Safety and technical feasibility of percutaneous ablation for lymph node metastases of hepatocellular carcinoma

Figures & data

Figure 1. Ablation therapies for lymph node metastases originating from hepatocellular carcinoma. (A) The preoperative MR imaging showed a porta hepatic LN metastasis. (B) The microwave antenna was advanced into the target lesion. (C) The MR imaging at 5 days later showed partial response and mild heterogenous enhancement. (D) The preoperative computed tomography scan showed a superior vena caval LN metastasis. (E) The radiofrequency electrode was advanced into the lesion. (F) The CT scan 6 months later showed complete response and no enhancement. (G) The preoperative computed tomography scan showed a retroperitoneal LN metastasis. (H) Absolute alcohol (20ml) was slowly injected into the retroperitoneal LN metastasis. (I) The CT scan 3 months later showed significant tumor shrinkage, complete response and no enhancement.

Table 1. The major characteristics of included patients who had lymph node metastases originating from hepatocellular carcinoma.

Characteristics	Patients (n)	%
Total	31
Sex
Male	28	90.3
Female	3	9.7
Age, year	57.26 ± 8.9
Child pugh
A	31	100
B	0	0
C	0	0
AFP, ng/mL	12.78（1–47,542）
Concurrent extrahepatic metastasis
No	22	71
Yes	9	29
Bone	1	3.2
Lung	5	16.1
Suprarenal gland	2	6.5
Pelvis	1	3.2
Vascular invasion
No	24	77.4
Yes	7	22.6
Previous treatment for intrahepatic disease	30	96.8
Resection	6	19.4
Ablation
RFA	22	71.0
MWA	11	35.5
Cryoablation	5	16.1
PEI	1	3.2
TACE	29	93.5
Sorafenib	2	6.5
Number of metastatic LN	1 (1–5)
The maximum diameter of LN, mm	30 (10–77)
The site of metastatic LN
Abdominal	26	83.9
Porta hepatic LNs	6	19.4
Aortocaval LNs	2	6.5
Portacaval LNs	2	6.5
Gastric LNs	1	3.2
Mesocolic LNs	2	6.5
Retroperitoneal LNs	11	35.5
Inferior diaphragmatic LNs	2	6.5
Distant	5	16.1
Mediastinal LNs	3	9.7
Superior vena caval LNs	1	3.2
Subcutaneous LNs	1	3.2
Session of ablations	1 (1–3)
Duration of hospitalization	6 (2–27)
Modality of ablation
RFA	14	45.2
MWA	5	16.1
PEI	12	38.7

Abbreviations: AFP: alpha-fetoprotein; RFA: radiofrequency ablation; MWA: microwave ablation; PEI: percutaneous ethanol injection; LN: lymph node.

Table E1. The complete characteristics of included patients who had lymph node metastases originating from hepatocellular carcinoma.

Characteristics	Patients (n)	%
Total	31
Diabetes
No	27	87.1
Yes	4	12.9
Liver cirrhosis
No	8	25.8
Yes	23	74.2
HBsAg
Negative	2	6.5
Positive	23	74.2
HBeAg
Negative	23	74.2
Positive	2	6.5
Ascites
No	25	80.6
Yes	6	19.4
ALT, U/L	44.3 (10–278.8)
AST, U/L	38.1 (4–667)
TBIL, μmol/L	17.36 ± 6.04
Albumin, g/L	38.67 ± 4.31
PT, s	11.99 ± 1.1
PTA, %	90.34 ± 11.98

Abbreviations: ALT: alanine aminotransferase; AST: aspartate transaminase; TBIL: total bilirubin; PT: prothrombin time; PTA: prothrombin activity; AFP: alpha-fetoprotein; RFA: radiofrequency ablation; MWA: microwave ablation; PEI: percutaneous ethanol injection; LN: lymph node.

Table 2. The treatment efficacy assessed at 24 h after ablation for lymph node metastases in different sites.

	Total (%)	Technique success (%)	Technical effectiveness (%)
Abdominal	26 (26/31,83.9)	26 (26/26,100)	17 (17/26,65.4)
Portahepatic	6 (6/31,19.4)	6 (6/6,100)	2 (2/6,33.3)
Aortocaval	2 (2/31,6.5)	2 (2/2,100)	2 (2/2,100.0)
Portocaval	2 (2/31,6.5)	2 (2/2,100)	1 (1/2,50.0)
Gastric	1 (1/31,3.2)	1 (1/1,100)	0 (0)
Mesocolic	2 (2/31,6.5)	2 (2/2,100)	1 (1/2,50.0)
Retroperitoneal	11 (11/31,35.5)	11 (11/11,100)	9 (9/11,81.8)
Inferior diaphragmatic	2 (2/31,6.5)	2 (2/2,100)	2 (2/2,100.0)
Distant	5 (5/31,16.1)	5 (5/5,100)	3 (3/5,60.0)
Mediastinal	3 (3/31,9.7)	3 (3/3,100)	2 (2/3,66.7)
Superior vena cava	1 (1/31,3.2)	1 (1/1,100)	1 (1/1,100.0)
Subcutaneous	1 (1/31,3.2)	1 (1/1,100)	0 (0)

Figure 2. Tumor response after percutaneous ablation therapy based on the Modified Response Evaluation Criteria in Solid Tumor. Abbreviations: CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease.

Table 3. The tumor response after ablation therapies for metastatic LNs based on mRECIST criteria.

	Total number	CR (%)	PR (%)	SD (%)	PD (%)	LCR (%)
1 mo	28	17 (17/28,60.7)	5 (5/28,17.9)	5 (5/28,17.9)	1 (1/28,3.6)	22 (22/28,78.6)
3 mo	21	15 (15/21,71.4)	4 (4/21,19.0)	2 (2/21,9.5)	0 (0)	19 (19/21,90.4)
6 mo	18	14 (14/18,77.8)	1 (1/18,5.6)	3 (3/18,16.7)	0 (0)	15 (15/18,83.3)

Abbreviations: RFA: radiofrequency ablation; LN: lymph node; mRECIST: Modified Response Evaluation of Solid Tumor; CR: complete response; PR: partial response; SD: stable disease; PD: progressive disease; mo: month; LCR: local control rate (CR + PR/total number, %).

Figure 3. Survival curves after ablation therapy for treatment of lymph node metastases in patients with hepatocellular carcinoma. (A) The overall survival (OS) rate of patients with lymph node metastases after percutaneous ablation therapy. (B) The local progression - free survival (LPFS) rate of patients with lymph node metastases after percutaneous ablation therapy. (C) The progression-free survival (PFS) rate of patients with lymph node metastases after percutaneous ablation therapy. (D) The OS rates after ablation therapies, including RFA, MWA, and PEI, in patients with lymph node metastases. (E) The LPFS rates after ablation therapies, including RFA, MWA, and PEI, in patients with lymph node metastases. (F) The PFS rates after ablation therapies, including RFA, MWA, and PEI, in patients with lymph node metastases. Abbreviations: RFA, radiofrequency ablation; MWA, microwave ablation; PEI, percutaneous ethanol injection; LNM, lymph node metastases.

Table 4. The 1-, 2-, 3-, 4- and 5-year OS, PFS, LPFS rates of metastatic lymph nodes after ablation.

	OS rate (%)	PFS rate (%)	LPFS rate (%)
1 year	74.6	24.7	78.7
2 year	50.3	13.2	69.9
3 year	50.3	0	69.9
4 year	50.3	NA	69.9
5 year	50.3	NA	69.9

Abbreviations: OS: overall survival; PFS: progression-free survival; LPFS: local progression-free survival; NA: not available.