Locoregional treatment for hepatocellular carcinoma: The best is yet to come

Table 1 Barcelona Clinic Liver Cancer classification[2]

BCLC classification
Stage	Description
Very early	PS 0, Child-Pugh A, single HCC, 2 cm
Early	PS 0, Child-Pugh A–B, single HCC or 3 nodules, 3 cm
Intermediate	PS 0, Child-Pugh A–B, multinodular HCC
Advanced	PS 1–2, Child-Pugh A–B, portal neoplastic invasion, nodal metastases, distant metastases
Terminal	PS 2, Child-Pugh C

HCC: Hepatocellular carcinoma; BCLC: Barcelona clinic liver cancer.

Table 2 Child-Pugh classification[3]

Child-pugh classification
Finding	1 point	2 points	3 points
Encephalopathy grade	None	Mild	Severe
Ascites	Absent	Mild to moderate	Severe, refractory
Serum bilirubin (mg/dL)	2	2-3	> 3
Serum albumin (g/dL)	> 3.5	2.8-3.5	< 2.8
INR	< 1.7	1.7-2.2	> 2.2

A: 5–6 points; B: 7–9 points; C: 10–15 points. INR: International normalized ratio.

Table 3 Various ablative methods for hepatocellular carcinoma

Chemical ablation	PAI
	PEI
Cryoablation	Nitrous oxide
	Liquid nitrogen
	Argon
Thermal ablation	RFA
	LITT
	HIFU
	MWA
Electroporation	IRE

PAI: Percutaneous acetic acid injection; PEI: Percutaneous ethanol injection; RFA: Radiofrequency ablation; LITT: Laser-induced thermotherapy; HIFU: High-intensity focused ultrasound; MWA: Microwave ablation; IRE: Irreversible electroporation.

Table 4 Comparison of radiofrequency ablation and percutaneous ethanol injection

Study and treatment	Initial complete	Treatment	Overall survival rate (%)		P value
	response rate (%)	failure rate (%)	1-yr	3-yr
Lin et al[18]
RFA (n = 52)	96	17	82	74	0.014
PEI (n = 52)	88	45	61	50
Shiina et al[19]
RFA (n = 18)	100	2	90	80	0.02
PEI (n = 114)	100	11	82	63
Lin et al[20]
RFA (n = 62)	97	16	88	74	0.031
PEI (n = 62)	89	42	96	51

PEI: Percutaneous ethanol injection; RFA: Radiofrequency ablation.

Table 5 Advantages of microwave ablation over radiofrequency ablation

Achieves higher temperatures and relatively larger ablative zones in a shorter time

Ablative zones are more consistent and uniform in character

Better safety profile

Less post procedural pain

Not affected by the heat sink effect

Multiple applicators can be used simultaneously

Table 6 Advantages of irreversible electroporation over other thermal ablative techniques

Selective cellular target

Cell death via apoptosis

Sparing effect on important structures

Not affected by heat sink (compared to RFA)

Sharp boundary between the treated and untreated areas

RFA: Radiofrequency ablation.

Table 7 Comparison of energy based therapies

	RFA	MWA	IRE
Principle	Thermal	Thermal	Non-thermal
Collateral damage	+	+	-
Ease of ablation titration	+	+	++
Cost	+	+	++
Duration of therapy	+	+	++
Tissue effect
Tumor	+	+	+
Nerve	+	+	-
Vessels	+	+	-
Hepatic architecture	+	+	-

RFA: Radiofrequency ablation; MWA: Microwave ablation; IRE: Irreversible electroporation.