Ultrasound-guided percutaneous microwave ablation vs. surgical resection for thoracoabdominal wall implants from hepatocellular carcinoma: intermediate-term results

Figures & data

Figure 1. A 46-year-old female patient with abdominal wall implants from hepatocellular carcinoma (HCC) after US-MWA treatment. US image shows one low level echo mass (3.1 × 2.5 × 2.2 cm) located on the abdominal wall (blue arrow). There is a high level echo field located behind the mass, and it is MWA field (red arrow).

Figure 2. Sixty-four year old male with abdominal wall implants from hepatocellular carcinoma (HCC). (A) Two nodules were found in the right abdominal wall in the arterial phase in the axial enhanced MRI (arrow) before US-guided MWA, and one was measured in 3.3 × 3.2 × 2.1 cm, another one was in 1.3 × 1 × 0.8 cm. (B) Two nodules were treated after 1 month undergoing US-guided MWA. The thermal ablation field was found in the right abdominal wall in the delay phase in the axial enhanced MRI (arrow).

Table 1. Baseline characteristics of patients undergoing MWA and SR.

Characteristic	MWA (n = 25)	SR (n = 22)	p value
Mean age (years) ± SD	54.5 ± 9.3 (30–70)	53.9 ± 17.5 (18–78)	0.892^a
Gender			0.956^b
Female	7	6
Male	18	16
Child–Pugh grade			0.479^b
A	21	20
B	4	2
Comorbid disease			0.014^b
No	16	8
Yes	9	14
KPS	42 (15–70)	65 (40–90)	0.032^c
Remnant intrahepatic tumour			0.096^b
No	11	15
Yes	14	7
Tumour characteristics
Mean tumour diameter (cm)	2.4 ± 1.3 (0.8–5.0)	2.7 ± 1.4 (0.5–5.0)	0.426^a
Tumour no.	1.2 ± 0.4 (1–2)	1.3 ± 0.4 (1–2)	0.365^a
Side of implanted nodules			0.133^b
Left	NA	2
Right	23	20
Subxiphoid	2	NA
Location of implanted nodules			0.234^b
abdominal wall	14	16
Thoracic wall	11	6
Pathological differentiation			0.918^b
Well/moderately differentiated	17	16
Poorly differentiated	8	6
Perioperative primary disease control			0.989^b
Well controlled or stable	13	16
Poorly controlled	12	6
Presumed cause of tumour implantation			0.765^b
Percutaneous procedure†	15	13
Rupture	9	7
Resection	1	2
Procedure session			0.629^b
1	23	21
>1	2	1
Pre-operative treatment for intrahepatic lesions			0.588^b
SR	13	13
MWA	5	4
TACE	5	5
125I brachytherapy	2	0
Mean total surgical time (min) ± SD	37.8 ± 4.8 (21–35)	113.6 ± 13.8 (55–287)	<0.001^a
Median estimated blood loss (ml) ± SD	7.5 (5–20)	79.6 (20–400)	<0.001^c
Blood transfusion^d^,^e	0 of 25 (0)	1 of 22 (4.5)	0.276^a
Mean post-operative hospitalisation (d) ± SD	7.8 ± 3.8	17.5 ± 2.9	0.032^a
Cost (yuan) ± SD	21056.6 ± 984.2	29064.9 ± 1273.7	0.015^a
LTP	6/25 (24)	4/22 (18.1)	0.113^b
Metastasis	9/25 (36)	8/22 (36.4)	0.979^b
Technique effectiveness^d^,^e	25 of 25 (100)	22 of 22 (100)	ND
Major complications^d^,^e	1 of 25 (4)	1 of 22 (4.5)	0.593^b

Unless otherwise indicated, numbers in parentheses are the range. ND: no data; SD: standard deviation.

^a Student t-test.

^b Pearson χ² test.

^c Wilcoxon signed rank test.

^d Data in parentheses are percentages.

^e Data are the number of treatments.

Table 2. The pre-operative liver function in two groups.

Parameter	MWA Group (n =25)	SR Group (n = 22)	p value
Pre-operative Child Pugh grade (A/B)	16/9	15/7	0.479^a
Pre-operative α-fetoprotein (μg/l)	68.1 (1.6–632.1)	66.2 (2–458.1)	0.959^b
Pre-operative total bilirubin (μmol/l)	19.3 (4.8–32.3)	17.5 (3.2–27.5)	0.615^b
Pre-operative direct bilirubin (μmol/l)	8.9 (2.8–45)	7.9 (3.1–33.6)	0.587^b
Pre-operative alanine transaminase (U/l)	64.8 (9.3–219.2)	62.1 (8.2–198.7)	0.569^b
Pre-operative aspartate transaminase (U/l)	83.9 (18.6–453.4)	77.4 (17.7–389.2)	0.449^b
Pre-operative alkaline phosphatase (U/l)	62.1 (10.2–100.3)	69.4 (9.7–111.4)	0.894^b

MWA: microwave ablation; SR: surgical resection.

^a Pearson χ² test.

^b Student t-test.

Figure 3. (A) Graph shows the 1-, 3- and 5-year overall survival rates in the MWA group and SR group; (B), Graph shows the 1-, 3- and 5-year disease-free survival rates in the MWA group and SR group; (C) Graph shows the 3-, 6-, 12-, 18- and 24-month local tumour reoccurrence-free (LTRF) rates in the MWA group and SR group.

Figure 4. The patients of intrahepatic HCC well controlled or stable in two groups. (A) Graph shows the 1-, 2- and 3-year overall survival rates in the MWA group and SR group; (B) Graph shows the 1-, 2- and 3-year disease-free survival rates in the MWA group and SR group; (C) Graph shows the 3-, 6-, 12-, 18- and 24-month local tumour reoccurrence-free (LTRF) rates in the MWA group and SR group.

Figure 5. The patients of intrahepatic HCC poorly controlled in two groups. (A) Graph shows the 1-, 2- and 3-year overall survival rates in the MWA group and SR group; (B) Graph shows the 3-, 6-, 12-, 18- and 24-month local tumour reoccurrence-free (LTRF) rates in the MWA group and SR group.

Table 3. Univariable analysis of factors affecting overall survival.

Characteristic	No. of patients	No. of deaths	χ^2 value	p value
Age			0.663	0.415
≤60	34	12
>60	13	7
Sex			1.551	0.213
Female	13	6
Male	34	13
Comorbid disease			0.002	0.969
No	30	12
Yes	17	7
Child–Pugh grade
A	41	15	1.248	0.264
B	6	4
Tumour diameter			36.074	<0.001^a
≤1 cm	9	3
1.1–3 cm	33	9
3.1–5 cm	19	7
No. of tumours
Solitary	35	14	0.118	0.731
Multiple	12	5
Side of implanted nodules			2.007	0.367
Left	2	1
Right	43	17
Subxiphoid	2	1
Location of implanted nodules			1.823	0.177
Abdominal wall	27	14
Thoracic wall	20	5
Remnant intrahepatic tumour			0.395	0.530
Present	21	8
Absent	26	11
Pathological differentiation			0.512	0.474
Well-moderately	36	15
Poorly	11	4
Perioperative primary disease control			6.021	0.013^a
Well controlled or stable	29	10
Poorly controlled	18	9
Presumed cause of tumour implantation			3.669	0.160
Percutaneous procedure^b	28	14
Rupture	16	4
Resection	3	1
Procedure Session			0.029	0.864
1	44	18
>1	3	1
Metastasis			5.121	0.024^a
Present	17	10
Absent	30	9
LTP			0.741	0.389
Present	10	3
Absent	40	17
Major complications			25.359	<0.001^a
Present	3	3
Absent	44	16
Treatment before operation			2.765	0.429
SR	29	13
MWA	10	5
TACE	5	NA
^125I brachytherapy	3	1
Treatment modality			0.471	0.493
SR	25	8
MWA	22	11

^a Univariate Kaplan–Meier analysis.

^b Percutaneous procedure mainly includes radiofrequency ablation, microwave ablation and needle biopsy.

Table 4. Multivariate analysis of prognostic factors with cox proportional hazards model.

Variable	B Level	SE	Wald	p value^a	OR	95% Confidence interval
Age	0.084	0.061	1.850	0.174	1.087	0.964	1.226
Tumour diameter	−0.654	0.518	1.590	0.207	0.520	0.188	1.437
Sex	1.943	1.133	2.940	0.086	6.977	0.757	64.26
Remnant intrahepatic tumour	3.308	1.220	7.357	0.007	27.326	2.503	298.318
Location	−2.473	1.377	3.227	0.072	0.084	0.006	1.253
Side	−1.162	1.758	0.437	0.508	0.313	0.010	9.806
Child–Pugh grade	4.698	1.801	6.802	0.009	109.733	3.214	3746.962
No. of tumours	1.713	1.153	2.209	00.137	5.546	0.579	53.095
Comorbid disease	0.383	1.182	0.105	0.746	1.466	0.144	14.882
Intrahepatic disease control	1.574	1.408	1.251	0.263	4.828	0.306	76.208
Metastasis	4.161	1.166	12.742	<0.001	64.167	6.531	630.474
Pathological differentiation	−1.357	1.062	1.634	0.201	0.257	0.032	2.062
Treatment modality	1.478	2.241	0.435	0.509	4.386	0.054	354.361
LTP	2.825	1.886	2.244	0.134	16.863	0.418	679.787
Major Complications	−19.668	99.523	0.039	0.843	0.000	0.000	1.486

^a Bold type indicates statistical significance.