Figure 1: Association of hepatocellular carcinoma with HBV and HCV by ethnicity

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Radiofrequency Ablation Using a Balloon Catheter for HepatocellularCarcinoma Adjacent to the Gastrointestinal Tract: Experimental and ClinicalStudyHidetaka Takenaka, Katsuyoshi Tamaki, Tatsuya Taniguchi, Tetsu Tomonari, Rie Harada,Katsutaka Sannomiya, Momoko Sato, Toshiya Okahisa, Seisuke Okamura, TetsujiTakayama

Purpose: Radiofrequency ablation (RFA) is a safe and effective technique for hepatocellularcarcinoma and it has minimal morbidity and mortality. One of the most important majorcomplications of RFA is perforation of the gastrointestinal tract, which occurs when thetumor is adjacent to the digestive tract. In particular, the risk is much higher in patientswith lesions located within 1 cm from the liver surface in proximity to the digestive tract.In such cases, an artificial ascites technique has been employed. However, the separationof adjacent digestive organ from the liver is insufficient in this method. Therefore, in thisstudy, to overcome this problem, we devised a novel RFA technique using a double-ballooncatheter. In the first step, an animal experiment was performed to evaluate the safety andfeasibility of the balloon RFA method. In the second step, the human pilot trial was carriedout to evaluate the safety, feasibility and effectiveness of this method. Materials and Methods:We produced an 8 Fr silicone catheter equipped with 2 balloons of 2.5 cm diameter. Inexperiments using pigs, we first inserted this balloon catheter percutaneously into theperitoneal space between the liver and gastrointestinal tracts, filled it with cooled water,and performed RFA for in normal liver 1 cm from the liver surface. Then, heat damage tothe excised liver and gastrointestinal tract was evaluated macroscopically andmicroscopically.In a human pilot study, balloon catheter RFA was performed in 4 patients with HCC (1.5± 0.7 cm) abutting the gastrointestinal tract. Results: In pigs, we performed each 6 RFAsessions with or without balloon catheter. It was technically easy to place the balloon catheterbetween liver and gastrointestinal tracts to separate them. Heat damage reached the liversurface in all lesions. In the groupwith balloon catheter, no heat damage of the gastrointestinaltracts was observed (0%, 0/6). In contrast, in the group without balloon catheter, heatdamage was observed in 5/6 (83.3%): stomach (2/6), small intestine (2/6), and omentum(1/6). The coolant temperature in the balloon was significantly increased after RFA, suggestingthat the heat generated by RFA was absorbed by the coolant. In the human pilot study,balloon catheter RFA was easily performed in all patients without associated complications.CT confirmed complete ablation with an appreciable safety margin in all patients, withoutrecurrence for 20.3 ± 4.5 months. Conclusions: RFA with our balloon catheter is safe andeffective for the treatment of HCC abutting the gastrointestinal tract, suggesting an expandedindication of these lesions for RFA.

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Serum Ferritin Level and Risk of Liver Cancer Development in Patients WithChronic Liver DiseasesKoji Uchino, Ryosuke Tateishi, Hayato Nakagawa, Toru Arano, Kenichiro Enooku, ErikoGoto, Ryota Masuzaki, Yuji Kondo, Yoshinari Asaoka, Tadashi Goto, Shuichiro Shiina,Hitoshi Ikeda, Masao Omata, Haruhiko Yoshida, Kazuhiko Koike

Backgrounds and Aims: Elevated serum ferritin level indicates increased liver iron concentra-tion that leads to exacerbation of hepatic necroinflammation in chronic liver diseases. Theaim of this study was to determine whether serum ferritin concentration is a risk factor forliver cancer development in chronic viral and non-viral liver diseases.Methods:Wemeasuredserum ferritin levels in 520 patients (mean age=61.8 ±11.5 yrs, M/F=234/286) who visited theauthors' liver clinic between January 2004 and December 2005. Patients with hepatocellularcarcinoma (HCC), iron-deficient anemia or decompensated disease at visit were excluded.They were divided into 5 groups according to serum ferritin levels: G1 (≤100 ng/mL, N=270), G2 (101-200 ng/mL, N=132), G3 (201-300 ng/mL, N=41), G4 (301-400 ng/mL, N=36) and G5 (>400 ng/mL, N=41). Patients were followed by periodical ultrasonographywith tumor markers for HCC development. We assessed the impact of serum ferritin levelon the hepatocarcinogenesis adjusted by multivariate Cox proportional hazard regressionwith other risk factors found significant in univariate analysis. Results: During mean followup period of 3.4 years, HCC developed in 55 patients. A V-shape relationship betweenserum ferritin levels and risk of HCC development was observed by univariate analysis usingG2 as a reference (hazard ratio [HR] for G1, G3, G4 and G5 were 1.63, 2.19, 2.86 and3.69, respectively). Multivariate analysis with stepwise variable selection revealed that serumferritin level > 400 ng/mL was a significant risk factor for HCC development (HR=2.492,p=0.02) along with sex, age, serum albumin level and liver stiffness measured by Fibroscan.Conclusions: Low ferritin levels might be a surrogate marker for more advanced disease.Excessive serum ferritin was a risk factor for HCC development in patients with chronicliver diseases.

S-925 AASLD Abstracts

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Serum Alfa-Feto Protein Level Does Not Predict Micro-Vascular Invasion inPatients Undergoing Orthotopic Liver Transplantation for HepatocellularCarcinomaFrank Czul, Andres Yarur, Cynthia Levy, Steven Rueda, Paul Martin

Background Multiple systems to predict the prognosis of hepatocellular carcinoma (HCC)have been formulated. Among them vascular invasion is a major determinant of outcomeafter orthotopic liver transplantation (OLT). Different preoperative means of assessing theprobability of micro-vascular invasion (MVI) have been studied in the past. Serum Alfa-fetoprotein (AFP) is a tumor marker, widely used to determine prognosis and recurrenceof disease. We sought to identify if serum levels of AFP before the OLT were correlated tothe degree of MVI found in the explanted livers. Methods A cohort of 179 patients whounderwent OLT for HCC between January of 2004 and December of 2008 at JacksonMemorial Hospital (Miami, FL) were identified, 28 were excluded because AFP was notavailable. Pathologic evidence of MVI was denoted on 49 (32%) of the studied population.AFP level was recorded before OLT on each patient. Other data such as ethnicity, tumorlocation, size, level of differentiation and relation to hepatitis B and C was also abstracted.The primary outcome was correlation of AFP levels and MVI defined as invasion of theperipheral portal or hepatic veins in the resected liver. The associations between the continu-ous and the categorical clinico-pathological variables and MVI were analyzed using ANOVAand chi-square test respectively. Logistic regression was used to identify association betweenMVI and the studied variables. Results Data from 151 patients was abstracted; patients withMVI (n=49,32%) had a mean serum AFP of 137 ng/ml compared to a mean serum AFP of81,1 ng/ml on patients where MVI was not found (p = 0.54). In the multivariate model,the adjusted OR for developing MVI for AFP level was 1.0 (95%CI 0.98-1.02). Twenty fivepercent of patients with single tumors and 43% with multiple tumors had MVI (p = 0.02).Only 18% of patients with tumors less than 2 cm had MVI compared to 30% and 78%with tumors greater than 2 to 5 cm and larger than 5 cm, respectively (p = 0.001). Among120 (79%) patients who had positive hepatitis C antibody, 33% had MVI compared to thecounterpart population negative for hepatitis C antibody where 29% had MVI (p = 0.83).Tumor grade was also analyzed: 23% of patients with well-differentiated tumors had MVI,compared to 30% and 75% with moderately or poorly differentiated tumors respectively(p = 0.01). Conclusions In our population, pre-operative serum AFP levels do not correlatewith MVI in patients undergoing OLT for hepatocellular carcinoma. The independent pre-dictors of MVI were tumor size greater than 5 cm, tumor grade (poorly differentiated) andmultiple tumors.

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Palliative Care for Hepatocellular Carcinoma PatientsYaa Oppong, Victor J. Navarro, Barbara Reville, Parminder K. Bath Sohal, Susan Parks

Management of patients with hepatocellular carcinoma (HCC) is usually focused on medicaltherapy aimed at prolonging life. The most effective therapy, liver transplantation, is offeredby convention only to patients with early stage disease. Few effective therapies are availablefor patients with advanced HCC which offer a substantive prolongation of life, makingpalliative care an important intervention in this group. Palliative care focuses on symptommanagement and end-of-life decision-making during medical care. The National Compre-hensive Cancer Network (NCCN) clinical guidelines support the incorporation of palliativecare (PC) into the treatment of cancer at time of diagnosis regardless of stage. However,there is little research on PC interventions for patients with hepatocellular carcinoma (HCC).To expand the body of literature on PC in HCC, we retrospectively examined our center'sexperience of the frequency of PC interventions, defined as referral to our PC service, hospiceprogram, or discussion about end-of-life preferences, code status, and family meetings,among these patients. Our HCC program is multidisciplinary and has been in place since2003, caring for approximately 100 patients at any one time. We identified 474 HCC patientstreated between 2004 and September 2010. Overall, PC interventions, as defined above,occurred in 62 patients (13%); 8.4% had referral to our inpatient palliative care team and4.4% to hospice. 3.8% of patients had documented code status, of these, 78% were DNI/DNR. Family meetings were documented in less than 1% of all patients.186 patients wereidentified with early disease (stage I), these are patients who at time of diagnosis whereeligible for transplant, only 17 (9%) received transplants and none had any end-of-lifeintervention. PC interventions for patients with advanced HCC were infrequent. Specifically,of 141 patients identified as having advanced HCC, defined as either stage III or IV disease,or involvement of the portal vessels; only 15 (10.6%) had any PC intervention. Our singlecenter experience indicates that any PC intervention is an infrequent occurrence, even inadvanced HCC. Given the growing incidence of HCC, and the limited survival despitetherapy, particularly for advanced disease, our findings indicate the need for fuller integrationof palliative care in this population.

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The Advantage in Long-Term Survival of Radiofrequency Ablation forHepatocellular Carcinoma Patients: Historical Comparison With EthanolInjectionSatoshi Oeda, Toshihiko Mizuta, Hiroshi Isoda, Takuya Kuwashiro, Shinji Iwane, YasunoriKawaguchi, Iwata Ozaki, Kazuma Fujimoto

Background and Aim: In 1999, we adopted radiofrequency ablation (RFA) for treatment ofsmall hepatocellular carcinoma (HCC). Since this time, the main local therapy for HCC hasshifted from percutaneous ethanol injection (PEI) to RFA. However, little is known onwhether there is a difference in the long-term efficacy between the two methods. Therefore,we historically compared the long-term survival rates of HCC patients treated with RFAwith those treated with PEI. Patients and Methods: Among 213 patients with HCC whowere initially treated with PEI or RFA at Saga Medical School Hospital between 1990 and2004, we examined 190 patients who could be followed up for more than 3 years aftertreatment. They consisted of 98 patients treated with PEI (PEI group) from 1990 to 1999

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