Radical surgery is the best potentially curative therapy for HCC, regardless of pregnancy. Moreover, various surgeries under general anesthesia have been safely performed during the second trimester . Accordingly, termination of pregnancy is not always necessary to perform surgery, except during the first trimester. In addition, delivery before 32 weeks of gestation should be avoided because of fetus immaturity.
In our case, the tumor was resectable at diagnosis but the patient refused to undergo resection because she could not dispel her concern about surgery under pregnancy despite assuring her of the safety. Previous literature reported that the pregnancy itself could promote rapid HCC growth and increase the risk of tumor rupture . Therefore, it could threaten both maternal and fetal life to delay treatment until delivery after 32 weeks of gestation.
We explored an alternative treatment strategy for her and discussed about RFA, the efficacy and the safety for a pregnant patient and her fetus.
A previously published article reported that overall survival and local control of both RFA and surgery for HCC nodules up to 2 cm are the same . In contrast, local recurrence increased in nodules of > 3 cm but local control with RFA was still high . In our case, only RFA could not have attained curability because the nodule was > 4 cm. We expected that RFA could decrease the risk of rapid growth and increase the chance that radical surgery could be performed after delivery.
There are no reports proving the safety of RFA for a pregnant patient. RFA causes tumor necrosis by inducing local hyperthermia accompanied by intravascular thrombosis and microvascular rupture. Because the treatment’s efficacy is localized, limiting complications to the surrounding structures only, we considered RFA might be safe for a patient and her fetus .
In addition, we must ponder the possibility of critical complications relating to RFA for pregnant patients such as hemorrhage, symptomatic pleural effusion, or massive ascites although they rarely occur .
Regarding other negative influence upon a patient, we must consider about the risk of dissemination by RFA which especially increases in HCC which is poorly differentiated, is highly invasive, and contacts with portal branches . Fortunately, the patient in our case did not have any characters of them and we believed this patient had low risk of dissemination by RFA.
We got the sufficient informed consent about both the benefit and the risks of RFA during pregnancy from the patient and her family and then, we decided to perform RFA for the local control until her delivery. As for medications used during RFA procedure, we usually choose lidocaine for local anesthesia and NSAIDs for pain control in our institution. In this case, we used lidocaine as usual, but we changed NSAIDs into acetaminophen which is safer for the fetus .
Pathological analysis revealed most of the tumor had become necrotic after RFA, and this proved to provide favorable local control of HCC. Moreover, the left viable lesion proved that the combination of RFA and surgery could indeed accomplish curability in our case.
Patients in our case have survived without recurrence for 6 years after the surgery. However, a previous article reported that RFA itself increased recurrent risk in a particular type of HCC which shows triple positive tumor marker: AFP, AFP-L3, and DCP . Both AFP and DCP were elevated but not AFP-L3 in our case. The problem is that AFP and AFP-L3 usually elevate due to pregnancy and it is difficult to evaluate the increase of those tumor markers straightforwardly as prognostic factors for pregnant patients with HCC. Even though, we must consider about this aggressive phenotype whenever we plan to perform RFA for HCC regardless of pregnancy.
In our case, no complication related to RFA occurred and RFA could be safely performed in our case; however, this was not enough to prove its safety during the second trimester. Moreover, its safety status during the first trimester is unknown. If RFA could be a choice throughout pregnancy and not present a risk to maternal or fetal life, it may be applicable in more cases. We expect to see more case reports demonstrating the safety and efficacy of RFA for HCC during pregnancy.