Ultrasound Dosimetry In The HIFU Ablation And Clinical Study Combined With Orgon-helium Cryoablation For Hcc Patients

Section1Ultrasound dosimetry in the HIFU ablation for HCC patientsObjectiveBased on the results of SCT imaging, to establish dosimetry model by analyzingthe data from the HIFU ablation for HCC patients, considering the safety andefficacy. The aim was to provide the dosimetry basement for the TPS of HCC.Materials and Methods1. SubjectsFrom December2009to June2013,122patients (aged24to78years old,avergage:53.82±10.44years) were recruited in this study.Inclusion criteria:(1) Based on the diagnostic criteria of HCC in “primaryhepatic carcinoma linical guidelines (2011)”;(2) No other treatment before HIFUablation;(3) No distant metastasis and Inferior vena cava tumor emboli;(4) Nosurgery chance or refused to surgery treatment;(5) No severe systemic disease;(6)Patients who were aware of the danger and want to receive the HIFU treatment.Exclusion criteria:(1) Metastatic hepatic carcinoma;(2) Diffused hepatocellularcarcinoma;(3) Patients with unstable crdiac status and severe cerebrovasculardisease;（4）Patients with diabetes without controll.2. EquipmentJC200Focused Ultrasound Tumor Therapeutic System (Chongqing Haifu(HIFU) Tech Co, Ltd.)GE LightSpeed CT Imaging System 3. Methods3.1Image evaluation before treatmentA clinical imaging evaluation, including SCT and US, was completed beforeHIFU treatment. The three dimensional lines of HCC, D1, D2and D3weremeasured. The gross tumor volume (GTV)=0.5233*D1*D2*D3. The vasculardistribution of HCC was classified to grade0, grade I, II and grade Ⅲ, accordingSCT results.3.2HIFU ablation3.2.1Preparation:(1) Imitative positioning by the HIFU treatment system for smallHCC before formal treatment;(2) Skin preparation, indwelling catheter;(3) Bowelpreparation for patients with tumors near intestinal tract;(4) costectomy wasabandon.3.2.2The process of HIFU: a patient lied down in the right lateral position (HCClocated in right-lobe) or prone position (HCC located in left-lobe). Real-time guidingultrasonography was used to determine the lacation of HCC. Treatment was pointscanning and line scanning. Hyperechoic regions appeared on the US image andcovered all of planning treatment region.3.2.3Obserbation data:(1) Dose prarmeters: treatment time, exposure time andultrasonic power;(2) Safety evaluation: side effects and complications.3.3Post-treatment imaging evaluationEnhanced SCT imaging was carried out1months after the treatment for everypatient. Non-perfused volume ratio (NPVR)=non-perfused volume (NPV)/grosstumor volume (GTV).3.4ComplicationsSIR grading system was used to evaluate the severity.3.5Dosimetry analysis Energy effect factor (EEF) was usedEEF=η. Pt/V (J/mm3)η is focus coefficient(=0.7); P is ultrasonic power; t is exposure time; V isnon-perfused volume (NPV)(mm3); EEF is dosage for a unit tissue ablation.3.6Statistical analysisSPSS17.0Statistical software package was used to analyze the data. P value isless than0.05.Results1. Ablation technical results122patients received the HIFU treatment. The mean treatment time was2.76±1.34hours and mean exposure time was2301.98±1225.15seconds. The meansize of HCC was57.67±32.73mm and NPVR was73.73±22.37%.2. ComplicationsThe main complication was fever, pain, transaminase rise, skin numbness,pleural effusion, and so on. One case was skin burn Ⅲ grade in the groin area andother case was gaslrointestinal perforation. Most events are SIR classification A-B.3. Results of dosimetryThe ultrasonic dose are correlation with the size, distance from the liver edge,vascular distribution classificationand rib gap width. There was no correlationbetween EEF and abdominal wall thickness.Conclusions1.HIFU is safe and effective for HCC patients.2. EEF is a direct reflection of relationship between energy and ablation efficacy forHCC.3. The size, distance from the liver edge, vascular distribution classification and ribgap width can be used as measurement for prediction of US ablation dose. 4. Prediction equation of HIFU for HCC as follows: y=-56.096+21.029X1+1.165X2-0.502X3。(X1is1plus vascular distribution classification, X2is the distance fromthe tumor to liver edge, X3is mean diameter of HCC) Objecive1. The aim was to provide the basis to choose the best way to treat HCC bycomparing the efficacy of HIFU and argon-helium cryoablation in the treatment ofHCC with different blood supply and different sizes.2. Combined HIFU and argon-helium cryoablation treatment for hypervascular largeHCC. To evaluate the therapeutic efficacy of this combined therapy and comparewith single HIFU or argon-helium cryoablation treatment. To discuss theeffectiveness and feasibility of the combined therapy.Materials and Methods1. From June2011to June2013,120patients, aged28to76years old with a meanof53.70±9.82years old, were treated with HIFU and argon-helium cryoablationrespectively in our hospital. These patients were divided in two groups randomly.There was no significant difference in age, gender, size and blood supply betweenthe two groups. All patients were divided into four subgroups by their tumordiamerers (<3cm;3~5cm;5~10cm;>10cm) and blood supply (grade0; gradeⅠ;gradeⅡ; gradeⅢ). All these patients were examined by SCT after1month toevaluate the HIFU and argon-helium cryoablation therapeutic response.2. From December2009to June2013,20patients with hypervascular large HCC(diameter>5cm, blood supply is grade Ⅱ~Ⅲ), were treated with combined therapy(HIFU+argon-helium cryoablation). In these cases,12patients first received HIFU treatment,1week after treatment all patients were examined by SCT and foundresiduals, the nargon-helium cryoablation was used to treat these residuals as acompensatory treatment. Other8patients first received argon-helium cryoablationand HIFU were used to treat residuals.Results1. There are no significant difference between the efficacy of total ablation rate ofHIFU and argon-helium cryoablation. According to diameter, when diameter<3cm or3cm≤diameter<5cm, the difference between the efficacy of HIFU andargon-heliumcryoablation had no significant difference (P>0.05). However, when diameter≥5cm,the efficacy of argon-helium cryoablation was better than of HIFU (P<0.05).According to blood supply, in the hypovascular team (grade0~Ⅰ), there wasnosignificant difference between the efficacy of HIFU and argon-helium cryoablation.However in hypervascular team (grade Ⅱ~Ⅲ), the efficacy of argon-heliumcryoablation was better than that of HIFU.2. The patients with HIFU treatment had no severe complication. The commoncomplication of HIFU usually could be cured by symptomatic treatment orobservation. Only one patient with argon-helium cryoablationhad with “cold shock”suffered renal failure.3. According to Non-perfused volume ratio (NPVR), combined team(75%) hadbetter efficacy than HIFU team(30%)(P<0.05), but had no significant differencecompared with argon-helium cryoablation team(56.67%)(P>0.05). According to theimprovement of symptoms, there was no significant difference in three teams.According to the degree of AFP decline, combined team(76.47%) had better efficacythan HIFU team(43.48%) and argon-helium cryoablation team(44.00%).Conclusions1. Both HIFU and argon-helium cryoablation are effective on treating HCC. Especially, both of them are very effective to small and hypovascular HCC. Howeverthe curative effect of them would fall down in case big hypervascular HCC, and theeffect of argon-helium cryoablation would be better than that of HIFU.2. Both HIFU and argon-helium cryoablation are safe from treating HCC. We shouldmonitor and prevent the appearance of severe complications, such as cold shock andhaemorrhage3. The treatment combined HIFU with argon-helium cryoablation treatment is betterthan single HIFU or argon-helium cryoablation treatment for hypervascular largeHCC. Combined treatment are safe and effective.