Feasibility and outcomes of percutaneous radiofrequency ablation for intrahepatic recurrent hepatocellular carcinoma after liver transplantation: a single-center experience

Figures & data

Figure 1. Flow chart of selection patients.

Table 1. The baseline characteristics of the patients.

Characteristics	n
Gender
Male	34
Female	3
Age
Mean ± SD (range)	48.7 ± 10.5 (18–72)
≤60 years	34
>60 years	3
Liver cirrhosis etiology
HBV	20
HCV	1
Others	16
Therapy before transplantation
Liver resection	9
RFA	3
TACE	1
None	24
Stage of HCC before transplantation
Within Milan	10
Beyond Milan	27
Type of transplantation
DDLT	37
LDLT	0
Child-Pugh classification
A	37
B	0
ECOG performance status
0	36
1	1
AFP
≤20 μg/L	17
>20 μg/L	20
Time from LT to recurrence
≤12 months	19
>12 months	18
Intrahepatic tumor number
Single	23
Multiple	14
Maximum tumor diameter
≤3 cm	29
>3 cm	8
Location of tumor recurrence
Intrahepatic	19
Intrahepatic + limited extrahepatic	18

HBV: hepatitis B virus; HCV: hepatitis C virus; RFA: radiofrequency ablation; TACE: transarterial chemoembolization; HCC: hepatocellular carcinoma; DDLT: deceased donor liver transplantation; LDLT: living donor liver transplantation; ECOG: Eastern Cooperative Oncology Group; AFP: alpha fetoprotein.

Table 2. The location and treatment for limited EM.

Location	Treatment	n
Lung	Sorafenib	6
Lung	Sorafenib + chemotherapy	2
Lung + lymph node	Sorafenib + radioactive seed implantation	1
Bone	Sorafenib	3
Lymph node	Sorafenib + ablation	3
Adrenal gland	Ablation	1
Subcutaneous lesions	Ablation	1
Subcutaneous lesions	Sorafenib + ablation	1

EM: extrahepatic metastasis.

Figure 2. Images in a 60-year-old man received radiofrequency ablation (RFA) for a recurrent hepatocellular carcinoma (r-HCC) in the transplanted liver. A, Pre-interventional B-mode ultrasound showed a tumor sized 1.5 cm × 1.4 cm (arrow). B and C, Contrast-enhanced ultrasound (CEUS) before RFA showed obvious enhancement in the artery phase (B) and washout in the late phase (C) (arrow). D and E, Contrast-enhanced computed tomography (CECT) before RFA showed obvious enhancement in the artery phase (D) and washout in the late phase (E) (arrow). F, Electrode placement during the ablation (arrowhead). G, Tumor appeared completely hyperechoic after the beginning of RFA. H, CEUS obtained 1 month after RFA showed no contrast enhancement, suggesting complete ablation.

Table 3. The details of the patients with incomplete ablation after the first session of RFA.

Case	Gender	Age (years)	Etiology	Therapy before LT	Time from LT to recurrence (months)	Limited EM	AFP (μg/L)	Intrahepatic tumor number	Tumor diameter (cm)	High risk location	Combined with EI	Additional treatment	Treatment outcome
1	M	33	HBV	None	19.3	Lung	2560.00	Single	4.5	Yes (near to heart)	Yes	RFA	CA
2	M	39	HBV	None	9	Lung	14689.03	Single	1.2	Yes (near to intestines)	No	RFA	ICA
3	M	38	HBV	Liver resection	14.2	None	27.51	Single	2	No	No	RFA	CA

RFA: radiofrequency ablation; LT: liver transplantation; EM: extrahepatic metastasis; AFP: alpha fetoprotein; EI: ethanol injection; M: male; HBV: hepatitis B virus; CA: complete ablation; ICA: incomplete ablation.

Figure 3. Local tumor progression in patients performed RFA for r-HCC after liver transplantation.

Figure 4. Recurrence-free survival in patients performed RFA for r-HCC after liver transplantation. A, in all patients; B, comparison between patients with maximum tumor diameter ≤ 3 cm and > 3 cm.

Table 4. Prognostic factors of RFS in patients performed RFA for r-HCC after LT.

	Univariate	Multivariate
	p value	HR	95%CI	p value
Gender (M/F)	.664	–	–	–
Age (≤60/>60 years)	.421	–	–	–
Etiology (viral-related/others)	.496	–	–	–
Therapy before LT (Y/N)	.415	–	–	–
Stage of HCC before LT (within /beyond Milan criteria)	.314	–	–	–
ECOG performance status (0/1)	.332	–	–	–
LT to recurrence (≤12/>12 months)	.819	–	–	–
AFP (≤20/>20μg/L)	.647	–	–	–
Intrahepatic tumor number (Solitary/multiple)	.160	–	–	–
Tumor size (≤3/>3cm)	.038	2.557	1.015–6.444	.046
Location of tumor recurrence (Intrahepatic /intrahepatic + limited extrahepatic)	.211	–	–	–

RFS: recurrence-free survival; RFA: radiofrequency ablation; r-HCC: recurrent hepatocellular carcinoma; LT: liver transplantation; HR: hazard ratio; CI: confidence interval; M: male; F: female; ECOG: Eastern Cooperative Oncology Group; AFP: alpha fetoprotein.

Figure 5. Overall survival in patients performed RFA for r-HCC after liver transplantation. A, in all patients; B, comparison between patients with and without limited extrahepatic metastasis.

Table 5. Prognostic factors of OS in patients performed RFA for r-HCC after LT.

	Univariate	Multivariate
	p value	HR	95%CI	p value
Gender (M/F)	.228	–	–	–
Age (≤60/>60 years)	.610	–	–	–
Etiology (viral-related/others)	.519	–	–	–
Therapy before LT (Y/N)	.032	6.417	0.823–50.030	.076
Stage of HCC before LT (within /beyond Milan criteria)	.105	–	–	–
ECOG performance status (0/1)	.761	–	–	–
LT to recurrence (≤12/>12 months)	.584	–	–	–
AFP (≤20/>20μg/L)	.311	–	–	–
Intrahepatic tumor number (Solitary/multiple)	.300	–	–	–
Maximum tumor diameter (≤3/>3cm)	.386	–	–	–
Location of tumor recurrence (Intrahepatic /intrahepatic + limited extrahepatic)	0.019	4.031	1.218–13.339	.022

OS: overall survival; RFA: radiofrequency ablation; r-HCC: recurrent hepatocellular carcinoma; LT: liver transplantation; HR: hazard ratio; CI: confidence interval; M: male; F: female; ECOG: Eastern Cooperative Oncology Group; AFP: alpha fetoprotein.