European Radiology

, Volume 23, Issue 1, pp 190–197 | Cite as

Early diffuse recurrence of hepatocellular carcinoma after percutaneous radiofrequency ablation: analysis of risk factors

  • Hee Young Lee
  • Hyunchul Rhim
  • Min Woo Lee
  • Young-sun Kim
  • Dongil Choi
  • Min Jung Park
  • Young Kon Kim
  • Seong Hyun Kim
  • Hyo Keun Lim
Interventional

Abstract

Objective

To evaluate the risk factors affecting early diffuse recurrence within 1 year of percutaneous ultrasound-guided radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).

Methods

Out of 146 patients who received transcatheter arterial chemoembolisation (TACE) for treatment of recurrent HCC after percutaneous ultrasound-guided RFA, we selected 23 patients with early diffuse recurrence. Early diffuse recurrence was defined as three or more new recurrent HCCs within 1 year of initial RFA. As a control group, we selected 23 patients, matched exactly for age and sex, in which there was no local tumour progression or new recurrence after RFA. To analyse the risk factors, we examined patient factors and tumour factors.

Results

Recurrent tumours occurred from 30 to 365 days after RFA (median time, 203 days). Univariate analysis indicated that larger tumour size and poorly defined margin were significant risk factors (P < 0.05). Multivariate analysis indicated that poorly defined margin was a significant risk factor (P < 0.05).

Conclusion

Larger tumour size and poorly defined margin may be risk factors for early diffuse recurrence of HCC within 1 year of RFA. Tumours with such risk factors should be treated with a combination of TACE to minimise the potential for therapeutic failure.

Key Points

Ultrasound-guided radiofrequency ablation (RFA) is widely used for hepatocellular carcinoma (HCC).

Early diffuse recurrence after RFA is an important prognostic factor

The risk factors for recurrence are larger tumour size and poorly defined margins

Tumours with such risk factors should be treated with transarterial chemoembolisation.

Keywords

Hepatocellular carcinomas Radiofrequency catheter ablation Percutaneous catheter ablation Recurrence Risk factors 

Introduction

Hepatocellular carcinoma (HCC) is the third most common cause of cancer death worldwide, accounting for about 315,000 deaths annually [1]. The optimal curative therapy for patients with HCC is surgical resection or liver transplantation. However, these therapies are often not feasible. There are many limiting factors for successful surgical resection in patients with HCC such as severe impairment of hepatic functional reserve, bilobar distribution of the tumours, extrahepatic metastasis or involvement of the portal vein. Only 9–27% of the patients with HCC are eligible for surgical resection [2, 3]. A shortage of donors limits the possibility of hepatic transplantation. Thus, various local ablation therapies, such as ethanol ablation, microwave ablation and radiofrequency ablation (RFA), have been developed as an alternative to resection [4] or liver transplantation.

RFA is currently recognised as a minimally invasive and highly curative local treatment for HCC with a diameter of 3 cm or less [5], and has proven to be superior to ethanol ablation with respect to local tumour control without seriously affecting hepatic reserve [6, 7, 8]. Moreover, Chen et al. [9] recently showed that the survival rates of HCC patients after RFA were similar to those of patients who underwent surgical resection for small, solitary HCC in a randomised control study.

Nonetheless, even though these ablation therapies can achieve complete necrosis of small HCC, recurrence is still common. Early recurrence, defined as recurrence within a year of liver resection, is one of the most important factors affecting the prognosis and survival of patients with HCC. Regimbeau et al. [10] reported that the 1-year mortality rate after liver resection for HCC was 22% (123 out of 547 patients). Of these, 53 patients (43%) died of recurrence during the first postoperative year. In addition, a recent study by Park et al. [11] showed that the 3-year survival rate was 32% in the early recurrence group and 87% in the non-recurrence group, implying that early recurrence is closely related to postoperative survival rates. Among these diverse patterns of early recurrence after surgical resection or liver transplantation, diffuse intra-hepatic recurrence and multiple systemic recurrences are associated with short remaining survival times [12, 13].

Similarly, cases showing early and diffuse recurrence of HCC after RFA have recently been reported. Kotoh et al. [14] reported that the incidence of rapid and diffuse recurrent tumours after RFA is also associated with poor prognosis. Within the observation period, the mortality rates of patients with early and diffuse recurrences (within 7 months of RFA) were higher than those of patients without diffuse recurrences, reflecting worse prognoses for patients with early diffuse recurrences. Among the 127 patients without early diffuse recurrences, 40 patients died within the observation period: eight owing to liver failure, two from variceal rupture and the remainder owing to the progression of HCC. On the other hand, eight out of 11 patients with early diffuse recurrences died owing to advanced HCC. Thus, risk factors for the early diffuse recurrence after surgical resection or RFA may be reliable prognostic factors for long-term survival. Therefore, understanding the patterns and risk factors for early diffuse recurrence of HCC after RFA will help clinicians to (1) correct factors that are correctable, (2) tailor post-ablational management and (3) identify patients who may benefit from adjuvant therapy for the improvement of overall survival.

Early diffuse recurrence is rare but, if it occurs, prognosis is often dismal. Although there are several case reports describing the early diffuse recurrence of small HCC after RFA [15, 16], to the best of our knowledge, analyses of risk factors for the early diffuse recurrence after RFA for HCC have not been performed [17]. Therefore, the purpose of this study was to evaluate the patterns and risk factors for early diffuse recurrence of HCC after RFA.

Materials and methods

Study sample

From April 1999 to October 2009, we treated 1220 patients with HCC using RFA as the first-line treatment. Inclusion criteria for performing RFA in patients with HCC were as follows: the tumour or tumours should be visualised with ultrasound; a single tumour no greater than 5 cm in the largest dimension; multiple tumours (≤ 3) with each tumour measuring no greater than 3 cm; no portal venous thrombosis and extra-hepatic metastasis; prothrombin time ratio over 50% (prothrombin time with international normalised ratio [INR] < 1.7) and platelet count greater than 50,000/μl without transfusion support. We performed RFA under ultrasound guidance with local and conscious sedation.

Among the 1,220 patients, we identified 146 patients who underwent transcatheter arterial chemoembolisation (TACE) for the treatment of recurrent HCC within 1 year of initial RFA. We selected 35 patients showing early diffuse recurrence. We defined “early and diffuse recurrence” as three or more new recurrent tumours within 1 year of initial RFA. We excluded a total of 12 patients for the following reasons: the patient had undergone segmentectomy and intra-operative RFA (n = 6); the patient had untreated HCC after RFA because of its location or proximity to the main portal vein or hepatic vein (n = 3); the patient had a follow-up period of less than 12 months (n = 3). Thus, a total of 23 patients were included in this retrospective study (Fig. 1). Written informed consent for the RFA procedure was obtained from all patients. The institutional review board of our hospital waived the consent requirement for inclusion in this retrospective study.
Fig. 1

Flow chart of inclusion and exclusion criteria for our study

A total of 32 HCCs in 23 patients (17 men, 6 women; mean age, 65 years) were evaluated (Group A). The diagnosis of HCC was made based on AASLD guidelines [18]. Five tumours were diagnosed by percutaneous ultrasound-guided biopsy for initial diagnosis before RFA. The remaining 27 tumours were diagnosed by imaging criteria. The maximum diameter of the index tumours ranged from 1.2 cm to 4.8 cm (mean, 2.5 cm). The aetiology of hepatitis or liver cirrhosis was viral in all 23 patients (HBV, n = 19; HCV, n = 4). Child–Pugh classifications were A in 19 and B in four patients.

As a control group (Group B), we selected 23 out of 1,074 patients, matched to the cases for age and sex, in whom there was no local tumour progression or new recurrence after the initial RFA during the same study period.

RFA procedure and follow-up

All RFA procedures were performed percutaneously under ultrasound guidance (HDI 5000, Philips Healthcare, Best, The Netherlands; Acouson Sequoia 512, Siemens Medical Solutions, Mountain View, CA, USA; LOGIQ E9, GE Healthcare, Milwaukee, WI, USA). Procedures were performed on an inpatient basis by one of six radiologists (Y.S.K., H.K.L., H.R., M.W.L., D.C. and W.J.L.), each of whom had had at least 7 years’ experience performing this procedure by the end of the study period. We used either internally cooled, multi-tined expandable or perfusion electrode systems from one of six vendors (Cool-tip RF System, Covidien, Mansfield, MA, USA; VIVA RFA System, STARmed, Ilsan, Korea; Starburst RFA System, AngioDynamics, Latham, NY, USA; LeVeen Needle Electrode and RF 3000 Generator, Boston Scientific, Natick, MA, USA; Elektrotom 106 HiTT, Berchtold Corporation, Tuttlingen, Germany; Jet-Tip RF electrode, RF Medical, Seoul, Korea) according to temporal availability or operator preference. When we used internally cooled electrodes, we started from 50 W and continuously increased the power during the initial 2 min to minimise the popping phenomenon. We did not apply stepwise deployment when we used multi-tined expandable electrodes.

All patients were treated with 2% lidocaine hydrochloride at the puncture site and intravenous drip infusion of 50 mg pethidine hydrochloride mixed with 50 ml of 5% dextrose water. Patient cardiovascular and respiratory systems were continuously monitored during the procedures. We treated tumours with complete necrosis by ablating at least 0.5 cm of the normal hepatic parenchyma surrounding the tumour.

All patients underwent serial monitoring of alpha-fetoprotein, chest X-ray, and helical dynamic triple phase CT at 3- to 4-month intervals for the detection of local tumour progression, new intra-hepatic recurrence, and extrahepatic metastasis. Baseline and post-treatment imaging evaluations of HCC were performed using CT with intravenous contrast medium administration. CT was performed with one of two helical systems (Somatom Plus and Somatom Plus 4; Siemens, Erlangen, Germany). A total of 120 ml non-ionic contrast material (Iopromide, Ultravist 300; Schering-Korea, Ansung, Korea) was administered intravenously via the antecubital vein at a rate of 3 ml/s. A triple-phase contrast enhancement CT technique was used with delay times of 30, 60 and 180 s after the initiation of contrast medium injection. Helical CT unenhanced and contrast-enhanced images were acquired using a 5– to 8-mm collimation and 5– to 8-mm/s table speed.

Diagnoses of local tumour progression or new intra-hepatic recurrence were based on CT and/or MRI. Needle biopsies of recurrent tumours were not performed. Recurrent HCC was defined as a new enhancing mass in the arterial phase with washout in the portal or the delayed phase of dynamic liver CT. If the mass showed arterial enhancement without washout, we used the interval growth of the mass on follow-up imaging or lipiodol retention of the tumour after TACE to confirm recurrent HCC. Local tumour progression was defined as tumour recurrence within or at the periphery of the original ablative zone on subsequent CTs. New intra-hepatic recurrence was defined as any new tumour that occurred in the liver separate from the RFA zone. In this study, early diffuse recurrence was defined as three or more new intra-hepatic recurrent tumours within 1 year after initial RFA, regardless of local tumour progression.

Analysis of risk factors for early diffuse recurrence

We compared 11 clinical variables that may be related to the risk of early diffuse recurrence after RFA. These included four patient factors (pre-RFA alpha-fetoprotein [AFP], Child–Pugh classification, hepatitis B surface antigen status, hepatitis C antibody status) and seven tumour factors (size, location, margin, contact with portal vein, hepatic hilum, hepatic capsule and presence of an ablative margin).

For the analysis of patient-related risk factors for early diffuse recurrence, we compared (1) level of baseline serum AFP level at the time of RFA procedure, (2) degree of underlying hepatic reserve (categorised as Child–Pugh class A, B, and C), and (3) presence or absence of hepatitis B surface antigen (HBs Ag) or hepatitis C antibody at the time of RFA between the two groups.

For the analysis of tumour-related risk factors for early diffuse recurrence, we examined (1) maximum diameter of HCCs on ultrasonography, (2) margin of the HCCs after dividing the tumours into poorly marginated and well marginated groups according to the degree of border definition (well or poorly marginated, i.e. greater than or less than 50% of the border sharply defined on CT), (3) segmental location of HCCs according to Couinaud’s classification, (4) whether the tumour had contact with the portal vein, more than 3 mm in diameter at the contact point, (5) whether the tumour was in close proximity to the hepatic hilum (centre of the tumour was located within 1 cm of the hepatic hilum), (6) whether the tumour was located within 5 mm from the liver capsule, and (7) whether the ablative margin, defined as ablated normal surrounding parenchyma more than 5 mm in thickness, compared with the location of tumour before RFA, was established in an immediate three-phase CT scan. These risk factors were assessed by the consensus of two radiologists.

Statistical analysis

Risk factors for early diffuse recurrence were evaluated with univariate analyses using Cox regression tests. If multiple risk factors were shown to be significant by this test, we performed multivariate analysis using Cox regression tests. All reported P values were two-tailed, and P levels < 0.05 were considered statistically significant. All statistical analyses were performed using SPSS for Windows v. 18 (SPSS, Chicago, IL).

Results

There were 17 male and six female patients (mean age, 65 years) with early diffuse recurrence (Group A; examples in Figs. 2 and 3), while there were 17 male and six female patients (mean age, 59 years) with no intra-hepatic recurrence or distant metastasis (Group B; example in Fig. 4). There were 32 tumour nodules before RFA in Group A and 26 in Group B. The mean sizes of tumours before RFA were 2.5 cm in Group A and 1.9 cm in Group B. The recurrent tumours in Group A occurred from 30 to 365 days (median, 203 days) after RFA. The locations of recurrence were surrounding and limited to the site of the ablation segment in eight cases, and spread over one lobe or both lobes in the other 15 cases. Nine out of 23 patients (39.1%) had at least four or more recurrent HCCs. Three patients had early diffuse intra-hepatic recurrence as well as extrahepatic recurrence (lung metastasis, n = 2; abdominal wall metastasis, n = 1) at the time recurrence was diagnosed. Twenty (86.9%) out of 23 patients survived for 1 year, and three patients (13%) survived more than 3 years. After 5 years of follow-up study, we found that the survival rate had fallen to 4.3%, with only one survivor. Advanced HCC was the most common cause of death (82.6%), followed by hepatic failure (8.7%).
Fig. 2

A 77-year-old woman with large and infiltrating HCC presenting with early recurrent HCC after RFA. a Arterial phase of the pre-RFA CT shows an enhancing mass measuring approximately 4 cm in diameter in S5 and S6. b Early washout of contrast medium for this mass is observed during the equilibrium phase, an enhancement pattern consistent with HCC. cf CT obtained after radiofrequency ablation in the same patient reveals multiple recurrent HCC in both lobes of the liver. Note that the two risk factors are associated. The recurrent tumours are disseminated and scattered in both lobes of the liver

Fig. 3

A 50-year-old man with small and well-defined HCC presenting with early recurrent HCC after RFA. a Arterial phase of the initial CT shows an HCC (arrowheads) measuring 2.1 cm in diameter in S5. b CT obtained 4 months after RFA in the same patient reveals new intra-hepatic recurrence in S5 (large arrow), which was treated with RFA. c After second RFA, there are multiple recurrent tumours (arrows) in S5 and S6. Note that the recurrent tumours are relatively confined within the same or adjacent liver segments

Fig. 4

A 66-year-old man with small and well-defined HCC had no evidence of local tumour progression or intra-hepatic metastasis after RFA. a Arterial phase of the initial CT shows an HCC (arrows) measuring 1.4 cm in diameter in S8. b Early washout of contrast medium for this mass (arrows) is observed during the equilibrium phase, an enhancement pattern consistent with HCC. c CT obtained 6 years after RFA in the same patient reveals no evidence of local tumour progression or intra-hepatic metastasis

Table 1 shows the results of univariate analysis of host and tumour factors associated with early diffuse recurrence. Two tumour factors were associated with early diffuse recurrence: maximal diameter (P = 0.036) and margin of HCC (P = 0.001). Multivariate analyses identified margin of HCC as the only independent risk factor for early diffuse recurrence after RFA (Table 2).
Table 1

Risk factors related to early diffuse recurrence of HCC: univariate analysis (n = 46)

 

Group A

Group B

P value

Patient factors

Pre-RFA AFP (ng/ml)

306.8

263.1

0.645

Child–Pugh status

  

0.08

A

19

16

 

B or C

4

7

 

Cause of cirrhosis

  

0.997

HBV

19

17

 

HCV

4

4

 

Alcohol or idiopathic

0

2

 

Tumour factors

Maximal diameter (cm)

2.5

1.9

0.036

Margin

  

0.001

well-defined

24

26

 

poorly-defined

8

0

 

Segmental location

  

0.933

S3

1

2

 

S4

3

2

 

S5

7

4

 

S6

5

5

 

S7

7

6

 

S8

9

7

 

Contact of the tumour with the portal vein

  

0.566

No contact

20

18

 

Contact

12

8

 

Contact of the tumour with the hepatic hilum

  

0.693

No contact

30

24

 

Contact

2

2

 

Contact of the tumour with the hepatic capsule

  

0.381

No contact

20

18

 

Contact

12

8

 

Ablative margin at immediate follow-up CT

  

0.263

Insufficient

9

1

 

Sufficient

23

25

 

Group A early diffuse recurrence group, Group B control group; RFA radiofrequency ablation, AFP alpha-fetoprotein, HBV hepatitis B, HCV hepatitis C

Table 2

Independent risk factors related to early diffuse recurrence of HCC: multivariate analysis

 

B

SE

95% CI

P value

Maximal diameter

0.009

0.02

0.970-1.050

0.666

Margin

-1.251

0.532

0.101-0.812

0.019a

B regression coefficient, SE standard error, CI confidence interval

aStatistically significant (multiple linear regression test)

Patient factors

Pre-RFA alpha-fetoprotein

The mean values of AFP were 306.8 ng/ml and 263.1 ng/ml for patients with early diffuse recurrence and for patients without recurrence, respectively. There were no significant differences in pre-RFA AFP between Group A and Group B.

Child–Pugh status and cause of cirrhosis

Thirty-six patients had cirrhosis caused by hepatitis B infection, and eight patients had cirrhosis due to hepatitis C. All patients from Group A had cirrhosis caused by viral infection. Two patients from Group B had different causes of cirrhosis: chronic alcohol abuse (n = 1) and idiopathic cirrhosis (n = 1). The causes of cirrhosis and Child–Pugh status were not related to early diffuse recurrence.

Tumour factors

Maximal diameter of the tumour

The mean diameter of HCCs was 2.5 cm in Group A and 1.9 cm in Group B. Small tumours had a significantly lower rate of early diffuse recurrence compared with the larger tumours (P = 0.036). However, the difference was not sustained in multivariate analysis (P = 0.666).

Margins

Eight tumours in Group A (25.0%) and 0 (0%) in Group B had poorly defined margins. The degree of border definition was significantly related to early diffuse recurrence between two groups (P = 0.001). The poorly defined margin was the only significant risk factor for early diffuse recurrence in multivariate analysis (P = 0.019).

Miscellaneous

There were no differences between the two groups in terms of the anatomical location of HCC, contact of the tumour with the portal vein, hepatic hilum and hepatic capsule, or ablative margin at immediate follow-up CT.

Discussion

We demonstrated that larger tumours and poorly defined tumour margins are risk factors for early diffuse recurrence for HCCs after RFA. This result partly agrees with the results of previous studies indicating that large tumour size [19], absence of tumour capsule, indistinct margins [20], elevated AFP serum levels [21] and microscopic vascular invasion [13] are risk factors for early tumour recurrence after curative surgical resection. Causes may include the presence of a micro-metastatic lesion before surgery or tumour cell metastasis caused by compression or movement of the liver or tumour rupture during hepatectomy [12, 13].

Early recurrence after curative resection is considered to be related to tumour size, possibly because of the frequent presence of micro-metastases of tumour cells beyond the resection margins at the time of surgery. Lai et al. [22] reported that 11 out of 14 large HCCs (larger than 5 cm) had either microsatellites and/or histological venous permeation beyond 1 cm from the tumour. They also reported that intra-hepatic micro-satellite lesions are found at greater distances from primary tumours > 4 cm in size. The mechanism for such intra-hepatic microscopic metastasis is vascular invasion, which is considered to be a risk factor for early post-operative recurrence. Similarly, we hypothesised that microscopic metastasis which was not visible on preoperative imaging may be related to the early recurrence of large HCC after RFA [23]. These observations imply not only that larger tumours indicate a greater possibility of systemic dissemination, but also that larger tumours may require strict control with adjuvant therapy to prevent early recurrence as a consequence of circulating cancer cells or micro-metastatic lesions after RFA for HCC.
Table 3

Reported cases of intra-hepatic rapid progression after RFA

Author

Year

Age (years)

Sex

Tumour size (cm)

Initial LAT

Interval (month)

Seki et al.

2001

75

M

2.5

RFA + TACE

1.5

Takada et al.

2003

68

F

2.7

RFA

4

Takada et al.

2003

64

M

2

RFA

6

Nicoli et al.

2004

66

F

3.5

RFA

2

Ruzzenente et al.

2004

66

M

3.5

RFA

NA

Ruzzenente et al.

2004

75

M

3.8

RFA

NA

Ruzzenente et al.

2004

59

M

4.5

RFA

NA

Ruzzenente et al.

2004

62

M

4.5

RFA

NA

Izai et al.

2005

71

M

2

RFA

1

Masuda et al.

2008

52

M

1.5

RFA

NA

Masuda et al.

2008

63

M

3

RFA

NA

LAT local ablational therapy, Interval interval from initial LAT to recurrence (months), NA not available

Another hypothesis that may explain early diffuse recurrence after RFA is that rapid heating of a tumour may lead to an unpredicted increase in internal pressure and cause the dislodging and scattering of malignant cells around the ablated tumour [24, 25]. Kotoh et al. [14] reported that 11 out of 138 patients who were treated with RFA suffered from rapid and scattered recurrences within 7 months of ablation. After evaluating a series of HCC cases treated by RFA with different devices and protocols and switching from the original full-expansion method to the modified stepwise deployment of internal prongs, no scattered recurrences were observed. Therefore, to reduce intra-tumoural pressure during RFA, stepwise deployment of internal prongs may be warranted when using a multi-tined electrode [26].

We demonstrated that size and poorly defined HCC margins are significant risk factors for early diffuse recurrence of HCC after RFA. Ruzzenente et al. [17] described four patients (4.5%) with recurrences out of 87 consecutive cirrhotic patients with 104 HCCs and suggested that the following risk factors should be considered: high AFP level (>200 kU/l), location of the tumour near the portal vein branches (< 1 cm from the main or segmental portal branches) and poor differentiation. However, in the current study, only a few tumours (5/32, 15.6%) were confirmed histologically, so risk factors based on the results of surgical pathological features could not be analysed. In addition, Ruzzenente et al. [17] included only four patients in their sample, whereas we included 23 patients with early diffuse recurrence. Differences in sample size may explain the identification of different risk factors affecting rapid tumour progression.

In a previous study by Yu et al. [27], tumour size, poor pathological differentiation of tumour cells and advanced tumour staging were shown to be risk factors for early local tumour recurrence within 1 year of RFA. However, Yu et al. [27] defined early recurrence as local tumour recurrence within 1 year of initial RFA, and included only three patients with early local tumour recurrence and eight patients with early intra-hepatic metastasis after RFA of single small HCC (tumour size: 3.2 ± 0.7 cm in the early local recurrence group, 2.4 ± 0.8 cm in the early intra-hepatic metastasis group) in their sample. In addition, they did not clarify the patterns of early recurrence (number of tumours, presence of extrahepatic metastasis). Based on accumulative mortality rates (2/27 patients, 7.4%), we hypothesised that the patterns of early recurrence were probably not diffuse as in our cases. Therefore, it is not reasonable to compare the series by Yu et al. with our series.

Large tumour size [19], absence of tumour capsule, indistinct margins [20], elevated serum levels of AFP [21] and microscopic vascular invasion [13] have been reported to increase the risk of early tumour recurrence after curative resection. Except for AFP levels, our results are in line with those of previous studies of the early diffuse recurrence after curative liver resection. Previous studies have indicated that increased levels of serum AFP are associated with intra-hepatic recurrence after RFA for HCC. In our study, the relationship between serum AFP and intra-hepatic recurrence was not significant (P = 0.645).

To our knowledge, this is the first study to analyse risk factors of early diffuse recurrence of HCC after RFA as a first-line treatment. Moreover, this is the largest series to date comparing patients with early diffuse recurrence with those without any recurrence. However, the present study has several limitations. First, this study was retrospective and was not a randomised or controlled trial. Second, only a small number of the tumours in this study (5/32, 15.6%) were histologically confirmed. Finally, data regarding the duration and number of sessions of RFA were unavailable.

In addition, during the study period, we have used a few different types of electrodes. More than 90% of cases were performed with Cool-tip RF system (Covidien, Boulder, CO, USA) in both groups. Because of small number of other electrodes used and missing data regarding the type of electrode used in several cases, it was impossible to perform any statistical analysis to clarify the relationship between the electrode type and early diffuse recurrence. The lack of the record on the RFA electrode, RFA technique and duration of ablation made it impossible to compare the rates of early diffuse recurrence between the two groups using different RFA technique and type of electrodes.

In conclusion, our results indicate that poorly defined margin was the only independent factor predicting early diffuse recurrence of HCC. Therefore, patients at risk of early diffuse recurrence should be treated with a combination of TACE [28, 29] to minimise the potential for therapeutic failure and should be closely monitored during the first year after treatment.

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Copyright information

© European Society of Radiology 2012

Authors and Affiliations

  • Hee Young Lee
    • 1
  • Hyunchul Rhim
    • 1
  • Min Woo Lee
    • 1
  • Young-sun Kim
    • 1
  • Dongil Choi
    • 1
  • Min Jung Park
    • 1
  • Young Kon Kim
    • 1
  • Seong Hyun Kim
    • 1
  • Hyo Keun Lim
    • 1
  1. 1.Department of Radiology and Center for Imaging ScienceSamsung Medical Center, Sungkyunwan University, School of MedicineSeoulKorea

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