Feasibility of Hepatology-Directed Microwave Ablation in Management of Hepatocellular Carcinoma in North America: A Pilot Project
Mohammad S. Ansari*, Tomohiro Tanaka**,
, Sandeep T. Laroia***, Shiliang Sun***
Corresponding author
* Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
** Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
*** Division of Vascular and Interventional Radiology, Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Total HAV infections data from the National System for Epidemiological Surveilleance (SUIVE) by the SSA in 1994 and 2017 were collected and classified in HAV-infections by each state from Mexico, <span class="elsevierStyleBold">A</span>. Represents HAV infection distribution by state in 1994; a total of 9700 HAV cases were reported. <span class="elsevierStyleBold">B</span>. Represents HAV infection distribution by state in 2017; a total of 4636 HAV cases were reported.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge L. Trujillo-Ochoa, Oliver Viera-Segura, Nora A. Fierro" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jorge L." "apellidos" => "Trujillo-Ochoa" ] 1 => array:2 [ "nombre" => "Oliver" "apellidos" => "Viera-Segura" ] 2 => array:2 [ "nombre" => "Nora A." 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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2019;18:6-10" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 163 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 85 "PDF" => 70 ] ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Alcohol and the Liver: The Return of the Prodigal Son" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "6" "paginaFinal" => "10" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Octavio Campollo" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Octavio" "apellidos" => "Campollo" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S166526811930300X?idApp=UINPBA00004N" "url" => "/16652681/0000001800000001/v2_201907270857/S166526811930300X/v2_201907270857/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "titulo" => "Feasibility of Hepatology-Directed Microwave Ablation in Management of Hepatocellular Carcinoma in North America: A Pilot Project" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "11" "paginaFinal" => "13" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mohammad S. Ansari, Tomohiro Tanaka, Sandeep T. Laroia, Shiliang Sun" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Mohammad S." "apellidos" => "Ansari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "aff1" ] ] ] 1 => array:4 [ "nombre" => "Tomohiro" "apellidos" => "Tanaka" "email" => array:1 [ 0 => "tomohiro-tanaka@uiowa.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">**</span>" "identificador" => "aff2" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 2 => array:3 [ "nombre" => "Sandeep T." "apellidos" => "Laroia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">***</span>" "identificador" => "aff3" ] ] ] 3 => array:3 [ "nombre" => "Shiliang" "apellidos" => "Sun" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">***</span>" "identificador" => "aff1" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA" "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA" "etiqueta" => "**" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Division of Vascular and Interventional Radiology, Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA" "etiqueta" => "***" "identificador" => "aff3" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Introduction</span><p id="p0010" class="elsevierStylePara elsevierViewall">In both transplant and non-transplant settings, the establishment of a multidisciplinary approach for patients with hepatocellular carcinoma (HCC) has been reported to improve outcomes.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1,2</span></a> In North America, the management of HCC and survival outcomes is affected by having access to multidisciplinary tumor boards and specialists. The role of Hepatologists in active management of HCC is usually limited, however is associated with up to 30% reduction in mortality.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We theorize that access to Interventional Radiology for care in tumor management may be limited to large tertiary-care facilities and academic institutions, whereas Hepatologists are more readily available in the community setting. We therefore conducted this pilot study to investigate the feasibility of Hepatology-directed microwave ablation (MWA) of HCC tumors in collaboration with Interventional Radiology at an academic liver transplant (LT) center in North America.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Material and Methods</span><p id="p0015" class="elsevierStylePara elsevierViewall">We reviewed a prospective cohort of consecutive HCC cases receiving MWA for tumor treatment administered by a Hepatologist Dr. Tomohiro Tanaka (TT), who is also the primary Hepatologist involved in the care of these patients at the University of Iowa - Division of Gastroenterology/Hepatology and Organ Transplant Center. TT has completed a fellowship in Gastroenterology/Hepatology at a high volume liver cancer center in Japan.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> This training included comprehensive hands-on teaching of tumor ablative techniques for liver cancers, under the direct supervision of experienced attending Hepatologists. Upon completion of the 3-year fellowship, TT had successfully completed over 120 ablations and was certified for independent practice in performing the procedures. At the onset of this project in January 2017, TT had over 10 years of experience practicing as a Hepatologist.</p><p id="p0020" class="elsevierStylePara elsevierViewall">This project was conducted in collaboration with the Division of Interventional Radiology at the University of Iowa, where professional charges were divided equally amongst the two services depending on the primary practitioner.</p><p id="p0025" class="elsevierStylePara elsevierViewall">The HCC diagnosis was confirmed by multiphase magnetic resonance imaging (MRI) or computed tomography (CT). Board-certified radiologists diagnosed HCC on the basis of Liver Imaging Reporting and Data System (LI-RADS). Prior to the procedure, all patients with LI-RADS 4 or 5 were reviewed at our Multidisciplinary Hepatobiliary Tumor Board.</p><p id="p0030" class="elsevierStylePara elsevierViewall">MWA was performed from January 2017 to April 2018 under general anesthesia, using either Emprint Ablation System with Thermosphere Technology (Covidien, Boulder, CO) or Solero Microwave Tissue Ablation System (AngioDynamics, Latham, NY); both were used under real-time ultrasound guidance.</p><p id="p0035" class="elsevierStylePara elsevierViewall">Follow-up was performed with multiphase MRI or CT following ablation. Time to initial imaging varied between 4 and 6 weeks. MRI or CT was obtained every 3 months to evaluate disease progression in those with an initial complete response (CR), or earlier in those without. Response was evaluated by modified response evaluation criteria in solid tumor (mRECIST) criteria.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a> This project was approved by the institutional review board (#201708797).</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Outcomes</span><p id="p0040" class="elsevierStylePara elsevierViewall">During the study period, the Hepatologist conducted 14 cases of MWA for HCC (<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>). The first 5 cases were by Emprint system and the following 8 were by Solero system. Median follow up period was 3.1 (1.2 - 13.4) months post-treatment. 13 patients had solitary lesions which were between 11-44 mm (median 20.5 mm) in diameter, with 1 patient having 2 smaller sub-centimeter nodules (LI-RADS4) that were not amenable to treatment. BCLC stages were 0-A for all 14 patients. CLIP scores were between 0 and 3, with a median of 1. No patients experienced adverse events related to the procedures. All of the 14 underwent at least one (range, 1-4) follow up CT or MRI with 13 (93%) achieving complete remission (CR) and 1, who initially had largest tumor size of 44 mm, achieving partial response (PR). The 1 patient with PR was not indicated for TACE due to non-tumor portal vein thrombosis, and was alive at the end of the study period. Only 1 patient died, from primary lung cancer which was diagnosed 8 months following the MWA for HCC, and no further liver lesions amenable to intervention were observed throughout the follow-up period. All other 12 patients were alive without local or distant recurrence at the end of the study period.</p><elsevierMultimedia ident="t0010"></elsevierMultimedia></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Discussion</span><p id="p0045" class="elsevierStylePara elsevierViewall">Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second most frequent cause of cancer-related death worldwide.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> Liver resection, thermal ablation, and liver transplantation are potentially curative treatments, with 5-year survival up to 70%, with thermal ablative techniques being used for treatment of non-resectable HCC.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> No conclusive studies have been done comparing MWA to radiofrequency ablation (RFA), however likely advantages include shorter ablation time, less pain, and less heat sink effect. MW energy produces faster heating and higher temperatures, which results in better demarcated and larger area of necrosis as compared with RFA,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> thus MWA was chosen for this project.</p><p id="p0050" class="elsevierStylePara elsevierViewall">The treatment of HCC is particularly complex, and thus often involves both tumor-specific (size, number, and portal vein thrombosis) and liver disease-specific (cirrhosis, portal hypertension and/or coagulopathy) considerations. Therefore, the delivery of care to patients with HCC is best conducted with a multidisciplinary approach.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">2,3</span></a> Although multiple studies have shown that multispecialty involvement in regards to treatment of HCC has overall improved survival benefit and patient outcomes, this is often limited by geographical limitations in access to facilities and specialists and may delay initiation of treatment.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1,2</span></a> In the United States, thermal ablation has been traditionally conducted by trained Radiologists rather than Hepatologists. In contrast, in other parts of the world such as East Asia, Hepatologists have been trained in ultrasound-guided locolesional therapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a> There are no studies comparing Hepatology-directed thermal ablation therapy to Radiology-directed procedures. We believe that allowing trained Hepatologists to play a pivotal and direct role in HCC treatment using ultrasound-guided MWA in collaboration with Radiologists is a new and innovative strategy to the comprehensive multidisciplinary team approach, with improved early access to treatment and improved patient survival and satisfaction.</p><p id="p0055" class="elsevierStylePara elsevierViewall">The limitations of the pilot study include the relatively small number of patients enrolled thus far without a control arm. In addition, 1 out of the 14 patients died from primary lung cancer in addition to primary liver cancer. It is unlikely that the liver tumor treated was a metastatic lesion given negative chest imaging immediately before the initial diagnosis of HCC, however this has to be taken into consideration. The current training curriculum in North America for Gastrotenterology/Hepatology fellows typically does not include learning image-guided procedures for liver tumors including thermal ablative techniques, which may be an important future consideration for training programs.</p><p id="p0060" class="elsevierStylePara elsevierViewall">Overall, Hepatology-directed thermal ablative management of HCC may be an innovative strategy to improving the patient access and treatment rates, decrease dropouts in LT waitlist, and ultimately allow for improved overall survival with a comprehensive multidisciplinary team approach. Further studies with large number of patients including a control arm and longer follow up period is required to draw more robust conclusions.</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Abbreviations</span><p id="p0065" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">•</span><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CR</span>: complete response.</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">•</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CT</span>: computed tomography.</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">•</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HCC</span>: hepatocellular carcinoma.</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">•</span><p id="p0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LI-RADS</span>: liver imaging reporting and data system.</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">•</span><p id="p0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">mRECIST</span>: modified response evaluation criteria in solid tumor.</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">•</span><p id="p0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MRI</span>: magnetic resonance imaging.</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">•</span><p id="p0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MWA</span>: microwave ablation.</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">•</span><p id="p0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PR</span>: partial response.</p></li><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">•</span><p id="p0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">RFA</span>: radiofrequency ablation.</p></li></ul></p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Conflict of Interest</span><p id="p0115" class="elsevierStylePara elsevierViewall">The authors declares that there is no conflict of interest regarding the publication of this article.</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Funding</span><p id="p0120" class="elsevierStylePara elsevierViewall">This study is not funded.</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Author Contributions</span><p id="p0125" class="elsevierStylePara elsevierViewall">MSA (acquisition of data; drafting of the manuscript), TT (study concept and design; analysis and interpretation of data; critical revision of the manuscript), STL and SS (study concept and design; supervision of the study).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1224753" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1138819" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "s0010" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "s0015" "titulo" => "Material and Methods" ] 4 => array:2 [ "identificador" => "s0020" "titulo" => "Outcomes" ] 5 => array:2 [ "identificador" => "s0025" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "s0030" "titulo" => "Abbreviations" ] 7 => array:2 [ "identificador" => "s0035" "titulo" => "Conflict of Interest" ] 8 => array:2 [ "identificador" => "s0040" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "s0045" "titulo" => "Author Contributions" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-29" "fechaAceptado" => "2018-12-12" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1138819" "palabras" => array:4 [ 0 => "Multidisciplinary approach" 1 => "Hepatology" 2 => "Radiology" 3 => "HCC" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">In North America, the role of Hepatologists in treatment of hepatocellular carcinoma is limited. We conducted a pilot project wherein a Hepatologist participated directly in microwave ablation of HCC at an academic center in the United States (n = 14). The pilot project shows promising outcomes, with complete remission rate of 93%.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "t0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Unless otherwise indicated, numbers are shown as median (range).</span>" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age 60 (35-73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(n = 12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(n = 2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MELD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (6-22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Child-Pugh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6-A (5-9, A-B) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCLC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A (0-A) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CLIP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0-3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AFP (ng / mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.70 (2-69.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumor number \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1-3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumor size (largest diameter, cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 (0.7-4.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n= 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">S8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">mRECIST at First CT / MRI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n= 13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">mRECIST at Last CT / MRI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow up period (m) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 (1.2 - 14.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092074.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Profile of patients with HCC undergoing MWA.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0010" "etiqueta" => "1." 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"autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Arii S." 1 => "Yamaoka Y." 2 => "Futagawa S." 3 => "Inoue K." 4 => "Kobayashi K." 5 => "Kojiro M." 6 => "Makuuchi M." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/jhep.2000.20456" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2000" "volumen" => "32" "paginaInicial" => "1224" "paginaFinal" => "1229" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11093728" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/16652681/0000001800000001/v2_201907270857/S1665268119303011/v2_201907270857/en/main.assets" "Apartado" => array:4 [ "identificador" => "77722" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Viewpoint" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/16652681/0000001800000001/v2_201907270857/S1665268119303011/v2_201907270857/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119303011?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 9 | 12 | 21 |
| 2024 September | 16 | 13 | 29 |
| 2024 August | 19 | 7 | 26 |
| 2024 July | 12 | 4 | 16 |
| 2024 June | 12 | 3 | 15 |
| 2024 May | 9 | 4 | 13 |
| 2024 April | 10 | 3 | 13 |
| 2024 March | 12 | 9 | 21 |
| 2024 February | 23 | 5 | 28 |
| 2024 January | 17 | 7 | 24 |
| 2023 December | 12 | 8 | 20 |
| 2023 November | 13 | 6 | 19 |
| 2023 October | 12 | 9 | 21 |
| 2023 September | 8 | 1 | 9 |
| 2023 August | 14 | 7 | 21 |
| 2023 July | 9 | 6 | 15 |
| 2023 June | 26 | 1 | 27 |
| 2023 May | 34 | 2 | 36 |
| 2023 April | 49 | 0 | 49 |
| 2023 March | 20 | 2 | 22 |
| 2023 February | 13 | 3 | 16 |
| 2023 January | 11 | 2 | 13 |
| 2022 December | 11 | 8 | 19 |
| 2022 November | 20 | 11 | 31 |
| 2022 October | 9 | 4 | 13 |
| 2022 September | 11 | 9 | 20 |
| 2022 August | 9 | 7 | 16 |
| 2022 July | 12 | 6 | 18 |
| 2022 June | 12 | 12 | 24 |
| 2022 May | 9 | 8 | 17 |
| 2022 April | 15 | 9 | 24 |
| 2022 March | 12 | 12 | 24 |
| 2022 February | 12 | 9 | 21 |
| 2022 January | 19 | 7 | 26 |
| 2021 December | 6 | 10 | 16 |
| 2021 November | 11 | 9 | 20 |
| 2021 October | 11 | 12 | 23 |
| 2021 September | 18 | 9 | 27 |
| 2021 August | 27 | 5 | 32 |
| 2021 July | 35 | 8 | 43 |
| 2021 June | 11 | 6 | 17 |
| 2021 May | 16 | 10 | 26 |
| 2021 April | 20 | 19 | 39 |
| 2021 March | 7 | 4 | 11 |
| 2021 February | 7 | 5 | 12 |
| 2021 January | 7 | 11 | 18 |
| 2020 December | 6 | 6 | 12 |
| 2020 November | 12 | 9 | 21 |
| 2020 October | 7 | 8 | 15 |
| 2020 September | 5 | 9 | 14 |
| 2020 August | 7 | 11 | 18 |
| 2020 July | 10 | 10 | 20 |
| 2020 June | 6 | 5 | 11 |
| 2020 May | 7 | 7 | 14 |
| 2020 April | 6 | 1 | 7 |
| 2020 March | 4 | 3 | 7 |
| 2020 February | 9 | 9 | 18 |
| 2020 January | 5 | 6 | 11 |
| 2019 December | 5 | 7 | 12 |
| 2019 November | 4 | 1 | 5 |
| 2019 October | 7 | 2 | 9 |
| 2019 September | 8 | 3 | 11 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 9 | 5 | 14 |
| 2019 June | 8 | 16 | 24 |
| 2019 May | 7 | 10 | 17 |
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