1. Introduction

Hepatocellular carcinoma (HCC) is the 5th leading cause of cancer in the US and 2nd most common cause of cancer related death worldwide [1]. HCC has a dismal prognosis with a ratio of mortality to incidence of 0.95 [2]. The incidence of HCC is rising as its primary risk factors, hepatitis B and C, become more prevalent in the population, especially in developing countries where hepatitis B is endemic [3]. The majority of patients with HCC are often diagnosed in intermediate or advanced stage disease where curative therapeutic options are no longer available [4]. Moreover, HCC is associated with liver cirrhosis, which also limits therapeutic options. The management of HCC is generally based on the guideline of the Barcelona Clinic Liver Cancer (BCLC) staging system. If HCC is detected in its early stages (BCLC-0 or BCLC-A), the 5-year survival may be as high 70–80% with optimal therapies such as resection, orthotopic liver

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

transplantation, or percutaneous ablation [5]. In the intermediate stage (BCLC-B), patients are managed with image-guided catheter based therapies such as transarterial embolization or chemoembolization (TAE/TACE). However, intra-arterial locoregional therapies are palliative and most patients experience disease progression. In 2017, several new therapeutic options have become available for advanced HCC although this is beyond the scope of this chapter where locoregional therapies will be reviewed.

large pores in the cellular membranes leading to apoptosis. The advantage of IRE is the ability to ablate tumors that are in close proximity to vital structures such as the portal veins or bile ducts. IRE is a technically difficult procedure, as it requires multiple devices to be inserted in a

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Based on the BCLC, percutaneous ablation is reserved for patients with very early disease or early stage HCC that are not amenable to surgical resection or transplantation. The criteria for very early stage include a single tumor less than 2 cm. The criteria for early stage include a

Absolute contraindications include intrahepatic biliary ductal dilatation, uncorrectable bleeding diathesis, or decompensated liver failure. Relative contraindications include tumor burden to be greater than five lesions, tumors larger than 3 cm, or tumors in close proximity to vital

Patients are usually monitored for a few hours post-procedure. If vital signs and lab values are not significantly changed, patients can be discharged the same day or the day after the

Major complications include intraperitoneal bleeding, intestinal perforation, bile duct stenosis, pneumothorax or hemothorax, liver abscess formation, or skin burns. Skin burns occur in less than 1% [7]. Late complication would include tumor seeding along the needle track which was found to occur 0.5% of cases with HCC based on a multicenter survey [8]. Other complications include minor symptoms such as pain, fever, or self-limited bleeding. The procedural mortality rate is between 0.1 and 0.5% which are due to sepsis, liver failure, portal venous thrombosis, or

In patients with HCC, RFA was shown to have complete tumor necrosis in 83% for lesions less than 3 cm and 88% for lesions in non-perivascular locations [9]. RFA had higher efficacy compared to ethanol ablation. The complete response rate is close to 97% with 5-year survival rates of 68% [10]. A study conducted by Cho et al. showed that RFA was just as effective as surgical resection for very early stage HCC [11]. A study conducted by Lencioni et al. showed that surgical resection remains the most effective treatment for patients with early stage HCC when compared to RFA [12]. A meta-analysis of over 21,000 patients demonstrated that surgery has higher post-operative mortality but improved 5 year overall survival compared to ablation. Of note, this study combined chemical and thermal ablation even though chemical

The studies comparing MWA to RFA have varying results. A study by Abdelaziz reported local recurrence rates of MWA, 3.9%, to be superior to RFA, 13.5%. Another study reported

procedure. Follow up imaging with CT or MRI is obtained 4–8 weeks post procedure.

near-perfect parallel conformation.

single tumor less than 5 cm or 3 nodules less than 3 cm each.

structures such as the portal vein, biliary tree, or gastrointestinal tract.

2.1. Management

2.2. Complications

gastrointestinal perforation.

ablation is known to be less efficient [13].

2.3. Results
