J Liver Cancer.  2024 Sep;24(2):131-144. 10.17998/jlc.2024.08.04.

Local ablation for hepatocellular carcinoma: 2024 expert consensus-based practical recommendation of the Korean Liver Cancer Association

• Han S
• Sung PS
• Park SY
• Kim JW
• Hong HP
• Yoon JH
• Chung DJ
• Kwon JH
• Lim S
• Kim JH
• Shin SK
• Kim TH
• Lee DH
• Choi JY
• Research Committee of the Korean Liver Cancer Association

• KMID: 2559461
• DOI: http://doi.org/10.17998/jlc.2024.08.04

Abstract

Local ablation for hepatocellular carcinoma (HCC), 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 firstline treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure 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 posttreatment management of patients.

Keyword

Hepatocellular carcinoma; Hepatoma; Liver cancer; Local ablation; Practical recommendation; Guideline; Guidance

Figure

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  Figure 1. Schematic of local ablation techniques. The applicator was positioned in the tumor under guidance. (A) With radiofrequency ablation, the electrode delivers alternating radiofrequency energy, inducing friction among nearby molecules, thereby raising the tissue temperature and inducing tumor necrosis. (B) With microwave ablation, the antenna transmits microwave energy and increases the vibration of the surrounding water molecules, increasing the temperature and inducing tumor necrosis. (C) In cryoablation, high-pressure gas is passed through a probe, lowering the surrounding temperature to induce tumor necrosis.

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  Figure 2. Locations which require caution before performing local ablation therapy. Tumors located in areas such as the perihilar region (which encompasses major vessels and bile ducts), subcardiac and subphrenic areas, near the colon at the right liver tip, GB fossa, and left liver tip, often result in less favorable treatment outcomes and an increase in the incidence of procedurerelated complications. Therefore, the tumor location should be meticulously evaluated before proceeding with treatment. GB, gallbladder.

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  Figure 3. Schematic of the US-CT/MRI fusion technique. This technique involves aligning cross-sectional images (shown as MRI images) with real-time US images, matching the relevant anatomical structures, and synchronizing their positions. Real-time US images are subsequently aligned with the cross-sectional images and evaluated simultaneously. US, ultrasonography; CT, computed tomography; MRI, magnetic resonance imaging.

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  Figure 4. Schematic of artificial injection of ascites. Subphrenic tumors may not be clearly visible on ultrasonographic imaging owing to poor sonic windows. Injecting artificial ascites creates a space between the diaphragm and liver, improving the sonic window by filling this space with fluid. Creating and filling the spaces between the liver and diaphragm, the liver and abdominal wall, the gastrointestinal tract, and other nearby organs can reduce the risk of inadvertent damage to adjacent organs during local ablation procedures.

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  Figure 5. Post-procedural ablation zone evaluation. Technical success in local ablation is achieved when the tumor is fully encompassed within the ablation zone. Meanwhile, the safety margin refers to the distance between the tumor boundary and the ablation margin. In the figure provided, the tumor is completely included in the ablation zone, which signifies technical success. It is worth noting that the safety margin is smallest at the 3 o’clock position and largest at the 9 o’clock position.

Reference

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