). The lesion appears with heterogeneous contrast enhancement and is rough-ly round in shape. In the portal and late phases, the same lesion is highly hypodense. This type of lesion is entirely compatible with atypical HCC. The carci-noma has been morphologically verified as a moder-ately differentiated subtype. Thermal radiofrequen-cy ablation (RFA) under ultrasound (US) guidance was performed up to maximum impedance, without postprocedural complications. For this lesion, locat-ed in the left lobe of the liver, the subcostal approach was the most appropriate. A monopolar bipolar nee-99Natalia Yosifova, Mariya Leonidova, Miryana Kondakovato six months of monitoring (6,8). The liver’s macro-nodular cirrhotic structure remained persistent. Fur-ther patient monitoring at 3-month intervals showed satisfactory postprocedural results without signifi-cant changes in dynamics.There is no universal ablation technique avail-able; the individualized approach and method of choice are crucial and take advantage of the patient’s treatment (3,8). In our case, we chose radiofrequency ablation (RFA) to achieve devitalization and clearer borders of the lesion. Existing criteria for locoregion-al response allow us to make an adequate assessment of the condition. There are a few standardized scales for locoregional therapy monitoring: RECIST, mRE-CIST, and EASL. In our patient’s case, it is important to note the following:• Partial response to the procedure (on RECIST – reduction in lesion size);dle was inserted into the central zone of the tumor, after a subcutaneous lidocaine injection. The needle tip was placed in the center of the neoplasm under US guidance, and the electrode’s repositioning was minimized to prevent tumor dissemination. During the ablative procedure, we assessed efficacy through the size of the area’s echogenicity. The patient under-went postprocedural follow-up and results assess-ment. Subsequent CT images showed a reduction in the size of the lesion, down to 23 mm. No post-con-trast enhancement was observed in all three phases compared to the native density of the lesion (Fig. 3 and 4). The postablative response criteria were suc-cessfully met, with a reduction in lesion size and no evidence of periablative inflammatory reaction up Fig. 1. Arterial phase (pre-procedure) – the finding in the left lobe (30 mm) of the liver is presented with post-contrast enhancement compared to the native scanning.Fig. 2. Native CT (pre-procedure) – the finding in the left lobe (30 mm) of the liver is presented with an average measured density of up to 40 Hounsfield units (HU).Fig. 3. After thermal ablation (post-procedure) – the finding in the left lobe is presented with reduced size down to 23 mm and an average native density of up to 39 HU.Fig. 4. After thermal ablation (post-procedure) – in all three phases after the administration of contrast material, no post-contrast enhancement is observed following the procedure.CT Assessment of Diagnostic Findings in Patients with Hepatocellular Carcinoma (HCC)100• Full response after thermal ablation (on mRE-CIST – the tumors do not show post-contrast enhancement);• Full response on EASL (there is no enhance-ment compared to the native density).DISCUSSIONThe presented case report highlights the impor-tance of conducting the radiofrequency ablation (RFA) procedure in patients with hepatocellular car-cinoma (HCC) for achieving neoplastic lesion size re-duction. The right choice of preprocedural imaging methods and interventional procedures gives us the opportunity to accurately assess the postprocedural results and provide appropriate images for compari-son—ensuring perfect correlation for patient condi-tion monitoring. Indeed, the presence of these imag-es can categorically confirm the success of the proce-dure (9). The absence of any vascular, biliary, infec-tious, or gastrointestinal complications is the greatest evidence of the procedure’s safety and the operator’s experience (3,4,8).There are several advantages to performing RFA under ultrasound (US) guidance: real-time imaging, lower costs compared to other available alternatives, and no radiation exposure for the patient or the op-erator. US diagnostics also allows for the use of color Doppler imaging, enabling us to evaluate the blood supply to the tumor as well as the dimensional re-lationships with nearby anatomical structures (liver capsule, hilum, blood vessels, biliary tree, etc.). The radiologist faces the challenges of postprocedural im-aging diagnostics in terms of finding the best modal-ity to accurately follow up on locoregional response. A good understanding of postprocedural complica-tions allows the selection of the right method with high predictive value and significance (1,2,4).It is worth noting the increasing number of pa-tients undergoing the RFA procedure; what were once considered “forbidden zones” or “nonstandard indications” are now relative contraindications. The expansion of ablative criteria provides great oppor-tunities for treating existing lesions (1). Another im-portant milestone is the screening recommendations for monitoring patients with cirrhosis or chronic hepatitis B infection. Despite the well-known pathol-ogy in these cases, these patients continue to pres-ent with advanced comorbid conditions that are in-appropriate for resection, transplantation, or RFA (4).Optimization and personalization of therapeutic perspectives concerning size, localization, anatom-ical relationships, histopathological variants of the carcinoma, and the presence of comorbidities are of key significance for extending patients’ survival and improving their quality of life. Interdisciplinary col-laboration and preprocedural imaging diagnostics are highly important, especially since patients are conventionally treated in other departments. Accu-rate image evaluation should involve noting every new radiological finding and its correlation with the combined therapy (if applicable). Patient monitoring every three months is crucial for adequate control of the current condition.The method of choice for monitoring in our case is CT. CT with intravenous contrast media applica-tion is an excellent modality due to the unaffected kidney function. The devitalized lesion should be presented with native density in Hounsfield units af-ter contrast media application—without enhance-ment. We do not expect significant changes in the dynamics of the macronodular liver structure. Fur-thermore, any of the following CT diagnostics could serve not only to check the existing condition but also as diagnostic imaging, since we cannot exclude any possible changes during chemotherapy. If there are any contraindications for surveillance with CT, alternatives such as US or MRI are available.Address for correspondence:Natalia Yosifova,Student - DemonstratorDepartment of Diagnostic Imaging, Interventional RadiologySt. Marina University Hospital,  Medical University of Varna, Bulgfaria1 Hristo Smirnenski BlvdVarna 9010e-mail: nataliyayosifova7@gmail.com101Natalia Yosifova, Mariya Leonidova, Miryana KondakovaREFERENCES1.  Zhou Y, Yang Y, Zhou B, Wang Z, Zhu R, Chen X, Ouyang J, Li Q, Zhou J. Challenges facing percutaneous ablation in the treatment of hepatocellular carcinoma: extension of ablation criteria. J Hepatocell Carcinoma. 2021;8:625-44. doi: 10.2147/JHC.S298709.2.  Hui TC, Kwan J, Pua U. Advanced techniques in the percutaneous ablation of liver tumours. Diagnostics (Basel). 2021 Mar 24;11(4):585. doi: 10.3390/diagnostics11040585.3.  De Muzio F, Cutolo C, Dell’Aversana F, Grassi F, Ravo L, Ferrante M, Danti G, Flammia F, Simonetti I, Palumbo P, Bruno F, Pierpaoli L, Fusco R, Giovagnoni A, Miele V, Barile A, Granata V. Complications after thermal ablation of hepatocellular carcinoma and liver metastases: imaging findings. Diagnostics (Basel). 2022 May 5;12(5):1151. doi: 10.3390/diagnostics12051151.4.  Covey AM, Hussain S. Liver-directed therapy for hepatocellular carcinoma: an overview of techniques, outcomes, and post-treatment imaging findings. AJR Am J Roentgenol. 2017;209(1):67-76. doi: 10.2214/AJR.17.17799.5.  Seror O. Ablative therapies: advantages and disadvantages of radiofrequency, cryotherapy, microwave, and electroporation methods, or how to choose the right method for an individual patient. Diagn Interv Imaging. 2015;96(6):617-24. doi: 10.1016/j.diii.2015.04.007.6.  Di Muzio B, Chieng R, Knipe H, et al. Percutaneous liver tumor ablation. Radiopaedia.org. Available from: https://doi.org/10.53347/rID-76211.7.  Ndhlovu E, Zhang B-X, Chen X-P, Zhu P. Thermal ablation for hepatic tumors in high-risk locations. Clin Res Hepatol Gastroenterol. 2024;48(3):102300. doi: 10.1016/j.clinre.2024.102300.8.  Kinoshita A, Onoda H, Fushiya N, Koike K, Nishino H, Tajiri H. Staging systems for hepatocellular carcinoma: current status and future perspectives. World J Hepatol. 2015 Mar 27;7(3):406-24. doi: 10.4254/wjh.v7.i3.406.9.  Laimer G, Schullian P, Bale R. Stereotactic thermal ablation of liver tumors: 3D planning, multiple needle approach, and intraprocedural image fusion are the key to success—a narrative review. Biology (Basel). 2021 Jul 10;10(7):644. doi: 10.3390/biology10070644.10. Dyankova M. Possible diagnostic pitfalls in 68Ga-PSMA PET/CT interpretation. Varna Med Forum. 2021;10(1):42-49. Proceedings from IX Scientific Session of Medical College of Varna, Suppl. 1.

CT Assessment of Diagnostic Findings in Patients with Hepatocellular Carcinoma (HCC)

https://journals.mu-varna.bg/index.php/conf/article/download/9919/8710

CT Assessment of Diagnostic Findings in Patients with Hepatocellular Carcinoma (HCC)

Abstract

Similar works

Full text

Available Versions

Varna Medical University Press: Journals