Combined therapy with conventional trans-arterial chemoembolization (cTACE) and microwave ablation (MWA) for hepatocellular carcinoma >3–<5 cm

Figures & data

Figure 1. Flowchart of the inclusion process for the study population.

Table 1. Patients’ data.

Patients’ data	TACE	MWA	Combined	p Value
	(n = 84)	(n = 92)	(n = 89)
Age (years), mean ± SD (range)	51.3 ± 9.2 (41–75)	53.8 ± 10.3 (38–72)	52.1 ± 9.5 (48–76)	0.177*
Sex, n (%)				0.596^#
Male	52 (61.9)	50 (54.3)	52 (58.4)
Female	32 (38.1)	42 (46.7)	37 (41.6)
BMI (WT/m^2), mean ± SD (range)	29 ± 1.2 ( 23.2–39.2)	28.7 ± 1.5 (25.2–40.1 )	28.5 ± 1.6 (25–39.5 )	0.07*
Causes of liver disease, n (%)				0.5^#
Hepatitis C	73 (86.9)	79 (85.9)	72 (80.9)
Hepatitis B	11 (13.1)	13 (3.3)	17 (19.1)
Child-Pugh, n (%)				0.502^#
A	71 (84.5)	78 (84.8)	80 (89.9)
B	13 (15.5)	14 (15.2)	9 (10.1)
AFP level, ng/mL, n (%)				0.741^#
<400	66 (78.6)	76 (82.6)	70 (78.7)
>400	18 (21.4)	16 (17.4)	19 (21.3)
Tumor size (cm), mean ± SD (range)	3.6 ± 0.8 (3.2–4.8)	3.9 ± 0.9 (3–5)	3.7 ± 0.8 (3–5)	0.053*

n: number; TACE: trans-arterial chemoembolization; MWA: microwave ablation; Combined: TACE + MWA; AFP: alpha -fetoprotein; BMI: body mass index; SD: standard deviation; *one-way anova test (<0.05 is significant); ^#Chi-square test (<0.05 is significant).

Table 2. Postoperative adverse events and complications.

Postoperative adverse events	TACE	MWA	Combined
	(n = 84)	(n = 92)	(n = 89)
Minor
Nausea, vomiting	5 (6)	7 (7.6)	4 (4.5)
Abdominal pain	24 (28.6)	20 (21.7)	15 (16.9)
Low grade fever	11 (13.1)	8 (8.7)	3 (3.4)
Major
Severe hepatic dysfunction	3 (3.6)		1 (1.1)
Tumor seeding		2 (2.2)

Data represent the number of patients and percentage in parenthesis.

n: number; TACE: trans-arterial chemoembolization; MWA: microwave ablation; Combined: TACE + MWA.

Table 3. Follow-up and treatment response.

	TACE	MWA	Combined	p Value
	(n = 84)	(n = 92)	(n = 89)
mRECIST after one month				0.0002^#
CR	46 (54.8)	52 (56.5)	77 (86.5)
PR	27 (32.1)	25 (27.2)	3 (3.3)
SD	5 (6)	6 (6.5)	5 (5.6)
PD	6 (7.1)	9 (9.8)	4 (4.55)
Recurrence rate after 12 months	51 (60.7)	47 (51.1)	20 (22.47)	0.0001^#
Overall mortality rate, %	34.5	32	19.1	0.02^#
Overall survival rate	46 (54.8)	50 (54.3)	62 (69.6)	0.02^#
Median survival time (months)	19	21	24	0.02^#
Mean progression-free survival (months)	15.4	16.7	22.3	<0.001#

Unless otherwise indicated, data represent the number of patients and percentage in parentheses.

n: number; TACE: trans-arterial chemoembolization; MWA: microwave ablation; Combined: TACE + MWA; mRECIST: modified response evaluation criteria in solid tumor; CR: complete remission; PR: partial remission; SD: stable disease; PD: progressive disease; #Chi-square test (<0.05 is significant).

Figure 2. Comparison of the survival function among the three groups: transarterial chemoembolization (TACE), microwave ablation (MWA), and combined TACE + MWA. The overall survival rate was significantly higher in the combined group (69.6%) than the TACE group (54.8%) and the MWA group (54.3%) (p = 0.02).

Figure 3. Progression-free survival (PFS) analysis shows that the mean PFS was significantly higher in the combined group (22.3 months) than the TACE group (15.4 months) and the MWA group (16.7 months) (p < 0.001).

Figure 4. Receiver operating characteristic (ROC) curves show the sensitivity and specificity of serum alpha-fetoprotein concentration response among the three treatment groups: (a) transarterial chemoembolization (TACE), (b) microwave ablation (MWA), and (c) combined TACE + MWA.

Table 4. AFP evaluation among the three groups.

	TACE	MWA	Combined
	(n = 84)	(n = 92)	(n = 89)
Δ AFP response	48	63	75
Cutoff value	45.5	45.5	45.5
95% CI	0.88–0.99	0.85–0.99	0.77–0.99
Sensitivity	70.8	65.5	84
Specificity	80	83	88
Accuracy	93.8	92.9	88.5

Data represent the percentage.

n: number; AFP: alpha-fetoprotein; CI: confidence Interval; TACE: trans-arterial chemoembolization; MWA: microwave ablation; Combined: TACE + MWA.

Figure 5. A 65-year-old man with a history of antiviral treatment for hepatitis C virus. Contrast-enhanced MRI before treatment: (a) arterial, (b) portal, and (c) delayed phases show a single 4.9-cm focal lesion at segment VI with HCC criteria (arterial enhancement and delayed washout). The patient underwent TACE and then MWA after two weeks. Follow up contrast-enhanced CT 24 months after the procedure: (d) arterial, (e) portal, and (f) delayed phases show complete response. The effect of MWA is seen in the center of the lesion, and the effect of TACE is seen in the lesion periphery.

Figure 6. A 60-year-old man with a history of antiviral treatment for hepatitis C virus. Contrast-enhanced CT before treatment: (a) pre-contrast, (b) arterial, and (c) delayed phases show a single 4.8-cm focal lesion at segment VI with HCC criteria (arterial enhancement and delayed washout). TACE was performed and results of follow up contrast-enhanced CT after 12 months are shown: (d) pre-contrast, (e) arterial, and (f) delayed phases show complete response with no significant enhancement or washout. Follow-up contrast-enhanced CT after 24 months are shown: (g) pre-contrast, (h) arterial, and (i) delayed phases show complete response with a significant decrease in the size.

Figure 7. A 54-year-old man with a history of antiviral treatment for hepatitis C virus. Contrast-enhanced CT before treatment: (a) arterial, (b) portal, and (c) delayed phases show a single 4.4 cm focal lesion at segment VII with HCC criteria (arterial enhancement and delayed washout). MWA was performed and results of follow up contrast-enhanced CT after 12 months are shown: (d) arterial, (e) portal, and (f) delayed phases show tumor recurrence with significant enhancement at the arterial phase and characteristic washout at the delayed phases.