The median survival was 28 months in the group receiving both modalities compared to 18-19 months in those treated with only chemotherapy or ablation. As would be expected, survival was significantly correlated with the number of lesions ablated and therefore the extent of intrahepatic disease which likely reflected overall tumor biology.

An EORTC study (59) compared systemic chemotherapy (CT) alone to CT plus thermal tumor ablation and demonstrated a significant improvement in median progression free survival Inhibitors,research,lifescience,medical with the combined approach (16.8+ CT vs. 9.9 months, P=0.025), TWS119 although the 30-month overall survival difference was not significant. As a summary observation, for patients with unresectable CRHM, if thermal tumor ablation can

be safely performed, then the addition of TTA to systemic chemotherapy is a reasonable approach to control intrahepatic disease. Interestingly, recent literature suggests that both ablation and systemic agents may improve the host immune response to CRHM, which has been associated with improved survival (60). However, Inhibitors,research,lifescience,medical the superior Inhibitors,research,lifescience,medical outcomes of patients who received ablation in addition to systemic therapy may be in part dependent on selection of those with more favorable tumor biology. Should thermal tumor ablation be used in lieu of resection? This strategy may be applicable in select patients with contraindication to surgical resection in relation to extent of disease or medical co-morbidities. There are limitations Inhibitors,research,lifescience,medical to consider for avoiding treatment failure and/or hepatic damage. Initially, the size limit for tumors for RFA was 3cm, however over the last few years with increasingly powerful generators and improved needle configurations the lesion size cutoff has moved to 4cm. The advent of MWA technology has largely removed the theoretical limits of an ablation

size, although many lesions larger than 5cm are in close proximity to major Inhibitors,research,lifescience,medical portal structures. Although there have been no prospective randomized trials comparing RFA to resection, nor are there likely to ever be, the currently available data suggest evidence that RFA is an effective modality in the treatment of selected patients with CRHM <3cm in size, who are not suitable candidates for Casein kinase 1 surgical resection. In a study by Berber et al. (61), median overall survival for patients with unresectable CRHM, after laparoscopic RFA, was 28.9 months compared to historical controls with chemotherapy alone (10 to 14 months). In a study by Oshowo et al. (62), who treated patients with solitary CRHM, median survival after liver resection was 41 months compared to 37 months for RFA, while 3-year survival rate was 55.4% for resection compared to 52.6% for RFA, although 3-year follow up is not adequate. In another study (51), Hur et al. demonstrated that in RHM <3 cm, the 5-year survival rates following resection and RFA were similar, including overall (56.1% vs. 55.4%, P=0.451) and local recurrence-free (95.