TOPICS Hepatocellular carcinoma: Eastern and Western experiences Hepatocellular carcinoma: new options for image-guided ablation Riccardo Lencioni • Dania Cioni • Clotilde Della Pina • Laura Crocetti Received: 1 August 2009 / Accepted: 1 September 2009 / Published online: 1 December 2009 Ó Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer 2009 Abstract Image-guided percutaneous ablation is cur- rently accepted as the best therapeutic choice for patients with early-stage hepatocellular carcinoma (HCC) when transplantation and resection are precluded. Several meth- ods for chemical or thermal tumor destruction have been developed and tested clinically during the past two dec- ades. The seminal technique used for local treatment of HCC has been percutaneous ethanol injection (PEI). Sev- eral studies have provided indirect evidence that PEI improves the natural history of nonsurgical patients with early-stage HCC. Its major limitation is the high rate of local recurrence. Radiofrequency (RF) ablation has been the most widely assessed alternative to PEI. Five ran- domized controlled trials have shown that RF ablation achieves more effective and reproducible tumor destruction than PEI, leading to a better local control of the disease. As a result, RF ablation has been established as the primary ablative modality. The value of newer thermal and non- thermal methods for local tumor treatment, such as microwave ablation, irreversible electroporation (IRE), and light activated drug therapy, should be investigated in the setting of randomized controlled trials. Keywords Hepatocellular carcinoma Á Percutaneous ethanol injection Á Radiofrequency ablation Introduction Hepatocellular carcinoma (HCC) is the sixth most common cause of cancer, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infection [1]. Patients with cirrhosis are at the highest risk of developing HCC and should be monitored carefully to diagnose a possible tumor at an early-stage [2, 3]. Patients with early-stage HCC can benefit from curative therapies, including surgical resection, liver transplantation and per- cutaneous ablation, and have the possibility of long-term cure, with 5-year survival figures ranging from 50–75% [3, 4]. There is no firm evidence to establish the optimal first- line treatment for early-stage HCC because of the lack of randomized controlled trials comparing radical therapies. Image-guided percutaneous ablation is currently accepted as the best therapeutic choice for nonsurgical patients with early-stage disease [4]. Over the past two decades, several methods for chemical ablation or thermal tumor destruction through localized heating or freezing have been developed and clinically validated. More recently, new options that use non-thermal ablative techniques have started clinical investigation. Ethanol injection: the seminal technique The seminal technique used for local ablation of HCC is percutaneous ethanol injection (PEI). Ethanol induces coagulation necrosis of the lesion as a result of cellular dehydration, protein denaturation, and chemical occlusion of small tumor vessels. PEI is a well-established technique for the treatment of nodular-type HCC. HCC nodules have a soft consistency and are surrounded by a firm cirrhotic liver. Consequently, injected ethanol diffuses within them R. Lencioni (&) Á D. Cioni Á C. D. Pina Á L. Crocetti Division of Diagnostic Imaging and Intervention, Department of Liver Transplantation, Hepatology, and Infectious Diseases, Pisa University School of Medicine, Cisanello Hospital, Building 30C, Suite 197, 56124 Pisa, Italy e-mail: lencioni@med.unipi.it 123 J Hepatobiliary Pancreat Sci (2010) 17:399–403 DOI 10.1007/s00534-009-0233-0