Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Experience with more than 500 minimally invasive hepatic procedures

OBJECTIVE

To evaluate our experience with more than 500 minimally invasive hepatic procedures.

SUMMARY BACKGROUND DATA

Recent data have confirmed the safety and efficacy of minimally invasive liver surgery. Despite these reports, no programmatic approach to minimally invasive liver surgery has been proposed.

METHODS

We retrospectively reviewed all patients who underwent a minimally invasive procedure for the management of hepatic tumors between January 2001 and April 2008. Patients were divided into 3 groups: laparoscopy with intraoperative ultrasound and biopsy only, laparoscopic radiofrequency ablation (RFA), and minimally invasive resection. To compare the various forms of surgery, we analyzed the incidence of complications, tumor recurrence, mortality, and cost. Statistical analysis was performed using chi(2) analysis, Student t test, Kaplan-Meier survival analysis with the log-rank test, and multivariable Cox models.

RESULTS

A total of 590 minimally invasive hepatic procedures were performed during 489 operative interventions. The representative tumor histologies were: hepatocellular carcinoma (HCC; N = 210), colorectal carcinoma (N = 40), miscellaneous liver metastases (N = 42), biliary cancer (N = 20), and benign tumors (N = 176). Thirty-five patients underwent laparoscopic ultrasound and confirmatory biopsy alone; 201 patients underwent 240 laparoscopic RFAs, and 253 patients underwent 306 minimally invasive resections. Conversion rates to open surgery for the RFA and resection group were 2% overall. One hundred ninety-nine (40.6%) patients were cirrhotic; 31 resections were performed in cirrhotic patients. Complication and mortality rates for RFA and resection were comparable (11% vs. 16%, and 1.5% vs. 1.6%). However, complication rates (14% vs. 29%; P = 0.02) and mortality (0.3% vs. 9.7%; P = 0.006) rates were higher in the cirrhotic versus noncirrhotic resection group. Overall recurrence rates for RFA and resection groups were 24% and 23%, respectively. Local recurrence rates were higher in the RFA group (6.3% versus 1.5%; P < 0.06). Overall patient survival differed between HCC patients receiving RFA alone and those receiving RFA and OLT (P < 0.0001). Overall survival for cancer patients receiving RFA versus resection differed significantly when unadjusted for other covariates (P = 0.01), and remained marginally significant in a multivariable model (P = 0.056).

CONCLUSIONS

Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. Our present data are equivalent or superior to those encountered in any large open series. Our experience with RFA confirms a low local recurrence rate and an excellent technique for bridging patients to transplantation. Morbidity and mortality rates for minimally invasive hepatic resections in cirrhotics, is similar to other reported open resection series. This series confirmed excellent interim survival rates after laparoscopic HR and superiority over RFA in the treatment of cancer, with significantly lower local tumor recurrence rate.

Percutaneous radiofrequency ablation for treatment of hepatoblastoma recurrence

Radiofrequency ablation (RFA) has been widely reported as a minimally invasive treatment for liver tumours in adults, but has not been documented as a treatment for hepatoblastoma in a child. We report a 2-year-old boy with local recurrence of hepatoblastoma after partial hepatectomy. Percutaneous RFA was performed under real-time sonographic guidance. There was no imaging evidence of recurrence after a follow-up of 2 years. We consider this a promising technique in children.

Inoperable colorectal liver metastases: a declining entity?

BACKGROUND

Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation.

METHODS

Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease.

RESULTS

Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection).

CONCLUSION

A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.

Percutaneous cryosurgery for the treatment of hepatic colorectal metastases

AIM: To determine the safety and efficacy of efficacy of percutaneous cryosurgery for treatment of patients with hepatic colorectal metastases.

METHODS: Three hundred and twenty-six patients with non-resectable hepatic colorectal metastases underwent percutaneous cryosurgery under the guidance of ultrasound or CT. Follow-up was 1 mo after cryosurgery and then every 4 mo thereafter by assessment of tumor markers, liver ultrasonography, and abdominal CT. For lesions suspicious of recurrence, a liver biopsy was performed and subsequent repeat cryosurgery was given if histology was positive for cancer.

RESULTS: All patients underwent a total of 526 procedures of cryosurgery. There were 151 patients who underwent repeat procedures of cryosurgery for recurrent tumors in the liver and extrahepatic places. At 3 mo after cryosurgery, carcinoembryonic antigen (CEA) levels in 197 (77.5%) patients who had elevated markers before cryosurgery decreased to normal range. Among 280 patients who received CT following-up, cryotreated lesions showed complete response (CR) in 41 patients (14.6%), partial response (PR) in 115 patients (41.1%), stable disease (SD) in 68 patients (24.3%) and progressive disease (PD) in 56 patients (20%). The recurrence rate was 47.2% during a median follow-up of 32 mo (range, 7-61). Sixty one percent of the recurrences were seen in liver only and 13.9% in liver and extrahepatic areas. The recurrence rate at cryotreated site was only 6.4% for all cases. During a median follow-up of 36 mo (7-62 mo), the median survival of all patient was 29 mo (range 3-62 mo). Overall survival was 78%, 62%, 41%, 34% and 23% at 1, 2, 3, 4 and 5 years, respectively, after the treatment. Patients with tumor size less than 3 cm, tumor in right lobe of liver, lower CEA levels (< 100 ng/dL) and post-cryosurgery TACE had higher survival rate. There was no significant difference in terms of survival based on the number of tumors, pre-cryosurgery chemotherapy and the timing of the development of metastases (synchronous vs metachronous). Patients who underwent 2-3 procedures of cryosurgery had increased survival compared to patients who received cryosurgery once only. There was no intra-cryosurgery mortality. Main adverse effects, such as hepatic bleeding, cryoshock, biliary fistula, liver failure, renal insufficiency and liver abscess were only observed in 0.3%-1.5% of patients.

CONCLUSION: Percutaneous cryosurgery was a safe modality for hepatic colorectal metastases. Rather than an alternative to resection, this technique should be regarded as a complement to hepatectomy and as an additional means of achieving tumor eradication when total excision is not possible.

Role of B-mode ultrasound screening in detection of local tumor recurrence in the first year after radiofrequency ablation in the liver

BACKGROUND

Ultrasound is known to be useful in imaging radiofrequency ablation (RFA) lesions intra- and postoperatively. The presented study intends to prove the value of ultrasound examination as a means of screening RFA-treated patients for local tumor recurrence.

PATIENTS AND METHODS

During a period of 47 months, 91 RFA treatments were performed in 61 patients in a single institution. Indications for RFA were hepatocellular carcinoma (74%), colorectal metastases (18%), recurrent cholangiocellular carcinoma (5%) and one neuroendocrine tumor metastasis as well as one metastasis of pancreatic cancer (1.5% each). RFA was only considered in non-resectable liver cancer. All applications were conducted under sonographic guidance following preoperative evaluation. Postoperative screening included sonographic examinations at intervals of 3, 6 and 12 months postoperatively, and further annual follow-up examinations. Mean follow-up period was 11.8 months.

RESULTS

Within the first 12 months after treatment, the lesions become more and more inhomogenous with mixed echogeneity. Occasionally, this evolves as a misleading finding, mimicking early tumor recurrence. To clarify suspicious cases (31%), magnetic resonance imaging (20%) or computed tomography (10%) was engaged. Ultrasound led to the detection of local tumor recurrence in 78% of recurrent HCC (13 patients), but only in 67% of metastatic diseases (3 patients). Overall local recurrence rate was 18%.

CONCLUSION

Ultrasound screening as a follow-up of primary hepatic malignancies is, due to its sensitivity, capable of detecting early local recurrence despite its low specifity. Appropriate application of particular criteria of local recurrence allows B-mode ultrasound to play a major role in screening RFA-treated patients.

Current status of liver tumor ablation devices

The liver is a common site of disease for both primary and metastatic cancer. Since most patients have a disease that is not amenable to surgical resection, tumor ablation modalities are increasingly being used for treatment of liver cancer. This review describes the current status of ablative technologies used as alternatives for resection, clinical experience with these technologies, currently available devices and design rules for the development of new devices and the improvement of existing ones. It focuses on probe design for radiofrequency ablation, microwave ablation and cryoablation, and compares the advantages and disadvantages of each ablation modality.

Cryosurgery for hepatocellular carcinoma

Cryosurgery is an important treatment modality for unresectable hepatocellular carcinoma (HCC). There are different forms of cryosurgery for HCC including intraoperative cryoablation with or without excision, laparoscopic liver cryosurgery, percutaneous liver cryoablation under the guidance of ultrasonography, CT or MRI. Cryoablation, as a local therapy for HCC, has certain advantages over other forms of treatment. It is able to destroy only tumor tissue in the liver while sparing more noninvolved tissues. Tumors close to the vessel systems can safely undergo cryoablation due to the warming effect of circulating blood in large blood vessels. Liver cryoablation is more effective than surgical resection for multiple liver tumors. Cryosurgery in combination with transarterial chemoembolization (TACE), alcohol injection or ¹²⁵iodine seed implantation has a complementary efficacy. Clinically, cryosurgery for HCC is performed according to the following principles. Intraoperative or percutaneous cryosurgery may be performed for liver tumors < 5 cm or ≤3 cm, TACE for liver tumors > 5 cm followed by percutaneous cryosurgery. Liver tumors > 5 cm with an irregular margin, may also undergo intraoperative or percutaneous cryosurgery followed by alcohol injection or ¹²⁵iodine seed implantation in the margins of tumors.

Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works

The aim of this study was to evaluate prospectively post-radiofrequency ablation (RFA) syndrome and to determine its effect on the quality of life in the 15 days after percutaneous RFA treatment. We carried out an internal review board-approved prospective study of the delayed symptoms that occurred after 71 consecutive RFA sessions in 53 patients (12 women and 41 men; age range 45-83 years; mean age 71.6 years) with 45 primary liver tumours, 34 liver metastases, 3 renal cell carcinoma (RCC), 2 residual lesions from RCC after nephrectomy and 1 pancreatic metastases from RCC. Postablation symptoms occurred in 17 of 53 (32%) patients. Six of 17 patients developed low-grade fever (from 37.5 to 38.5 degrees C). Other symptoms included delayed pain (9/17), nausea (7/17), vomiting (3/17), malaise (3/17) and myalgia (1). Postablation syndrome is a common phenomenon after RFA of solid abdominal tumours. Not only in our study but also in the previous ones the occurrence is observed in approximately one-third patients. Patients should be informed that these symptoms are self-limiting after RFA and most patients should be able to resume near-complete preprocedural levels of activity within 10 days after the procedure.

Thermal ablation of hepatic malignancy: useful but still not optimal

The mortality associated with primary and metastatic hepatic malignancies remains high because few patients are candidates for hepatic resection or transplantation. Resection is the most effective treatment for liver tumors but may be contraindicated by factors such as the tumor's location; hepatic transplantation can cure primary hepatocellular carcinoma and underlying cirrhosis, but a donor may not be immediately available. When resection or transplantation is not possible, thermal ablation is a reasonable therapeutic option. Effective destruction of tumors can be achieved with low recurrence rates and minimal complications or risk of death. In patients with primary hepatic malignancy, ablation treatment does not preclude subsequent transplantation. Although radiofrequency ablation is currently the most widely used thermal ablative technique for hepatic malignancy, microwave ablation is gaining popularity and eventually may prove to be more effective.

Prudent application of radiofrequency ablation in resectable colorectal liver metastasis

Radiofrequency ablation (RFA) for liver metastasis of colorectal (H-CRC) origin is a well-documented technique in surgically unresectable disease. Overall recurrence figures appear inferior to resection but are based on a selection of patients with unresectable disease, often due to multiple localisations of extensive disease. Lesion based recurrence is probably more appropriate to predict results of RFA in surgically resectable H-CRC and figures may be good enough to consider RFA an alternative treatment in high risk patients.

A primer on transarterial, chemical, and thermal ablative therapies for hepatic tumors

BACKGROUND

Surgical resection is the only potentially curative approach for patients with primary and metastatic liver tumors. Unfortunately, most patients with hepatic malignancy are precluded from resection due to multifocal disease, anatomic limitations, inadequate functional liver reserve, extrahepatic metastases, or medical comorbidities. Consequently, several methods of tumor ablation have been developed as alternate treatment strategies for patients with unresectable hepatic tumors or as adjuncts in total cancer therapy. The purpose of this review is to inclusively define the various ablation modalities available (transarterial, chemical, and thermal ablative), and to describe the procedures, general applications, and reported outcomes.

DATA SOURCES

A MEDLINE and CINAHL search of the English-language literature was performed on transarterial, chemical, and thermal ablative therapies.

CONCLUSIONS

Presently, radiofrequency thermal ablation is the most widely applicable liver-directed modality for hepatic tumor ablation, enabling treatment of primary and metastatic tumors. However, other transarterial and thermoablative techniques are available with accumulating data for their use. Lacking at present are studies that define the role and potential benefit of the various liver-directed modalities in the treatment algorithm for hepatic tumors.

Thermo-ablation par radiofréquence des tumeurs hépatiques

The basic principle of radiofrequency ablation is that the deposit of electromagnetic energy in a tumor causes heat ("cooks the tumor") and thereby destroys it. In the liver, this ablation may be performed percutaneously (by needles) or surgically (laparotomy, laparoscopy). Guidance by an imaging technique is necessary: ultrasound, CT or magnetic resonance imaging. The principal hepatic indications are hepatocellular carcinoma and hepatic metastases smaller than <5 cm. There is no associated mortality and only slight morbidity, due principally to hemorrhage, infection or stenosis of the bile ducts. Results show a 5-year survival rate of 40% for hepatocellular carcinoma and 22% for metastases.

The Role of Radiofrequency Ablation in Multiple Liver Metastases to Debulk the Tumor: A Pilot Study before Alternative Therapies

INTRODUCTION

In this study, our aim was to proceed with the first study of our patients by evaluating different metastatic tumor to the liver to check whether, after debulking the tumor with radiofrequency ablation (RFA), the chemotherapy, could increase the survival in these patients as a pilot study before applying alternative therapies in the future.

MATERIALS AND METHODS

We studied 11 patients, 7 male, 4 female; age mean, 68 years (50-84). The tumors considered were carcinoid (3), gastrinoma (3), a new endocrine of unknown origin (2), colorectal (2), and breast (1).

RESULTS

All of the patients underwent laparoscopic RFA with a prior confirmatory biopsy and were discharged after 23 hours. No pain, bleeding, or wound infections were reported. One (1) patient with a gastrinoma died 9 months following surgery from a myocardial infarction. All other patients are still alive, although 2 experienced hepatic recurrences.

CONCLUSIONS

The 11 patients in this series showed that RFA combined with chemotherapy is a viable therapeutic choice for patients with cancer that has metastasized to the liver. New therapies are still needed.

Cryosurgery for resectable and unresectable hepatic metastases from colorectal cancer

AIMS

Hepatic cryosurgery is useful for patients with hepatic metastases from colorectal cancer confined to the liver but considered unresectables because of the number and location of lesions. While encouraging results were reported following cryosurgery for unresectable liver metastases we considered particularly valuable to examine the safety and effectiveness of cryosurgery in patients with resectable and unresectable metastases from colorectal cancer.

METHODS

Between January 1997 and September 2005, 53 patients with liver metastases from colorectal cancer underwent hepatic cryosurgery at our institution. Hepatic metastases were resectable in 31 (58.5%) patients and unresectable in 22 (41.5%).

RESULTS

A total of 136 liver metastases were treated in 53 patients. The size of treated lesions ranged from 0.5 to 10 cm (mean 2.7). There were 2 postoperative deaths (3.8%) from massive bleeding and from cryoshock. The overall morbidity rate was 66%. The median follow-up was 24.8 months. The overall survival rate at 12 months was 86.1%, at 48 months it was 27%. No significant difference was found between survival rates in patients with resectable or unresectable metastases. Among 31 patients with resectable liver metastases 7 (22.6%) patients developed recurrence at the site of cryosurgery.

CONCLUSION

Survival rates were comparables between patients with resectable and unresectable metastases but a high complication rate and a substantial rate of local recurrence following cryosurgery should caution against its use to treat resectable disease.

Local radiofrequency ablation techniques for liver metastases of colorectal cancer

Local ablative techniques have been used for several decades in the treatment of colorectal liver metastases and are gaining more and more interest. At this time radiofrequency ablation is the most popular local ablative technique with interesting results on local tumour control, disease free and overall survival. However, the exact place in the treatment of non-resectable colorectal liver metastases and its possible place in the treatment of resectable liver metastases has still to be defined. This article describes the feasibility, advantages and disadvantages of radiofrequency ablation, together with the results of the most cited articles, to form a critical review on the use of this technique in the treatment of colorectal liver metastases.

Radiofrequency ablation for minimally invasive treatment of breast carcinoma. A pilot study in elderly inoperable patients

OBJECTIVES

Radiofrequency ablation (RFA) has been used to treat hepatic, renal and prostate tumors. Preliminary experiences in breast cancer, followed by surgical excision, were encouraging. We performed a pilot trial of ultrasound-guided percutaneous RFA, not followed by surgery, in three elderly inoperable patients with breast carcinoma. The study was undertaken to determine the feasibility of treating small breast malignancies with RFA only and to evaluate the safety and complications related to this treatment.

METHODS

Three patients with core-needle biopsy-proven invasive carcinoma (<2 cm in greatest dimension) underwent ultrasound-guided RFA under local anesthesia, as outpatient procedure. Treatment was planned to ablate the tumor and a margin of surrounding breast tissue. All the patients were evaluated after a 1, 6, 12 and 18 months of follow-up.

RESULTS

All the patients completed the treatment with minimal or no discomfort and returned home after 1 h. The mean age was 81.3 years (range, 76-86 years) and the mean tumor size was 11.6 mm (range, 10-13 mm). The tumors laid more than 10 mm from chest wall and from the skin. The mean time required for ablation was 10.3 min (range, 8-12 min). There were no treatment-related complications. Post-ablation ultrasound scan, mammography, Magnetic Resonance Imaging scan and core biopsy, confirmed the tumor necrosis. After 18 months of follow-up no recurrence occurred.

CONCLUSIONS

RFA was feasible and safe for minimally invasive treatment of elderly inoperable patients with early-stage, primary breast carcinoma.

Comparison between local ablative therapy and chemotherapy for non-resectable colorectal liver metastases: a prospective study

BACKGROUND

There is a growing interest for the use of local ablative techniques in patients with non-resectable colorectal liver metastases. Evidence on the efficacy over systemic chemotherapy is, however, extremely weak. In this prospective study we aim to assess the additional benefits of local tumour ablation.

METHODS

A consecutive series of 201 colorectal cancer patients, without extrahepatic disease, that underwent laparotomy for surgical treatment of liver metastases, were prospectively followed for survival and HRQoL. At laparotomy three groups were identified: patients in whom radical resection of metastases proved feasible, patients in whom resection was not feasible and received local ablative therapy, and patients in whom resection or local ablation was not feasible for technical reasons and who received systemic chemotherapy.

FINDINGS

Patients in the chemotherapy and in local ablation group were comparable for all prognostic variables tested. For the local ablation group overall survival at 2 and 5 years was 56 and 27%, respectively (median 31 months, n = 45), for the chemotherapy group 51 and 15%, respectively (median 26 months, n = 39) (P = 0.252). After resection these figures were 83 and 51%, respectively (median 61 months, n = 117) (P < 0.001). The median DFS after local ablation was 9 months, HRQoL was restored within 3 months. Patients after local ablation gained far more QALY's (317) than in the chemotherapy group (165) (P < 0.001).

INTERPRETATION

Although overall survival did not reached statistical significance, the median DFS of 9 months suggests a beneficial effect of local tumour ablation for non-resectable colorectal liver metastases. Moreover, compared with systemic chemotherapy more QALY's were gained after local ablative therapy.

Radio-Frequency Ablation in a Realistic Reconstructed Hepatic Tissue

This study uses a reconstructed vascular geometry to evaluate the thermal response of tissue during a three-dimensional radiofrequency (rf) tumor ablation. MRI images of a sectioned liver tissue containing arterial vessels are processed and converted into a finite-element mesh. A rf heat source in the form of a spherically symmetric Gaussian distribution, fit from a previously computed profile, is employed. Convective cooling within large blood vessels is treated using direct physical modeling of the heat and momentum transfer within the vessel. Calculations of temperature rise and thermal dose are performed for transient rf procedures in cases where the tumor is located at three different locations near the bifurcation point of a reconstructed artery. Results demonstrate a significant dependence of tissue temperature profile on the reconstructed vasculature and the tumor location. Heat convection through the arteries reduced the steady-state temperature rise, relative to the no-flow case, by up to 70% in the targeted volume. Blood flow also reduced the thermal dose value, which quantifies the extent of cell damage, from ∼3600min, for the no-flow condition, to 10min for basal flow (13.8cm∕s). Reduction of thermal dose below the threshold value of 240min indicates ablation procedures that may inadequately elevate the temperature in some regions, thereby permitting possible tumor recursion. These variations are caused by vasculature tortuosity that are patient specific and can be captured only by the reconstruction of the realistic geometry.

Liver-directed therapies for patients with primary liver cancer and hepatic metastases

Liver cancer, whether primary or metastatic, is a major cause of death throughout the world. The surgical management of these diseases varies according to the extent of disease and the overall health of the patient. Surgical resection of hepatic disease remains the only chance for cure. However, a large proportion of patients with liver cancer are unable to undergo a complete surgical resection. These patients are often treated with liver-directed therapies. Although not as effective as surgical resection, these approaches can help to improve the survival of patients. In patients with primary liver cancer, underlying liver disease often prohibits surgical intervention. However, survival advantages have been gained with the application of percutaneous alcohol injection and radiofrequency ablation (RFA). In patients with hepatic metastases, the number of metastases is often what prevents surgical resection. In these patients, RFA, cryoablation, and hepatic artery infusional therapy have all aided in prolonging survival. As chemotherapeutic agents improve and targeted therapies are developed, more patients will be able to undergo surgical management of their liver cancer, primary or metastatic.

External beam radiotherapy to treat intra- and extra-hepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation

BACKGROUND

Radiofrequency ablation (RFA) is an alternative to percutaneous ethanol injection therapy (PEIT) for single non-surgical hepatocellular carcinoma. However, the risk of seeding along the needle track has been reported.

METHODS

Seven patients presenting with neoplastic seeding after RFA or PEIT were treated with external beam radiotherapy using conventional fractionation. All patients underwent irradiation with a total dose in the range of 44-61 Gy (median and mode value: 50 Gy).

RESULTS

An objective response to treatment was achieved in six of seven patients (86%). A complete response was obtained in two patients (29%). The median survival time was 14.7 months and the actuarial 1- and 2-year survivals were 67% and 50%, respectively.

CONCLUSIONS

The response to treatment was relatively good without serious complications. Seeding from hepatocellular carcinoma is sensitive to external beam radiotherapy. It is useful in the treatment of these patients with 50 Gy in 25 fractions.

Radiofrequency ablation for hepatocellular carcinoma and liver metastases: Experience in Hospital La Paz

INTRODUCTION

Radiofrequency ablation for patients presenting with non-resectable primary or metastatic liver tumours seems to be a valid therapeutic alternative. In the present study, we show a descriptive list of indications, results and complications of Radiofrequency Ablation Technique for treating non-resectable solid hepatic tumours.

MATERIALS AND METHODS

Twenty two patients were included in this study; eleven of them (50%) sustained liver metastases from colorectal adenocarcinoma, ten patients (45.5%) had hepatocellular carcinoma and 1 patient had insulinoma.

RESULTS

Local recurrence rate of hepatocellular carcinoma was 22.7% and 27.3% for colorectal carcinoma, after a respective median follow-up of 21 and 14 months. Complications rate was 6.9% and technique-associated mortality rate was 0%.

CONCLUSIONS

Radiofrequency ablation is an easy to make, safe and useful technique for the treatment of primary and metastatic liver tumours.

Multiple fiber laser-induced thermotherapy for ablation of large intrahepatic tumors

OBJECTIVE

The aim of this study was to test three techniques used simultaneously to increase lesion size.

BACKGROUND DATA

Laser-induced thermotherapy (LITT) is a method of local tumor ablation, which may prolong survival in patients with unresectable liver metastases. The main limitation has been the production of lesions with sufficient tumor-free margin.

METHODS

LITT treatment was performed with water-cooled, multiple fiber application and hepatic blood flow occlusion in six patients with unresectable intrahepatic metastases. Response was measured by computed tomography scan.

RESULTS

In all patients, tumors were effectively ablated. In two patients with colorectal metastases, lesions up to 8.6 cm could be created.

CONCLUSION

The use of watercooled multiple fiber application and hepatic inflow occlusion makes LITT an effective ablative method, expanding the treatment options for patients with large intrahepatic masses.

Cryoablation of liver tumours -- a review of mechanisms, techniques and clinical outcome

Several techniques exist for in situ destruction or ablation of liver tumours not eligible for resection. Cryoablation, i.e. the use of low temperatures to induce local tissue necrosis, was among the first of the thermal ablative techniques widely used. The procedures have typically been performed by surgeons during laparotomy, but recently minimally invasive cryoablation has been reported feasible. The present review focuses on mechanisms of tissue destruction, techniques of ablation including procedural monitoring, and clinical outcome following cryoablation of liver tumours. Plausible causes of tumour persistence at the site of ablation, i.e. local treatment failure, are discussed. Shortcomings exist in monitoring of the freezing process and may be a main cause. The evidence for the long-term outcome following liver tumour cryoablation needs to be improved. Cryoablation has been challenged by other techniques of tumour ablation such as radiofrequency ablation. Randomised trials against these modern techniques may define the role of cryoablation in the treatment of liver tumours. With improved imaging technology and patient selection, cryoablation of liver tumours may hold promise for selected patients.

The treatment of hepatic metastases in colorectal carcinoma

Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.

Hepatocellular carcinoma: current treatment strategies

Hepatocellular carcinoma (HCC) is an increasingly prevalent clinical problem. The presence of cirrhosis in the majority of patients makes treatment difficult because both the stage of the tumor and the stage of cirrhosis must be taken into account. This is compounded by the difficulty in diagnosing HCC in the early stages, where treatment is most effective, and the lack of a globally accepted treatment policy. Liver transplantation and liver resection are the optimal treatments, with resection being preferred in patients with small lesions, clinically well-preserved liver function, and absence of portal hypertension. Patients unsuitable for these procedures, due to localized but large tumor bulk, are only treatable by ablative and palliative therapies. Ablation involves either thermal (preferably radiofrequency ablation) or chemical methods, with the choice of method being dependent on both the size and placement of the tumor and the operator. Ablation may also be used as a bridge to transplantation in centers where significant waiting times are anticipated. Tumors that are too large in size or number to ablate are treated with transarterial chemoembolization, involving the distribution of chemotherapeutic agents and the blocking of the blood supply to the tumor; this is not considered a curative therapy. Combination therapies may also be used. These treatment options need further evaluation for determination of the optimal course of therapy for individual patients.

Treatment of hepatic metastases from colorectal cancer: Many doubts, some certainties

About 50% of patients with colorectal cancer (CCR) are destined to develop hepatic metastases during the course of the disease. Surgery is currently the only potentially curative treatment with a five year survival rate after hepatectomy from 26% to 49%. The criteria for resectability are now less rigid than in the past and the tendency to adopt a more aggressive treatment of metastatic lesions is the rule. Systemic infusion chemotherapies based on 5-fluorouracil (5-FU), oxaliplatin (OHP) and irinotecan (CPT-11) are well tolerated and have been shown to be effective in non-operable patients. These regimens allow surgery for patients who are initially not suitable for resection, giving them a probability of survival at five years similar to that of patients operated on at diagnosis. Intra-arterial infusion chemotherapy (HAI) is very effective in inducing objective responses, but is costly, difficult to manage and encumbered by major side effects, so that its application is necessarily limited to centres with specific experience. However, despite the broader criteria and recent advances of chemotherapy, surgery is not possible in most patients. The role of other local therapeutic techniques like cryosurgery (CS) and radiofrequency ablation (RF), alone or combined with surgery or chemotherapy, is not yet established in a multidisciplinary therapeutic approach. Roughly two thirds of patients relapse during the first two years after surgery suggesting appropriate post-operative chemotherapy treatment after hepatic resection may be indicated, but no randomised studies have been published to date. In case of relapse, another hepatectomy should be considered. The role of novel targeted therapies in pre-operative, post-operative and palliative management has yet to be evaluated.

Management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.

Percutaneous Radiofrequency Ablation Therapy of Hepatocellular Carcinoma Using Multitined Expandable Electrodes: Comparison of Subcapsular and Nonsubcapsular Tumors

OBJECTIVE

Our objective was to compare the prognosis of subcapsular and nonsubcapsular hepatocellular carcinoma after percutaneous radiofrequency ablation using multitined expandable electrodes.

MATERIALS AND METHODS

Some controversies exist about the clinical usefulness of percutaneous radiofrequency ablation of subcapsular hepatocellular carcinoma. Twenty-eight patients underwent percutaneous radiofrequency ablation of 43 hepatocellular carcinomas using multitined expandable electrodes. Twelve tumors were subcapsular and 31 were nonsubcapsular. We attempted to use normal liver as a pathway to the tumor when possible. Tumor size ranged from 1.0 to 4.2 cm (mean, 1.8 cm). Median follow-up was 16 months. Initial ablation was considered to have been complete when no enhancement was seen in the region of the ablated lesion on 1-month follow-up CT or on follow-up CT performed immediately after repeated ablation. Initial complete ablation and local tumor progression rates were compared between subcapsular and nonsubcapsular tumors. Eleven patients had subcapsular tumors (group 1), whereas the other 17 patients did not have subcapsular tumors (group 2). Major complication and mortality rates were compared between the two groups.

RESULTS

No significant differences in initial complete ablation rate (100% vs 96.7%, p = 1.000) or local tumor progression rate (0% vs 10.0%, p = 0.545) were found between subcapsular and nonsubcapsular tumors. No procedure-related major complication or mortality occurred. The overall 1- and 3-year survival rates were 89.3% and 60.3%, respectively.

CONCLUSION

The rates of local tumor progression and complications for radiofrequency ablation using multitined expandable electrodes for subcapsular hepatocellular carcinomas were comparable to those for nonsubcapsular hepatocellular carcinomas.

Debunking dogma: surgery for four or more colorectal liver metastases is justified

Treatment of four or more colorectal liver metastases (CRLMs) is controversial and remains a relative contraindication to surgery at some institutions. We sought to assess the outcome of patients with four or more CRLMs treated with surgery. Patients (159) with four or more CRLMs were treated surgically at a single institution. The median number of treated lesions was 5 (range, 4-14). The majority of patients received neoadjuvant chemotherapy (89.9%). Forty-six (29.0%) patients underwent resection only, 12 (7.5%) underwent radiofrequency ablation (RFA) only, and 101 (63.5%) underwent resection plus RFA. The 5-year actuarial disease-free and overall survival rates were 21.5% and 50.9%, respectively. Patients who underwent RFA as part of their surgical procedure (hazard ratio [HR] = 1.81, P = 0.03) and those with a positive surgical resection margin (HR = 1.52, P = 0.01) were more likely to have a shorter time to recurrence. Patients who did not have a reduction in tumor size following neoadjuvant chemotherapy had a higher likelihood of death following surgical treatment (HR = 2.53, P = 0.01). Patients with four or more CRLMs should be considered for aggressive surgical treatment, including liver resection with or without RFA, in order to improve the chance of long-term survival. Certain clinicopathologic factors, including lack of response to neoadjuvant chemotherapy, were associated with a worse prognosis.

Prevention of biliary lesions that may occur during radiofrequency ablation of the liver: study on the pig

OBJECTIVE

To prevent bile duct injury by using a cold 5% glucose isotonic solution cooling in the bile ducts when radiofrequency (RF) is performed in a porcine model.

SUMMARY BACKGROUND DATA

Complications that may arise during liver RF ablation include biliary stenosis and abscesses.

METHODS

The RITA 1500 generator was used for the experiments. Two lesions were performed in the left liver. The pigs were killed 1 or 3 weeks after the procedure. An ex vivo cholangiogram was obtained by direct injection into the main bile duct. Samples of RF lesions, of liver parenchyma near and at a distance from the RF lesions, underwent pathologic studies. Two groups of 20 pigs each were treated: one without perfusion of the bile ducts and the other with perfusion of cold 5% glucose isotonic solution into the bile ducts. The Pringle maneuver was used in 50% of the RF procedures. Radiologic lesions were classified as biliary stenosis, complete interruption of the bile duct, or extravasation of the radiologic contrast liquid.

RESULTS

Histologic lesions of the bile ducts were observed near the ablated RF lesion site and at a distance from the RF lesions when a Pringle maneuver was performed. Radiologic and histologic lesions of the bile ducts were significantly reduced (P < 0.0001) when the bile ducts were cooled.

CONCLUSIONS

Cooling of the bile ducts with a cold 5% glucose isotonic solution significantly protects the intrahepatic bile ducts from damages caused by the heat generated by RF when performed close to the bile ducts.

The imprint of radiofrequency in the management of hepatocellular carcinoma

BACKGROUND

This article reviews the current results of radiofrequency application in the management of hepatocellular carcinoma (HCC) with reference to the comparison between the different surgical modalities.

METHOD

An electronic search was performed for studies on the treatment of HCC.

RESULTS

Thermoablation by means of radiofrequency (RFA), microwave coagulation therapy (MCT) and laser-induced thermotherapy (LITT) provides tumor necrosis with a low complication rate. These methods are still not predictable and it is difficult to monitor the extent of necrosis in a real-time manner. Combined transarterial embolization and RF ablation is a promising strategy for large HCCs. Radiofrequency-assisted liver resection is unique and has become very popular recently because it permits parenchymal transection with minimal blood loss.

CONCLUSION

Many alternative techniques have been applied recently for the management of HCC but their exact roles need to be defined by randomized studies. Advances in technology and refinements in technique may provide an effective and predictable way to ablate liver tumors using radiofrequency devices.

Cryosurgery and radiofrequency ablation for unresectable colorectal liver metastases

AIMS

To report immediate local treatment efficacy and long-term results of cryosurgical ablation (CSA) and radiofrequency ablation (RFA) in patients with colorectal liver metastases not eligible for resection.

METHODS

Fifty-eight patients with unresectable colorectal liver metastases were included. Under ultrasound guidance, CSA or RFA were performed with or without concomitant resection. CT scanning and FDG-PET were used to determine local efficacy of the ablative procedure.

RESULTS

Median follow-up was 26 and 25 months for CSA and RFA, respectively. One and 2-year survival rates were 76 and 61% for CSA and 93 and 75% for RFA, respectively. In a lesion based analysis, the local recurrence rate was 9% after CSA and 6% after RFA. Complication rates were 30 and 11% after CSA and RFA, respectively, (p=0.052). In a subgroup analysis on 43 patients with 104 ablated lesions, CT scan immediate after treatment was not able to predict local treatment failure, whereas FDG-PET scan within 3 weeks after local ablative treatment predicted six of the seven local recurrences.

CONCLUSIONS

In patients with unresectable colorectal liver metastases, CSA and RFA can be used either alone or as an effective adjunct to resection in achieving complete tumour clearance of the liver. More widespread use of these techniques seems promising but requires further investigation in randomized trials comparing local ablative treatment with chemotherapy.

Short- and-long term results of intraoperative radiofrequency ablation of liver metastases

BACKGROUND

Surgical resection is the only therapeutic option with curative effect on malignant liver tumours, but in over 70% of cases, this is not a feasible option. A prospective study was performed to assess the short- and long-term effects of intraoperative radiofrequency ablation on unresectable liver metastases.

PATIENTS

Between 1997 and 2001, 57 patients (mean age 61.9 years; range 31-83 years) with 297 unresectable liver metastases (colorectal adenocarcinoma, n=38; carcinoid tumour, n=4; malignant melanoma, n=3; other metastases, n=12) underwent intraoperative radiofrequency ablation.

RESULTS

No mortality was observed in patients managed solely with radiofrequency ablation. Eight postoperative complications occurred in eight patients (14%). Three occurred when radiofrequency ablation was combined with resection. Of the 33 patients completely ablated, 30 patients are still alive and 21 are disease-free after a median follow-up of 18.1 months (range 2-43). Ten patients underwent more than one intraoperative radiofrequency ablation episode. Overall survival was 72.5% at 1 year and 52.5% at 3 years. Complete ablation and the number of lesions were significant independent prognostic factors for survival, with p<0.001 and p<0.0001, respectively.

CONCLUSION

Radiofrequency ablation is a safe and effective option for patients with inoperable liver metastases without extra hepatic disease. Prospective controlled trials comparing the results of different treatments are required to assess which patients will benefit best from this emerging new treatment.

Image guided tumour ablation

Several different technologies have been employed for the local ablation of tissue by thermal techniques. At the present time the most widely favoured technique is radiofrequency ablation (RFA) but developments in other techniques, e.g. microwave may change this. In many countries RFA or percutaneous ethanol injection (PEI) are accepted therapies for patients with Childs Pugh Class A or B cirrhosis and early hepatocellular carcinoma (HCC). Results for RFA in large series of patients with liver metastases from colon cancer are very promising. Five-year survival rates of 26% from the time of first ablation and 30% from the diagnosis of liver metastases for patients with limited (<6, <5 cm) liver disease who are not surgical candidates compares well with post resection series where 5-year survival rates vary between 29% and 39% in operable candidates. Sufficient experience has now been gained in lung and renal ablation to show that these are minimally invasive techniques which can produce effective tumour destruction with a limited morbidity. More novel areas for ablation such as adrenal or pelvic recurrence are being explored.

Hepatic hemorrhage caused by percutaneous tumor ablation: radiofrequency ablation versus cryoablation in a porcine model

PURPOSE

To determine the extent of hepatic hemorrhage caused by percutaneous cryoablation performed with a small-diameter cryoablation probe compared with that caused by percutaneous radiofrequency (RF) ablation in a porcine model.

MATERIALS AND METHODS

The study was pre-approved by the institutional research animal care and use committee, and husbandry and experiments complied with National Institutes of Health standards for care and use of laboratory animals. Percutaneous hepatic ablation was performed in 18 domestic pigs (mean weight, 45 kg) by using a 17-gauge (1.5-mm-diameter) RF electrode (n = 6), a cluster of three RF electrodes (n = 6), or a 13-gauge (2.4 mm-diameter) cryoprobe (n = 6). Ablation was performed in four sites per liver. Total blood loss, minimum lesion diameter, maximum lesion diameter, and lesion volume were determined for each group and compared by using analysis of variance.

RESULTS

Mean blood loss was 11.11 mL +/- 11.47 (standard deviation), 105.29 mL +/- 175.58, and 28.06 mL +/- 30.97 with the single RF electrode, RF electrode cluster, and cryoablation probe, respectively. Mean minimum and maximum lesion diameters were largest with the RF electrode cluster (2.40 and 3.98 cm, respectively), followed by the cryoablation probe (2.38 and 3.94 cm) and single RF electrode (1.49 and 2.63 cm). Mean minimum and maximum lesion diameters were significantly different between the single RF electrode and the RF electrode cluster, as well as between the single RF electrode and the cryoablation probe (P < .001). Mean lesion volume was largest for the RF electrode cluster (24.03 cm3), followed by those for the cryoablation probe (17.46 cm3) and single RF electrode (9.05 cm3) (single RF electrode vs cryoablation probe, P < .05). Lesion volumes were not significantly different with the RF electrode cluster versus the single RF electrode (P = .052) or with the RF electrode cluster versus the cryoablation probe (P = .381).

CONCLUSION

Mean blood loss from percutaneous cryoablation in this model was between that for RF ablation with the single electrode and that for RF ablation with the electrode cluster.

Radiofrequency ablation for malignant liver tumor

Radiofrequency ablation (RFA) has been widely practiced to treat unresectable malignant liver tumors. It has the merits of localized tumor ablation and preservation of maximal normal liver parenchyma. In recent years, there has been a tremendous expansion in the application of RFA for patients with malignant liver tumors. However, the therapeutic effect of this local ablation treatment needs to be balanced against its risks and possible local failure. This review focuses on the current status of RFA for malignant liver tumors, with special attention to the indication, approaches, complications, survival benefits, combination therapies, and comparison with other treatment modalities. Although the results of most clinical studies of RFA seem favorable, the associated risks and tumor recurrence should not be underestimated. Careful patient selection, meticulous RFA techniques, and prompt treatment of residual and recurrent tumors are necessary to ensure a better outcome after RFA. Until recently, there has been no strong evidence showing that RFA can replace any other treatment modalities in the management of liver tumors. Nonetheless, more convincing evidence by randomized trials is required for the establishment of a treatment protocol of RFA for patients with malignant liver tumors.

Percutaneous Radiofrequency Ablation of Hepatic Tumors: Postablation Syndrome

OBJECTIVE

Our objective was to define the spectrum and possible predictors of symptoms that occur in patients after percutaneous radiofrequency ablation of hepatic tumors.

SUBJECTS AND METHODS

We performed 50 consecutive percutaneous radiofrequency ablation sessions on 39 patients with a total of 89 liver tumors. All patients had pre- and postablation laboratory studies and CT or MRI scans. After treatment, patients were followed for 3 weeks with a standardized questionnaire to assess for postablation symptoms. Comparisons of the presence or absence of symptoms were made for the laboratory test values, liver volumes, and pre- and postablation tumor volumes.

RESULTS

Postablation symptoms occurred in 14 of 39 (36%) patients after 17 of 50 (34%) ablation sessions. Symptoms consisted of fever (16/17), malaise (12/17), chills (6/17), delayed pain (5/17), and nausea (2/17). On average, the symptoms presented 3 days after ablation and lasted 5 days. Statistically significant (p < 0.01) predictors of symptoms were tumor volumes > 50 cm3 (4.5 cm diameter), ablated tissue volumes > 150 cm3 (6.5 cm diameter), a difference between preablation tumor volume and the volume of tissue ablated > 125 cm3, or postablation aspartate aminotransferase levels > 350 IU/L.

CONCLUSION

Approximately one third of patients undergoing percutaneous radiofrequency ablation of hepatic tumors develop delayed, transient flulike symptoms that can be treated conservatively and are significantly related to the volume of tissue ablated. Familiarity with this postablation syndrome should facilitate appropriate management of affected patients.

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review

BACKGROUND

Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC.

METHODS

On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed.

RESULTS

Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate.

CONCLUSION

TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.

Surgical strategies for colorectal liver metastases

Colorectal cancer remains the second commonest cause of death from cancer in Western society. Nearly half of all patients will develop liver metastases and many will die with disease confined to the liver. The accepted modern definitions of resectability now mean that over twenty per cent of patients are now resectable (with operative mortality of >2%) with curative intent, and nearly one third will be alive, disease free, five years later. The use of additional techniques such as radiofrequency ablation may bring many more patients the possibility of long term survival. The introduction of new chemotherapy regimens, including those based on oxaliplatin may convert one third of non-resectable patients to resectability with curative intent. Therefore, in 2004 nearly one third of patients with disease confined to the liver can now look forward to possibly curative liver surgery.

Results of radio frequency ablation of primary and secondary liver tumors: long-term follow-up with computed tomography and positron emission tomography-18F-deoxyfluoroglucose scanning

BACKGROUND

In the literature, promising results have been obtained with radiofrequency ablation (RFA) of primary liver malignancies (e.g. hepatocellular carcinoma, HCC) and secondary liver malignancies (e.g. metastases of colorectal tumors). In our center, positron emission tomography with FDG (FDG-PET) and computed tomography (CT) were used for follow-up. Patient outcome was compared with that in the literature, and PET and CT were analyzed regarding positive and negative predictive values for early detection of tumor recurrence.

METHODS

The data were analyzed of patients who were treated with RFA for primary or secondary liver tumors between January 1999 and December 2002. Indications for treatment with RFA were liver tumors that could not be resected owing to size, number, or tumor location. In all patients, a CT scan was performed before RFA, and follow-up was performed with a CT scan in all patients and with an additional PET scan at various intervals in 11 patients. At evaluation with PET, tumor recurrence was defined as positive uptake of tracer either at the previous RFA lesion or at a new site in the liver.

RESULTS

In total, 15 patients (8 M, 7 F) were treated in 21 sessions with RFA. The mean follow-up period was 16.8 months (range: 7-42). Average age of the patients was 63 years (range: 40-74). One patient had a primary liver tumor; all other patients had metastases of the breast (1), ovary (1), renal cells (1), and colorectal carcinoma (11 patients). The mean number of tumors per patient was 2.7 (range: 1-5). No treatment-related morbidity or mortality occurred. In 4 of 11 patients evaluated with PET at a mean period of 6.8 months, positive uptake of tracer was noted. At CT evaluation, tumor recurrence was observed in 4 of these patients, at a mean time of 9.8 months. Two patients (13.3%) died of cancer recurrence during follow-up.

CONCLUSIONS

Tumor recurrence is comparable with that in other studies. Centrally located tumors showed more recurrence than peripheral tumors. The use of PET in combination with CT scan at follow-up may lead to earlier detection of tumor recurrence than contrast-enhanced CT alone.

Surgical treatment of hepatocellular carcinoma in China: surgical techniques, indications, and outcomes

BACKGROUND AND AIMS

Surgery remains the most effective treatment for hepatocellular carcinoma (HCC). While resection and liver transplantation achieve the best outcomes in patients with small HCC, controversy surrounds treatment of large HCC, HCC with portal vein tumor thrombus, and HCC with hypersplenism.

PATIENT/METHODS

From January 1988 to December 2002, 2,102 patients with large HCC underwent hepatectomy in our hospital. The traditional resection method was used on 959 patients, after which the improved new method was used on 1,143 patients. Meanwhile, from January 1990 until December 2003, hepatic resection +/- thrombectomy has been performed in 438 patients with HCC and portal vein tumor thrombus. Among them, 286 patients showed portal vein tumor thrombus located in the primary and secondary branch of the main portal vein (group A), and 152 patients showed portal vein tumor thrombus (PVTT) involved in the main portal vein (group B). Additionally, out of 204 HCC patients with cirrhotic hypersplenism, 94 patients had hepatectomy and splenectomy, and 100 patients had only hepatectomy without hospital death.

RESULTS

The 3- and 5-year survival after resection of large HCCs (over 5 cm) with improved new method in China was between 50.7 and 58.8% and 27.9 and 38.7%, respectively. Tumor recurrence in the liver within 1 year after hepatic resection + thrombectomie was detected in 45% of group A and in 78.8% in group B. The cumulative 5-year overall survival rates were 18.1% for group A and 0% for group B. The 1-, 3-, and 5-year overall survival in HCC plus portal vein tumor thrombus (PVTT) was 58.7, 22.7, and 18.1%. The hepatectomy/splenectomy group had a 5-year tumor-free survival rate of 37.2% and the hepatectomy group alone had 27.2%.

CONCLUSION

The new resection methods, hepatic resection + thrombectomy and hepatectomy + splenectomy, are very effective treatments for large HCC, HCC with portal vein tumor thrombus, and HCC with hypersplenism, respectively. Local treatment modalities, e.g. percutaneous ethanol injection, cryosurgery, and radiofrequency ablation as well as microwave coagulation are used in patients with poor liver function in small and large HCCs.