Key clinical point: The primary outcome of local recurrence-free survival was significantly longer for lesions showing complete retention than for those showing incomplete retention, but overall survival was no different based on lipidiol retention.  

Major finding: After propensity score matching of 121 pairs of lesions with complete/incomplete retention, the median local recurrence-free survival for lesions exhibiting complete retention was 1,279 days, compared to a median of 819 days in the incomplete retention group (P = 0.030).

Study details: The data come from 198 adult patients with a total of 280 HCC lesions who underwent transarterial lipiodol injection and thermal ablation at three centers between June 2014 and September 2020.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Tan J et al. Abdom Radiol. 2021 Oct 12. doi: 10.1007/s00261-021-03305-3.

Key clinical point: The primary outcome of local recurrence-free survival was significantly longer for lesions showing complete retention than for those showing incomplete retention, but overall survival was no different based on lipidiol retention.  

Major finding: After propensity score matching of 121 pairs of lesions with complete/incomplete retention, the median local recurrence-free survival for lesions exhibiting complete retention was 1,279 days, compared to a median of 819 days in the incomplete retention group (P = 0.030).

Study details: The data come from 198 adult patients with a total of 280 HCC lesions who underwent transarterial lipiodol injection and thermal ablation at three centers between June 2014 and September 2020.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Tan J et al. Abdom Radiol. 2021 Oct 12. doi: 10.1007/s00261-021-03305-3.

Key clinical point: The primary outcome of local recurrence-free survival was significantly longer for lesions showing complete retention than for those showing incomplete retention, but overall survival was no different based on lipidiol retention.  

Major finding: After propensity score matching of 121 pairs of lesions with complete/incomplete retention, the median local recurrence-free survival for lesions exhibiting complete retention was 1,279 days, compared to a median of 819 days in the incomplete retention group (P = 0.030).

Study details: The data come from 198 adult patients with a total of 280 HCC lesions who underwent transarterial lipiodol injection and thermal ablation at three centers between June 2014 and September 2020.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Tan J et al. Abdom Radiol. 2021 Oct 12. doi: 10.1007/s00261-021-03305-3.

Key clinical point: Time to progression and progression-free survival significantly improved among adults with HCC who received a combination of trans-arterial chemoembolization (TACE) and sorafenib compared to those who received TACE alone or with placebo; both objective response rate and disease control rate also improved in combination therapy patients.

Major finding: The combination therapy of trans-arterial chemoembolization (TACE) and sorafenib significantly improved time to progression (hazard ratio 0.73; P = 0.03) and progression-free survival (HR 0.62; P < 0.00001) compared to TACE alone or with placebo; however, the combination did not improve overall survival compared to the other groups.

Study details: The data come from a meta-analysis of 7 randomized, controlled trials with a total of 1,464 patients; of these, 734 had TACE plus sorafenib and 730 had TACE plus placebo or TACE only.

Disclosures: The study was supported by the National Key Research and Development Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Dai Y et al. Transl Oncol. 2021 Oct 7. doi: 10.1016/j.tranon.2021.101238. 

Key clinical point: Time to progression and progression-free survival significantly improved among adults with HCC who received a combination of trans-arterial chemoembolization (TACE) and sorafenib compared to those who received TACE alone or with placebo; both objective response rate and disease control rate also improved in combination therapy patients.

Major finding: The combination therapy of trans-arterial chemoembolization (TACE) and sorafenib significantly improved time to progression (hazard ratio 0.73; P = 0.03) and progression-free survival (HR 0.62; P < 0.00001) compared to TACE alone or with placebo; however, the combination did not improve overall survival compared to the other groups.

Study details: The data come from a meta-analysis of 7 randomized, controlled trials with a total of 1,464 patients; of these, 734 had TACE plus sorafenib and 730 had TACE plus placebo or TACE only.

Disclosures: The study was supported by the National Key Research and Development Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Dai Y et al. Transl Oncol. 2021 Oct 7. doi: 10.1016/j.tranon.2021.101238. 

Key clinical point: Time to progression and progression-free survival significantly improved among adults with HCC who received a combination of trans-arterial chemoembolization (TACE) and sorafenib compared to those who received TACE alone or with placebo; both objective response rate and disease control rate also improved in combination therapy patients.

Major finding: The combination therapy of trans-arterial chemoembolization (TACE) and sorafenib significantly improved time to progression (hazard ratio 0.73; P = 0.03) and progression-free survival (HR 0.62; P < 0.00001) compared to TACE alone or with placebo; however, the combination did not improve overall survival compared to the other groups.

Study details: The data come from a meta-analysis of 7 randomized, controlled trials with a total of 1,464 patients; of these, 734 had TACE plus sorafenib and 730 had TACE plus placebo or TACE only.

Disclosures: The study was supported by the National Key Research and Development Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Dai Y et al. Transl Oncol. 2021 Oct 7. doi: 10.1016/j.tranon.2021.101238. 

Key clinical point: Nucleotide analog therapy (NtA) significantly reduced risk of HCC recurrence and increased overall survival compared to nucleoside analog therapy (NsA) in patients who underwent curative hepatectomy.

Major finding: Compared to NsA therapy, NtA therapy significantly decreased the risk of HCC recurrence (hazard ratio 0.64; P < 0.001) and HCC-related death (HR 0.52; P = 0.001) in patients after surgical resection.

Study details: The data come from a retrospective study of 1,303 adults with hepatitis B-related HCC who received curative hepatectomy at five centers between April 2014 and April 2019.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Qi W et al. Cancer Med. 2021 Oct 13. doi: 10.1002/cam4.4348.

Key clinical point: Nucleotide analog therapy (NtA) significantly reduced risk of HCC recurrence and increased overall survival compared to nucleoside analog therapy (NsA) in patients who underwent curative hepatectomy.

Major finding: Compared to NsA therapy, NtA therapy significantly decreased the risk of HCC recurrence (hazard ratio 0.64; P < 0.001) and HCC-related death (HR 0.52; P = 0.001) in patients after surgical resection.

Study details: The data come from a retrospective study of 1,303 adults with hepatitis B-related HCC who received curative hepatectomy at five centers between April 2014 and April 2019.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Qi W et al. Cancer Med. 2021 Oct 13. doi: 10.1002/cam4.4348.

Key clinical point: Nucleotide analog therapy (NtA) significantly reduced risk of HCC recurrence and increased overall survival compared to nucleoside analog therapy (NsA) in patients who underwent curative hepatectomy.

Major finding: Compared to NsA therapy, NtA therapy significantly decreased the risk of HCC recurrence (hazard ratio 0.64; P < 0.001) and HCC-related death (HR 0.52; P = 0.001) in patients after surgical resection.

Study details: The data come from a retrospective study of 1,303 adults with hepatitis B-related HCC who received curative hepatectomy at five centers between April 2014 and April 2019.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Qi W et al. Cancer Med. 2021 Oct 13. doi: 10.1002/cam4.4348.

Key clinical point: Patients with recurrent hepatocellular carcinoma had increased recurrence-free survival after rHR compared to RFA, but significantly lower morbidity and shorter hospital stays with RFA compared to rHR; overall survival rates were not significantly different between groups.

Major finding: The median recurrence-free survival was longer in recurrent HCC patients treated with rHR compared to RFA (23.6 months vs 15.2 months, hazard ratio 0.76). However, RFA was significantly association with lower morbidity of grade 3 and above (0.6% vs 6.2%) and with a shorter hospital stay (8.0 days vs 3.0 days) compared to rHR.

Study details: The data come from a retrospective, multicenter study including 847 HCC patients; of these, 307 underwent repeat hepatic resection (rHR) and 540 underwent radiofrequency ablation (RFA) between January 2003 and January 2018.

Disclosures: The study was supported by the Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Guangxi BaGui Scholars’ Special Fund, the Gunagxi Natural Science Foundation, and the Science Research and Technology Development Programme of Guangxi. The researchers had no financial conflicts to disclose.

Source: Zhong J-H et al. Br J Surg. 2021 Oct 13. doi: 10.1093/bjs/znab340.

Key clinical point: Patients with recurrent hepatocellular carcinoma had increased recurrence-free survival after rHR compared to RFA, but significantly lower morbidity and shorter hospital stays with RFA compared to rHR; overall survival rates were not significantly different between groups.

Major finding: The median recurrence-free survival was longer in recurrent HCC patients treated with rHR compared to RFA (23.6 months vs 15.2 months, hazard ratio 0.76). However, RFA was significantly association with lower morbidity of grade 3 and above (0.6% vs 6.2%) and with a shorter hospital stay (8.0 days vs 3.0 days) compared to rHR.

Study details: The data come from a retrospective, multicenter study including 847 HCC patients; of these, 307 underwent repeat hepatic resection (rHR) and 540 underwent radiofrequency ablation (RFA) between January 2003 and January 2018.

Disclosures: The study was supported by the Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Guangxi BaGui Scholars’ Special Fund, the Gunagxi Natural Science Foundation, and the Science Research and Technology Development Programme of Guangxi. The researchers had no financial conflicts to disclose.

Source: Zhong J-H et al. Br J Surg. 2021 Oct 13. doi: 10.1093/bjs/znab340.

Key clinical point: Patients with recurrent hepatocellular carcinoma had increased recurrence-free survival after rHR compared to RFA, but significantly lower morbidity and shorter hospital stays with RFA compared to rHR; overall survival rates were not significantly different between groups.

Major finding: The median recurrence-free survival was longer in recurrent HCC patients treated with rHR compared to RFA (23.6 months vs 15.2 months, hazard ratio 0.76). However, RFA was significantly association with lower morbidity of grade 3 and above (0.6% vs 6.2%) and with a shorter hospital stay (8.0 days vs 3.0 days) compared to rHR.

Study details: The data come from a retrospective, multicenter study including 847 HCC patients; of these, 307 underwent repeat hepatic resection (rHR) and 540 underwent radiofrequency ablation (RFA) between January 2003 and January 2018.

Disclosures: The study was supported by the Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Guangxi BaGui Scholars’ Special Fund, the Gunagxi Natural Science Foundation, and the Science Research and Technology Development Programme of Guangxi. The researchers had no financial conflicts to disclose.

Source: Zhong J-H et al. Br J Surg. 2021 Oct 13. doi: 10.1093/bjs/znab340.

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Results of a new analysis based on benchmarks from the National Institute for Occupational Safety and Health (NIOSH) suggest that the levels of metals and volatile organic compounds generated during laser tattoo removal procedures are generally safe.

While tattoo removal plume has not been previously studied, an analysis from 2016 found that laser hair removal plume contains toxic compounds, including carcinogens and environmental toxins, underscoring the importance of using smoke evacuators, good ventilation, and respiratory protection. “Ultrafine particles can become lodged in human alveoli in the lungs,” the study’s senior author, Mathew M. Avram, MD, JD, said during a virtual course on laser and aesthetic skin therapy. “This travels over distances, so it is potentially affecting people in your waiting room and others in areas within the clinic.”

For the study of laser tattoo removal plume, Yakir S. Levin, MD, PhD, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston; Dr. Avram, director of laser, cosmetics, and dermatologic surgery at MGH; and coinvestigators from NIOSH, conducted air sampling to determine the gaseous, particulate, and microbiological content of laser tattoo removal plume. They performed the study in ex vivo pig skin and in humans undergoing routine laser tattoo removal, and measured ultrafine particulate concentrations, metals, volatile organic compounds, and airborne bacteria.

For the swine portion of the study, they found that levels of metals including aluminum, copper, manganese, phosphorus, potassium, titanium, and zirconium were all below occupational exposure limits. All organic compounds including acetone and benzene were also below occupational exposure limits. “This is different than what we found in the study of laser plume generated during hair removal,” Dr. Avram said. “In laser hair removal, these were all elevated to a concerning extent.”

For the human part of the study, particle concentrations for ultrafine particulates were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the rest of the treatment room or outside of the room. Concentrations were 30 times lower for human skin than for pig skin. “We’re not sure why, but there were higher levels of ultrafine particulates right around the area we treated,” Dr. Avram said. “Still, they were all below exposure limits that would be concerning in terms of NIOSH. So, although they were elevated, they were still considered safe. That was the case for organic compounds as well.”

He pointed out that the study, which was supported by a grant from the American Society for Dermatologic Surgery (ASDS), did not include an analysis of viral particles generated during later tattoo removal “so there is a question about that,” and it is something worth studying, he said.

Dr. Avram, the current president of ASDS, noted that 17% of the estimated 40 million-plus Americans with tattoos have “tattoo regret,” and many turn to dermatologic surgeons for removal, which requires multiple treatments, and is painful and expensive.
 

Picosecond lasers

“One thing that’s changed in the past several years is the development of picosecond lasers, which produce extraordinarily high energy for an extraordinarily short period of time,” he said at the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. The desired endpoint is dermal whitening with cavitation and rupture. “You don’t want to see splatter with the epidermis flying off,” he said.

Several devices are commercially available with wavelengths of 532, 680, 755, 785, and 1064 nm, and pulse durations ranging from 300 to 750 picoseconds. Nd:Yag lasers target red and black ink, while alexandrite and ruby wavelengths target green and blue ink.

“After the treatment, we use simple Vaseline on top of the tattoo and a nonadherent Telfa dressing with paper tape over it,” Dr. Avram said. For patients with skin of color, he said, “occasionally I will add a steroid. Inflammation and redness can lead to hyperpigmentation. The steroid decreases some of that inflammation and therefore decreases the risk of hyperpigmentation.”

In his clinical experience, picosecond lasers are more effective at tattoo removal than Q-switched nanosecond lasers overall. With a picosecond laser, “you get some nonselective targeting of other pigments such as yellow to improve, even though you really don’t have the correct wavelength. I also think they are more effective for faded tattoos than the Q-switched nanosecond lasers, but they are significantly more expensive, so you need to think about that, and to what extent you are doing tattoo removal. In any event, it’s a multi-treatment process. You do it for multiple weeks between treatments and it takes time and patience. During the consultation, it is crucial to let patients know that.”

In 2012, R. Rox Anderson, MD, director of the Wellman Center for Photomedicine, and colleagues first described the R20 method for tattoo removal, which consists of four consecutive treatment passes with a Q-switched alexandrite laser separated by 20 minutes. “On the first treatment pass, there was an immediate whitening reaction “with little or no whitening on subsequent passes,” said Dr. Avram, who was not involved with the study. “Three months later, treatment with the R20 method was much more effective than conventional single-pass laser treatment. Light microscopy showed greater dispersion of the ink with the R20 method.” A follow-up study conducted at the Wellman Center did not completely support these findings, but a subsequent study led by Suzanne L. Kilmer, MD, was more supportive.

This concept has led to new treatment paradigms for tattoo removal, including the Food and Drug Administration–cleared perfluorodecalin patch, a transparent PFD-infused silicone patch that helps reduce scatter and improves efficacy. “It also allows for performing of repeat laser treatments at the same visit without waiting 20 minutes as you would with the R20 method,” Dr. Avram said. In a pilot study, 11 of the 17 patients showed more rapid clearance with the PFD patch than the control side versus one pass without the PFD patch. “It’s important to note that they used only one wavelength, and some of the tattoos weren’t appropriate for that wavelength, so 11 out of 17 is actually better than it might seem,” he said.

Ablative fractional resurfacing can play a role with tattoo removal, but Dr. Avram typically limits this option to recalcitrant tattoos. “Remember: You’re creating a zone of ablation with a cuff of coagulation, so you’re going to remove some of the tattoo just by creating those areas of clearance and vaporization,” he said. “You can do that in combination with the Q-switched or picosecond laser, which has better efficacy. The best way to do this is to start with the pigment laser – the picosecond or nanosecond laser – and then do the ablative fractional resurfacing afterward. You should never use IPL or laser hair removal lasers to remove tattoos, though. I see that occasionally. You’re going to burn your patients.”

Another approach is to use an Nd:Yag picosecond laser followed by microneedling. “What we’re trying to do here is get an egress of the tattoo pigments,” he explained. “We’re trying to mobilize the ink, get it out of the skin, and get it out of the macrophages to get improvement.”

In 2019, Soliton’s Rapid Acoustic Pulse (RAP) device was cleared by the FDA for tattoo removal. The device is indicated as an accessory to the 1064-nm Q-switched laser for black ink tattoo removal on the arms, legs, and torso in Fitzpatrick skin type I-III individuals. “It’s an application for 1 minute and that allows for additional laser passes,” Dr. Avram said. “You do the laser treatment, you do the acoustic shock wave device, and you do this as multiple passes. This is getting back to the R20 method, the idea that you are going to treat repeatedly. The rapid acoustic pulses result in dispersion and destruction of dermal vacuoles, which enables multiple laser passes in a single treatment session. If you can see the ink, you can ablate the ink.”

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, and Galderma. He is a member of the scientific advisory board for Allergan and Soliton, is an investigator for Endo, and holds stock options in La Jolla NanoMedical Inc.

[email protected]

Results of a new analysis based on benchmarks from the National Institute for Occupational Safety and Health (NIOSH) suggest that the levels of metals and volatile organic compounds generated during laser tattoo removal procedures are generally safe.

While tattoo removal plume has not been previously studied, an analysis from 2016 found that laser hair removal plume contains toxic compounds, including carcinogens and environmental toxins, underscoring the importance of using smoke evacuators, good ventilation, and respiratory protection. “Ultrafine particles can become lodged in human alveoli in the lungs,” the study’s senior author, Mathew M. Avram, MD, JD, said during a virtual course on laser and aesthetic skin therapy. “This travels over distances, so it is potentially affecting people in your waiting room and others in areas within the clinic.”

For the study of laser tattoo removal plume, Yakir S. Levin, MD, PhD, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston; Dr. Avram, director of laser, cosmetics, and dermatologic surgery at MGH; and coinvestigators from NIOSH, conducted air sampling to determine the gaseous, particulate, and microbiological content of laser tattoo removal plume. They performed the study in ex vivo pig skin and in humans undergoing routine laser tattoo removal, and measured ultrafine particulate concentrations, metals, volatile organic compounds, and airborne bacteria.

For the swine portion of the study, they found that levels of metals including aluminum, copper, manganese, phosphorus, potassium, titanium, and zirconium were all below occupational exposure limits. All organic compounds including acetone and benzene were also below occupational exposure limits. “This is different than what we found in the study of laser plume generated during hair removal,” Dr. Avram said. “In laser hair removal, these were all elevated to a concerning extent.”

For the human part of the study, particle concentrations for ultrafine particulates were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the rest of the treatment room or outside of the room. Concentrations were 30 times lower for human skin than for pig skin. “We’re not sure why, but there were higher levels of ultrafine particulates right around the area we treated,” Dr. Avram said. “Still, they were all below exposure limits that would be concerning in terms of NIOSH. So, although they were elevated, they were still considered safe. That was the case for organic compounds as well.”

He pointed out that the study, which was supported by a grant from the American Society for Dermatologic Surgery (ASDS), did not include an analysis of viral particles generated during later tattoo removal “so there is a question about that,” and it is something worth studying, he said.

Dr. Avram, the current president of ASDS, noted that 17% of the estimated 40 million-plus Americans with tattoos have “tattoo regret,” and many turn to dermatologic surgeons for removal, which requires multiple treatments, and is painful and expensive.
 

Picosecond lasers

“One thing that’s changed in the past several years is the development of picosecond lasers, which produce extraordinarily high energy for an extraordinarily short period of time,” he said at the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. The desired endpoint is dermal whitening with cavitation and rupture. “You don’t want to see splatter with the epidermis flying off,” he said.

Several devices are commercially available with wavelengths of 532, 680, 755, 785, and 1064 nm, and pulse durations ranging from 300 to 750 picoseconds. Nd:Yag lasers target red and black ink, while alexandrite and ruby wavelengths target green and blue ink.

“After the treatment, we use simple Vaseline on top of the tattoo and a nonadherent Telfa dressing with paper tape over it,” Dr. Avram said. For patients with skin of color, he said, “occasionally I will add a steroid. Inflammation and redness can lead to hyperpigmentation. The steroid decreases some of that inflammation and therefore decreases the risk of hyperpigmentation.”

In his clinical experience, picosecond lasers are more effective at tattoo removal than Q-switched nanosecond lasers overall. With a picosecond laser, “you get some nonselective targeting of other pigments such as yellow to improve, even though you really don’t have the correct wavelength. I also think they are more effective for faded tattoos than the Q-switched nanosecond lasers, but they are significantly more expensive, so you need to think about that, and to what extent you are doing tattoo removal. In any event, it’s a multi-treatment process. You do it for multiple weeks between treatments and it takes time and patience. During the consultation, it is crucial to let patients know that.”

In 2012, R. Rox Anderson, MD, director of the Wellman Center for Photomedicine, and colleagues first described the R20 method for tattoo removal, which consists of four consecutive treatment passes with a Q-switched alexandrite laser separated by 20 minutes. “On the first treatment pass, there was an immediate whitening reaction “with little or no whitening on subsequent passes,” said Dr. Avram, who was not involved with the study. “Three months later, treatment with the R20 method was much more effective than conventional single-pass laser treatment. Light microscopy showed greater dispersion of the ink with the R20 method.” A follow-up study conducted at the Wellman Center did not completely support these findings, but a subsequent study led by Suzanne L. Kilmer, MD, was more supportive.

This concept has led to new treatment paradigms for tattoo removal, including the Food and Drug Administration–cleared perfluorodecalin patch, a transparent PFD-infused silicone patch that helps reduce scatter and improves efficacy. “It also allows for performing of repeat laser treatments at the same visit without waiting 20 minutes as you would with the R20 method,” Dr. Avram said. In a pilot study, 11 of the 17 patients showed more rapid clearance with the PFD patch than the control side versus one pass without the PFD patch. “It’s important to note that they used only one wavelength, and some of the tattoos weren’t appropriate for that wavelength, so 11 out of 17 is actually better than it might seem,” he said.

Ablative fractional resurfacing can play a role with tattoo removal, but Dr. Avram typically limits this option to recalcitrant tattoos. “Remember: You’re creating a zone of ablation with a cuff of coagulation, so you’re going to remove some of the tattoo just by creating those areas of clearance and vaporization,” he said. “You can do that in combination with the Q-switched or picosecond laser, which has better efficacy. The best way to do this is to start with the pigment laser – the picosecond or nanosecond laser – and then do the ablative fractional resurfacing afterward. You should never use IPL or laser hair removal lasers to remove tattoos, though. I see that occasionally. You’re going to burn your patients.”

Another approach is to use an Nd:Yag picosecond laser followed by microneedling. “What we’re trying to do here is get an egress of the tattoo pigments,” he explained. “We’re trying to mobilize the ink, get it out of the skin, and get it out of the macrophages to get improvement.”

In 2019, Soliton’s Rapid Acoustic Pulse (RAP) device was cleared by the FDA for tattoo removal. The device is indicated as an accessory to the 1064-nm Q-switched laser for black ink tattoo removal on the arms, legs, and torso in Fitzpatrick skin type I-III individuals. “It’s an application for 1 minute and that allows for additional laser passes,” Dr. Avram said. “You do the laser treatment, you do the acoustic shock wave device, and you do this as multiple passes. This is getting back to the R20 method, the idea that you are going to treat repeatedly. The rapid acoustic pulses result in dispersion and destruction of dermal vacuoles, which enables multiple laser passes in a single treatment session. If you can see the ink, you can ablate the ink.”

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, and Galderma. He is a member of the scientific advisory board for Allergan and Soliton, is an investigator for Endo, and holds stock options in La Jolla NanoMedical Inc.

[email protected]

Results of a new analysis based on benchmarks from the National Institute for Occupational Safety and Health (NIOSH) suggest that the levels of metals and volatile organic compounds generated during laser tattoo removal procedures are generally safe.

While tattoo removal plume has not been previously studied, an analysis from 2016 found that laser hair removal plume contains toxic compounds, including carcinogens and environmental toxins, underscoring the importance of using smoke evacuators, good ventilation, and respiratory protection. “Ultrafine particles can become lodged in human alveoli in the lungs,” the study’s senior author, Mathew M. Avram, MD, JD, said during a virtual course on laser and aesthetic skin therapy. “This travels over distances, so it is potentially affecting people in your waiting room and others in areas within the clinic.”

For the study of laser tattoo removal plume, Yakir S. Levin, MD, PhD, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston; Dr. Avram, director of laser, cosmetics, and dermatologic surgery at MGH; and coinvestigators from NIOSH, conducted air sampling to determine the gaseous, particulate, and microbiological content of laser tattoo removal plume. They performed the study in ex vivo pig skin and in humans undergoing routine laser tattoo removal, and measured ultrafine particulate concentrations, metals, volatile organic compounds, and airborne bacteria.

For the swine portion of the study, they found that levels of metals including aluminum, copper, manganese, phosphorus, potassium, titanium, and zirconium were all below occupational exposure limits. All organic compounds including acetone and benzene were also below occupational exposure limits. “This is different than what we found in the study of laser plume generated during hair removal,” Dr. Avram said. “In laser hair removal, these were all elevated to a concerning extent.”

For the human part of the study, particle concentrations for ultrafine particulates were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the rest of the treatment room or outside of the room. Concentrations were 30 times lower for human skin than for pig skin. “We’re not sure why, but there were higher levels of ultrafine particulates right around the area we treated,” Dr. Avram said. “Still, they were all below exposure limits that would be concerning in terms of NIOSH. So, although they were elevated, they were still considered safe. That was the case for organic compounds as well.”

He pointed out that the study, which was supported by a grant from the American Society for Dermatologic Surgery (ASDS), did not include an analysis of viral particles generated during later tattoo removal “so there is a question about that,” and it is something worth studying, he said.

Dr. Avram, the current president of ASDS, noted that 17% of the estimated 40 million-plus Americans with tattoos have “tattoo regret,” and many turn to dermatologic surgeons for removal, which requires multiple treatments, and is painful and expensive.
 

Picosecond lasers

“One thing that’s changed in the past several years is the development of picosecond lasers, which produce extraordinarily high energy for an extraordinarily short period of time,” he said at the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. The desired endpoint is dermal whitening with cavitation and rupture. “You don’t want to see splatter with the epidermis flying off,” he said.

Several devices are commercially available with wavelengths of 532, 680, 755, 785, and 1064 nm, and pulse durations ranging from 300 to 750 picoseconds. Nd:Yag lasers target red and black ink, while alexandrite and ruby wavelengths target green and blue ink.

“After the treatment, we use simple Vaseline on top of the tattoo and a nonadherent Telfa dressing with paper tape over it,” Dr. Avram said. For patients with skin of color, he said, “occasionally I will add a steroid. Inflammation and redness can lead to hyperpigmentation. The steroid decreases some of that inflammation and therefore decreases the risk of hyperpigmentation.”

In his clinical experience, picosecond lasers are more effective at tattoo removal than Q-switched nanosecond lasers overall. With a picosecond laser, “you get some nonselective targeting of other pigments such as yellow to improve, even though you really don’t have the correct wavelength. I also think they are more effective for faded tattoos than the Q-switched nanosecond lasers, but they are significantly more expensive, so you need to think about that, and to what extent you are doing tattoo removal. In any event, it’s a multi-treatment process. You do it for multiple weeks between treatments and it takes time and patience. During the consultation, it is crucial to let patients know that.”

In 2012, R. Rox Anderson, MD, director of the Wellman Center for Photomedicine, and colleagues first described the R20 method for tattoo removal, which consists of four consecutive treatment passes with a Q-switched alexandrite laser separated by 20 minutes. “On the first treatment pass, there was an immediate whitening reaction “with little or no whitening on subsequent passes,” said Dr. Avram, who was not involved with the study. “Three months later, treatment with the R20 method was much more effective than conventional single-pass laser treatment. Light microscopy showed greater dispersion of the ink with the R20 method.” A follow-up study conducted at the Wellman Center did not completely support these findings, but a subsequent study led by Suzanne L. Kilmer, MD, was more supportive.

This concept has led to new treatment paradigms for tattoo removal, including the Food and Drug Administration–cleared perfluorodecalin patch, a transparent PFD-infused silicone patch that helps reduce scatter and improves efficacy. “It also allows for performing of repeat laser treatments at the same visit without waiting 20 minutes as you would with the R20 method,” Dr. Avram said. In a pilot study, 11 of the 17 patients showed more rapid clearance with the PFD patch than the control side versus one pass without the PFD patch. “It’s important to note that they used only one wavelength, and some of the tattoos weren’t appropriate for that wavelength, so 11 out of 17 is actually better than it might seem,” he said.

Ablative fractional resurfacing can play a role with tattoo removal, but Dr. Avram typically limits this option to recalcitrant tattoos. “Remember: You’re creating a zone of ablation with a cuff of coagulation, so you’re going to remove some of the tattoo just by creating those areas of clearance and vaporization,” he said. “You can do that in combination with the Q-switched or picosecond laser, which has better efficacy. The best way to do this is to start with the pigment laser – the picosecond or nanosecond laser – and then do the ablative fractional resurfacing afterward. You should never use IPL or laser hair removal lasers to remove tattoos, though. I see that occasionally. You’re going to burn your patients.”

Another approach is to use an Nd:Yag picosecond laser followed by microneedling. “What we’re trying to do here is get an egress of the tattoo pigments,” he explained. “We’re trying to mobilize the ink, get it out of the skin, and get it out of the macrophages to get improvement.”

In 2019, Soliton’s Rapid Acoustic Pulse (RAP) device was cleared by the FDA for tattoo removal. The device is indicated as an accessory to the 1064-nm Q-switched laser for black ink tattoo removal on the arms, legs, and torso in Fitzpatrick skin type I-III individuals. “It’s an application for 1 minute and that allows for additional laser passes,” Dr. Avram said. “You do the laser treatment, you do the acoustic shock wave device, and you do this as multiple passes. This is getting back to the R20 method, the idea that you are going to treat repeatedly. The rapid acoustic pulses result in dispersion and destruction of dermal vacuoles, which enables multiple laser passes in a single treatment session. If you can see the ink, you can ablate the ink.”

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, and Galderma. He is a member of the scientific advisory board for Allergan and Soliton, is an investigator for Endo, and holds stock options in La Jolla NanoMedical Inc.

[email protected]

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Key clinical point: The Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) effectively predicted tumor necrosis in patients treated for HCC with SBRT.

Major finding: The sensitivity was 71%-86% and specificity was 85%-96% for incomplete tumor necrosis of lesions treated with SBRT when the LR-TR Equivocal category was nonviable. When the LR-TR Equivocal category was viable, sensitivity was 88%-96% and specificity was

Study details: The data come from a retrospective study of 40 lesions treated with Stereotactic Body Radiation Therapy (SBRT) in 26 adult patients with HCC.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Mendiratta-Lala M et al. Int J Radiat Oncol Biol Phys. 2021 Oct 10. doi: 10.1016/j.ijrobp.2021.10.006.

Key clinical point: A combination of hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs) yielded a median of 10.6 months for progression-free survival with no treatment-related deaths over a 4- to 24-month follow-up period in advanced HCC patients.

Major finding: Combination chemotherapy and immunotherapy resulted in a median progression-free survival of 10.6 months with a median 12.9 months’ follow up; objective response rates and disease control rates were 63.0 and 92.6%, respectively.

Study details: The data come from a retrospective study of 27 adults with advanced hepatocellular carcinoma treated between May 2019 and November 2020 in a single center. Patients received hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs). 

Disclosures: The study was supported by the National Key R and D Program of China, the Key Projects of CSCO-Bayer Cancer Research Fund, the Beijing Municipal Science and Technology Commission, and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Liu B-J et al. Immunotherapy. 2021 Oct 5. doi: 10.2217/imt-2021-0192. 

Key clinical point: A combination of hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs) yielded a median of 10.6 months for progression-free survival with no treatment-related deaths over a 4- to 24-month follow-up period in advanced HCC patients.

Major finding: Combination chemotherapy and immunotherapy resulted in a median progression-free survival of 10.6 months with a median 12.9 months’ follow up; objective response rates and disease control rates were 63.0 and 92.6%, respectively.

Study details: The data come from a retrospective study of 27 adults with advanced hepatocellular carcinoma treated between May 2019 and November 2020 in a single center. Patients received hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs). 

Disclosures: The study was supported by the National Key R and D Program of China, the Key Projects of CSCO-Bayer Cancer Research Fund, the Beijing Municipal Science and Technology Commission, and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Liu B-J et al. Immunotherapy. 2021 Oct 5. doi: 10.2217/imt-2021-0192. 

Key clinical point: A combination of hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs) yielded a median of 10.6 months for progression-free survival with no treatment-related deaths over a 4- to 24-month follow-up period in advanced HCC patients.

Major finding: Combination chemotherapy and immunotherapy resulted in a median progression-free survival of 10.6 months with a median 12.9 months’ follow up; objective response rates and disease control rates were 63.0 and 92.6%, respectively.

Study details: The data come from a retrospective study of 27 adults with advanced hepatocellular carcinoma treated between May 2019 and November 2020 in a single center. Patients received hepatic artery infusion chemotherapy (HAIC), anti-PD-1 immunotherapy, and tyrosine kinase inhibitors (TKIs). 

Disclosures: The study was supported by the National Key R and D Program of China, the Key Projects of CSCO-Bayer Cancer Research Fund, the Beijing Municipal Science and Technology Commission, and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Source: Liu B-J et al. Immunotherapy. 2021 Oct 5. doi: 10.2217/imt-2021-0192. 

Key clinical point: Cabozatinib significantly improved overall survival and progression-free survival in HCC patients with ALBI grades 1 and 2 compared with placebo.

Major finding: Median overall survival in HCC patients with ALBI grade 1 was 17.5 months for in the cabozantinib group vs 11.4 months in the placebo group; median overall survival in patients with ALBI grade 2 was 8.0 months in the cabozantinib group vs 6.4 months in the placebo group.

Study details: The data come from a randomized trial of 707 adults with HCC with albumin-bilirubin (ALBI) grades 1 or 2 at baseline who received 60 mg of cabozantinib daily or a placebo.

Disclosures: The study was supported by Exelixis. Lead author Dr. Kelley disclosed relationships with multiple companies including Exelixis.

Source: Kelley RK et al. Br J Cancer. 2021 Oct 7. doi: 10.1038/s41416-021-01532-5.

Key clinical point: Cabozatinib significantly improved overall survival and progression-free survival in HCC patients with ALBI grades 1 and 2 compared with placebo.

Major finding: Median overall survival in HCC patients with ALBI grade 1 was 17.5 months for in the cabozantinib group vs 11.4 months in the placebo group; median overall survival in patients with ALBI grade 2 was 8.0 months in the cabozantinib group vs 6.4 months in the placebo group.

Study details: The data come from a randomized trial of 707 adults with HCC with albumin-bilirubin (ALBI) grades 1 or 2 at baseline who received 60 mg of cabozantinib daily or a placebo.

Disclosures: The study was supported by Exelixis. Lead author Dr. Kelley disclosed relationships with multiple companies including Exelixis.

Source: Kelley RK et al. Br J Cancer. 2021 Oct 7. doi: 10.1038/s41416-021-01532-5.

Key clinical point: Cabozatinib significantly improved overall survival and progression-free survival in HCC patients with ALBI grades 1 and 2 compared with placebo.

Major finding: Median overall survival in HCC patients with ALBI grade 1 was 17.5 months for in the cabozantinib group vs 11.4 months in the placebo group; median overall survival in patients with ALBI grade 2 was 8.0 months in the cabozantinib group vs 6.4 months in the placebo group.

Study details: The data come from a randomized trial of 707 adults with HCC with albumin-bilirubin (ALBI) grades 1 or 2 at baseline who received 60 mg of cabozantinib daily or a placebo.

Disclosures: The study was supported by Exelixis. Lead author Dr. Kelley disclosed relationships with multiple companies including Exelixis.

Source: Kelley RK et al. Br J Cancer. 2021 Oct 7. doi: 10.1038/s41416-021-01532-5.

Key clinical point: Barcelona Clinic Liver Cancer staging is applicable to recurrent HCC and should be used to formulate clinical stage criteria and develop treatment plans.

Major finding: The median time to tumor recurrence differed significantly among the BCLC staging groups A, B, and C (16 months, 10 months, and 6 months, respectively; P < 0.05). Median overall survival also differed significantly among groups A, B, and C (42 months, 22 months, and 13 months, respectively; P < 0.05).

Study details: The data come from a retrospective cohort study of 81 adults with recurrent HCC who were admitted to a single center between January 2013 and December 2017; they were divided into three groups based on the Barcelona Clinic Liver Cancer (BCLC) staging system to compare median time to tumor recurrence and median overall survival.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Yao S-Y et al. World J Clin Cases. 2021 Sep 26. doi: 10.12998/wjcc.v9.i27.8020.

Key clinical point: Barcelona Clinic Liver Cancer staging is applicable to recurrent HCC and should be used to formulate clinical stage criteria and develop treatment plans.

Major finding: The median time to tumor recurrence differed significantly among the BCLC staging groups A, B, and C (16 months, 10 months, and 6 months, respectively; P < 0.05). Median overall survival also differed significantly among groups A, B, and C (42 months, 22 months, and 13 months, respectively; P < 0.05).

Study details: The data come from a retrospective cohort study of 81 adults with recurrent HCC who were admitted to a single center between January 2013 and December 2017; they were divided into three groups based on the Barcelona Clinic Liver Cancer (BCLC) staging system to compare median time to tumor recurrence and median overall survival.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Yao S-Y et al. World J Clin Cases. 2021 Sep 26. doi: 10.12998/wjcc.v9.i27.8020.

Key clinical point: Barcelona Clinic Liver Cancer staging is applicable to recurrent HCC and should be used to formulate clinical stage criteria and develop treatment plans.

Major finding: The median time to tumor recurrence differed significantly among the BCLC staging groups A, B, and C (16 months, 10 months, and 6 months, respectively; P < 0.05). Median overall survival also differed significantly among groups A, B, and C (42 months, 22 months, and 13 months, respectively; P < 0.05).

Study details: The data come from a retrospective cohort study of 81 adults with recurrent HCC who were admitted to a single center between January 2013 and December 2017; they were divided into three groups based on the Barcelona Clinic Liver Cancer (BCLC) staging system to compare median time to tumor recurrence and median overall survival.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Yao S-Y et al. World J Clin Cases. 2021 Sep 26. doi: 10.12998/wjcc.v9.i27.8020.