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EDITORIALS |
From the Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas.
Correspondence: Address correspondence to: Jean-Nicolas Vauthey, MD, Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 444, Houston, TX 77030; Fax: 713-792-0722; E-mail: jvauthey{at}mdanderson.org
In this issue of the Annals of Surgical Oncology, Poon et al.1 analyze the outcome of radiofrequency ablation (RFA) in 80 patients with hepatocellular carcinoma (HCC) who were not candidates for resection or transplantation. In contrast to previous reports,2 the series reported no bleeding complication in 47 patients with subcapsular tumors and no instance of needle-tract seeding in 32 patients who underwent percutaneous RFA. This series reports systematic, meticulous RFA technique: subcapsular tumors were treated by indirect puncture through nontumorous liver, and the needle tract was systematically thermocoagulated during needle withdrawal. At 13 months median follow-up, the low overall local recurrence rate of 7.6% (4.3% for patients with one or more subcapsular tumor, 12.5 % for those without subcapsular tumor) is consistent with the best reported results.3,4 These results are also likely related to appropriate patient selection for ablation: only a few patients had multiple tumors (7/80) or tumors >5 cm (6/80) and the majority of patients had tumors 
3 cm (49/80).
Today, many centers perform simultaneous percutaneous image-guided fine-needle aspiration (FNA) and immediate cytologic evaluation before using RFA as a bridge to transplantation. As for RFA, the technique of instrumentation of the treated tumor likely impacts the outcome of the treatment. The 0% needle-tract recurrence detected during follow-up in Poon’s report is in sharp contrast to the 12.5% rate reported by Llovet et al.2 At M. D. Anderson Cancer Center, we have an experience similar to that of Poon et al., with no needle-tract recurrence following percutaneous treatment of more than 200 hepatic tumors5 using a noncooled RFA system (RadioTherapeutics RF 2000 or RF 3000 generator system, Boston Scientific, Natick, MA). Further evidence of the value of Poon’s appropriate patient selection is the low overall local recurrence rate of 7.6%. Complete treatment using RFA is extremely difficult if not impossible in large HCC, as reiterated in a recent report of Harrison et al., in which a local recurrence rate of 39% was reported in a series of 50 patients treated mainly by percutaneous (46/50) RFA for tumors with a median diameter of 3.5 cm and up to 12 cm in size.3 The correlation between increased size and local recurrence is well described.4–6 Reported unacceptable recurrence rates are expected after inappropriate treatment of huge tumors3 and should not be used to guide treatment decision making, whereas reports such as Poon’s, wherein appropriately selected patients are treated with meticulous technique, legitimately guide treatment planning.
There is little doubt that the optimal treatment for small HCC is hepatic resection or transplantation.7,8 Specifically, long-term survival is most often achieved in patients with small tumors. Screening has led to an increase in the diagnosis of small nodules in cirrhotic patients, whereas distinction between small HCC and non-malignant hyperplastic nodules in cirrhotic patients may not be possible despite advances in radiological imaging.9,10 Percutaneous FNA biopsy may be necessary in these patients to stratify treatment options ranging from observation to resection to transplantation to protocol-based treatment. Attention to technique during percutaneous intervention on liver tumors can minimize or eliminate complications such as tumor seeding or bleeding. For instance, complications of FNA are rare at specialized centers. The rate of needle-tract seeding is reported to be 0%11 to 3.4%12 for HCC, though most reports suggest the rate is approximately 2%.13–15 Bismuth’s group described the "protected double-needle" technique for biopsy of liver tumors and demonstrated that using this technique, seeding could be essentially eliminated.16 More recently, Durand et al. reassessed the value of ultrasound-guided FNA of HCC prior to resection or transplantation.2 The diagnostic accuracy of percutaneous ultrasound-guided FNA (91%) was reiterated in their study, and the safety demonstrated. Not only was a low needle-tract seeding rate reported (2 of 122 patients, 1.6%), but no recurrence occurred after local excision of these subcutaneous implants. In this series, a second biopsy was recommended when the first was nondiagnostic because risk-benefit of ultrasound-guided FNA favors accurate diagnosis over potentially nontherapeutic radical surgery.5 Policies designed to avoid biopsy in cirrhotic patients with small hypervascular nodules and normal serum 
-fetoprotein for fear of needle-tract seeding may lead to resection or transplantation of high-grade tumors (known to be associated with poor prognosis)17–19 or to unnecessary radical treatment of benign lesions.20
The significance of needle-tract recurrence after percutaneous instrumentation of HCC has long been debated, initially in the setting of biopsy for diagnosis and now in the setting of percutaneous RFA treatment. Careful multidisciplinary evaluation and treatment suggest that the percutaneous modality of tumor biopsy for diagnosis or treatment is not intrinsically problematic when applied to the appropriate patient population with careful attention to technique. The increasing use of liver transplantation as a result of the new Model for End Stage Liver Disease score prioritization for organ allocation for HCC in cirrhosis21 emphasizes the need for safe techniques for percutaneous intervention for treatment, diagnosis and evaluation of the biology of small hypervascular liver nodules.8 The article by Poon et al. timely revisits the importance of technique and selection and further supports the appropriate use of percutaneous interventions in HCC.
Received for publication January 20, 2004. Accepted for publication January 20, 2004.
REFERENCES
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