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Advanced Hepatocellular Carcinoma: Treatment with High-Intensity Focused Ultrasound Ablation Combined with Transcatheter Arterial Embolization¹

¹ From the Institute of Ultrasonic Engineering in Medicine and Clinical Center for Tumor Therapy of the 2nd Affiliated Hospital, Chongqing University of Medical Sciences, 1 Medical College Rd, Box 153, Chongqing 400016, China. Received June 20, 2003; revision requested August 29; final revision received August 5, 2004; accepted August 6. Supported by grants from the Ministry of Science and Technology of China (96–905-02–01) and the National Natural Science Foundation of China (39300125, 39630340, 39630340, 39670749, 39770841, 39770712, 30070217, 30171060). Address correspondence to F.W. (e-mail: mfengwu@yahoo.com).

View larger version (61K): [in a new window]   Figure 1. Schematic diagram shows the conformal therapeutic plan for high-intensity focused ultrasound therapy, which was used to ablate the whole volume of the tumor in human solid malignancies.

View larger version (12K): [in a new window]   Figure 2. Graph shows cumulative survival curves, calculated with the Kaplan-Meier method, for patients treated with either TACE alone (solid line, group 1, n = 26) or TACE and ultrasound ablation (dashed line, group 2, n = 24). Patients treated with TACE and ablation had substantially higher survival rates (P = .007, log-rank test) than those treated with TACE alone. The median survival time was 11.3 months in group 2 and 4.0 months in group 1 (P = .004). The 6-month survival rate was 80.4%-85.4% in group 2 and 13.2% in group 1 (P = .003), and the 1-year survival rate was 42.9% and 0%, respectively.

View larger version (12K): [in a new window]   Figure 3. Bar graph shows median rates of reduction in tumor size during the follow-up period from 3 to 12 months for patients treated with either TACE alone or TACE and ultrasound ablation. Tumor size was measured with Doppler US in each patient and expressed as a proportion of the initial tumor size. The median reductions in tumor size were 28.6%, 35.0%, 52.9%, and 50.0% in the combined treatment group and 4.8%, 7.7%, 10.0%, and 0% in the TACE only group at 1, 3, 6, and 12 months after initial treatment, respectively. During the follow-up period, tumors treated with TACE and ablation (black bars) exhibited substantially greater median reduction rates than those treated with TACE alone (white bars) (P < .01, unpaired Student t test).

View larger version (158K): [in a new window]   Figure 4a. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (158K): [in a new window]   Figure 4b. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (177K): [in a new window]   Figure 4c. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (163K): [in a new window]   Figure 4d. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (160K): [in a new window]   Figure 4e. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (149K): [in a new window]   Figure 4f. Transverse contrast-enhanced CT images (nonhelical) obtained in a 58-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC (arrowhead). Compared with tumor size before ablation, an obvious shrinkage was observed in the lesion treated with TACE plus ablation. Images were obtained (a) before TACE; (b) 3 weeks after TACE and just before ultrasound ablation; and (c) 4 weeks, (d) 6 months, (e) 1 year, and (f) 2 years after ablation.

View larger version (146K): [in a new window]   Figure 5a. Contrast-enhanced coronal fast multiplanar spoiled gradient-recalled-echo breath-hold MR images (90/2.3, 70° flip angle, 256 x 128 matrix, 8-mm section thickness, 2-mm gap) obtained in a 62-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC show a completely nonenhanced area at the site of the treated lesion after ultrasound ablation. (a) Before TACE, rich blood supply was observed in the HCC lesion (arrowheads). (b) At 4 weeks after TACE, just before ablation, tumor blood supply was reduced, but contrast enhancement still remained in some areas within the tumor (arrowheads). (c) At 2 weeks after ablation, no evidence of contrast enhancement was observed in the treated HCC (arrowheads). This was indicative of complete coagulation necrosis in the treated region.

View larger version (130K): [in a new window]   Figure 5b. Contrast-enhanced coronal fast multiplanar spoiled gradient-recalled-echo breath-hold MR images (90/2.3, 70° flip angle, 256 x 128 matrix, 8-mm section thickness, 2-mm gap) obtained in a 62-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC show a completely nonenhanced area at the site of the treated lesion after ultrasound ablation. (a) Before TACE, rich blood supply was observed in the HCC lesion (arrowheads). (b) At 4 weeks after TACE, just before ablation, tumor blood supply was reduced, but contrast enhancement still remained in some areas within the tumor (arrowheads). (c) At 2 weeks after ablation, no evidence of contrast enhancement was observed in the treated HCC (arrowheads). This was indicative of complete coagulation necrosis in the treated region.

View larger version (146K): [in a new window]   Figure 5c. Contrast-enhanced coronal fast multiplanar spoiled gradient-recalled-echo breath-hold MR images (90/2.3, 70° flip angle, 256 x 128 matrix, 8-mm section thickness, 2-mm gap) obtained in a 62-year-old patient who underwent one course of TACE and one session of ultrasound ablation for HCC show a completely nonenhanced area at the site of the treated lesion after ultrasound ablation. (a) Before TACE, rich blood supply was observed in the HCC lesion (arrowheads). (b) At 4 weeks after TACE, just before ablation, tumor blood supply was reduced, but contrast enhancement still remained in some areas within the tumor (arrowheads). (c) At 2 weeks after ablation, no evidence of contrast enhancement was observed in the treated HCC (arrowheads). This was indicative of complete coagulation necrosis in the treated region.