Joint Hospital Surgical Grand Round Radiofrequency Ablation for the management of liver tumours - PowerPoint PPT Presentation

Joint Hospital Surgical Grand RoundRadiofrequency Ablation for the management of liver tumours

Dr SH Chok

Department of Surgery

Ruttonjee & Tang Shiu Kin Hospitals

• Hepatocellular carcinoma (HCC) is one of the most common solid tumours
• Estimated incidence ~ 1 million worldwide
• Surgical resection offers only hope of cure
• Only ~15% of patients with HCC suitable for resection
• Multifocal disease
• Close proximity to major structures
• Inadequate liver remnant reserve

• Liver is the second most common site for distant metastasis from solid tumours
• Particularly from colorectal cancer (CRC)
• ~50% of patients with CRC will develop metastasis or local recurrence within 5 years after initial “curative” resection
• Surgical resection result in 20-35% long-term survival
• 10-15% of patients are surgical candidate

• Percutaneous injection
• Percutaneous ethanol injection (PEI)
• Acetic acid/ hypertonic saline/ water
• Radioactive agents/ chemotherapeutic agents
• Thermal ablative therapies
• Cryoablation
• Laser-induced thermotherapy (LITT)
• Microwave coagulation therapy (MCT)
• Radiofrequency ablation (RFA)

• First described by Rossi et al in 1993
• Utilising high-frequency (200kHz- 20MHz) alternating current applied via an electrode(s) placed within the tissue to generate ionic agitation
• Change direction of the ions in cells
• Creating localised frictional heat
• Causes coagulative necrosis and tissue desiccation

(Strasberg et al. Curr Probl Surg 2003)

(Radiotherapeutics, Boston Scientific INC)

• Indications:
• Unresectable tumours (primary/ secondary)
• Multiple lesions ( 3)
• Diameter ( 5cm)
• Contraindications:
• Coagulopathy
• Gross ascites (for percutaneous route)
• Difficult position (for percutaneous route)
• Near major structures (e.g. bile duct)
• Extrahepatic diseases

(Lau et al. Annals of Surgery 2003)

• Bridge therapy
• Pre-liver transplantation

(Pulvirenti et al. Transplantation Proceedings 2001)

• Salvage procedure
• Intra-operative bilobar disease
• Resection + RFA

(Strasberg et al. Curr Probl Surg 2003)

• Overall incidence: 0- 12%
• Abscess formation
• Bleeding
• Bile leakage
• Bile duct stricture
• Liver failure
• Grounding pad burn
• Acute renal failure
• Mortality: 0- 1%

(Seidenfeld et al. J Am Coll Surg 2002)

• “Heat sink” effect
• Tumours situated near the major vessels may not have adequate ablation
• Need longer period of ablation
• Pringle maneuver
• More uniform and faster ablation but increased chance of portal vein thrombosis
• Generally not recommended
• Margin
• Margin of ablation is difficult to assess
• Imaging (Pre-op/ Intra-op)

• Percutaneous, laparoscopic or open surgery
• Prospective, non-randomised study
• Study period: March 1999- April 2001
• 45 patients with unresectable liver tumours were recruited
• HCC/ metastatic tumours: 11/ 34
• Median follow-up: 12 months

(BW Kuvshinoff & DM Ota. Surgery 2002)

Months

(BW Kuvshinoff & DM Ota. Surgery 2002)

• MEDLINE search from 1966 – 2003
• Keywords: RFA, liver tumours

• RCT, Study period: Dec 1996- Nov 1999
• HCC,  3 lesions,  3 cm, percutaneous route
• All patients had Child A/ B cirrhosis
• Mean follow-up: 16.3  5.1 months

(Lencioni et al. Radiology 1999)

• Prospective, non-randomised study
• Study period: Jan 1992- March 1998
• Mean follow-up period: 15 months
• HCC and metastatic tumours (41:105)
• Laparotomy with IOUS

(Pearson et al. Am J Surg 1999)

• RCT, Study period: March 1999- Oct 2000
• HCC,  4 cm,  3 lesions, percutaneous route
• All patients had Child A cirrhosis
• Follow-up period: 6-27 (18) months

(Shibata et al. Vascular and Interventional Radiology. 2002)

• Retrospective, Study period: 1996- 1999
• Multi-focal HCC, all had child A cirrhosis
• Follow-up period: 12- 36 months
• Percutanous route

(Livraghi et al. Radiology 2002)

• Case series, unresectable colorectal liver metastases
• All received surgery for primary tumours
• Percutaneous route

(Rossi et al.* Am J Roentgenol 1998, Solbiati et al.‖Radiology 1997)

• Merits of local ablative therapies are to preserve maximal amount of normal liver parenchyma and destroy the tumour in-situ
• RFA is a safe and effective procedure
• Most of the reported series were done under percutaneous route
• Small sample size, short follow-up period
• Heterogeneity of different studies

• Technical consideration (mode of delivery)
• Maximal tolerance of RFA
• Salvage procedure
• Role in primary treatment for resectable tumours ?
• Need more studies to validate its clinical use in unresectable / resectable liver tumours

• Retrospective study
• 14 cirrhotic patients with small HCC ( 3.5cm)
• RFA prior to transplanatation
• Median follow-up: 16 months
• Histology of the explant:
• complete necrosis: 71%
• incomplete necrosis: 29%
• tumour satellites < 1cm from main tumour: 57%
• No complication/ death/ recurrence

(Solbiati et al.‖Radiology 1997, SEER US 2002*)