Artificial ascites is feasible and effective for difficult-to-ablate hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the second leading cause of cancer death worldwide. Curative treatments for early-stage HCC include local ablation, hepatic resection, and liver transplant. Radiofrequency ablation (RFA) is a minimally invasive treatment and can be used in patients who have an increased risk of hepatic resection, including a liver reserve of Child-Pugh B status and suboptimal general condition. However, a difficult location of HCC can interfere with the performance of RFA because of a conspicuous lesion, poor electrode path, or increased risk of thermal injury to adjacent organs. Difficult locations include tumors abutting the diaphragm or near vital organs such as the gastrointestinal tract and gallbladder. Because artificial ascites can provide an improved sonic view and protects adjacent vital organs from thermal injury, it widens the indication of RFA in the treatment of HCC. The systemic review showed that the technique of artificial ascites has a high success rate (>90 %) without the clear appearance of severe adverse events such as intraperitoneal hemorrhage or gastrointestinal perforation. The risk of intraperitoneal seeding is not increased. In addition, the therapeutic effectiveness, such as the complete ablation rate or local tumor progression rate, remains satisfactory for difficult-to-ablate HCCs. In conclusion, RFA after infusion of artificial ascites is feasible and effective for difficult-to-ablate HCCs. However, because data on the local tumor progression rate, heat-sink effect, and intraperitoneal seeding are scarce, additional studies are required.