Safety limit of large-volume hepatic radiofrequency ablation in a rat model

[Radiation therapy of hepatic haemangiomas: Review from a case report]

Haemangioma is the most frequent benign hepatic tumour. Haemangioma is generally asymptomatic but it can sometimes cause disabling symptoms depending on its size and location. Surgery and interventional radiology are the cornerstone of the treatment in this situation. Radiation therapy, already used with good efficacy and safety to treat hepatic malignant lesions as hepatocarcinoma and metastases, is a relevant option in case of contraindication to surgery because of multiple or very large lesions. In this context, we report the case of a patient presenting with multiple symptomatic hepatic haemangiomas, successfully treated by radiation therapy in our department. These good results justified a review of the literature to report series of patients treated in this indication and to describe the main treatment regimens used.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach-Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.

RESULTS

Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach-Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.

CONCLUSION

The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.

Radiofrequency ablation for hepatic hemangiomas: A consensus from a Chinese panel of experts

Recent studies have shown that radiofrequency (RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the treatment of hepatic hemangiomas: minimal invasiveness, definite efficacy, high safety, fast recovery, relatively simple operation, and wide applicability. It is necessary to formulate a widely accepted consensus among the experts in China who have extensive expertise and experience in the treatment of hepatic hemangiomas using RF ablation, which is important to standardize the application of RF ablation for the management of hepatic hemangiomas, regarding the selection of patients with suitable indications to receive RF ablation treatment, the technical details of the techniques, therapeutic effect evaluations, management of complications, etc. A final consensus by a Chinese panel of experts who have the expertise of using RF ablation to treat hepatic hemangiomas was reached by means of literature review, comprehensive discussion, and draft approval.

Update on treatment of liver metastases: focus on ablation therapies

There is substantial and growing interest in the use of local therapies to treat patients with metastatic cancer, especially those deemed to have "oligometastatic" disease. Much of the literature to date consists of reports on metastasectomy for liver and lung metastases. Non-surgical minimally or non-invasive treatments including thermal ablation, irreversible electroporation, and high-dose radiation therapy (stereotactic ablative radiation therapy) can also be used in the treatment of primary and secondary tumors, including in the treatment of liver metastases. In this review, we discuss the rationale for using these ablative treatments in the treatment of liver metastases including similarities and differences between them.

What is changing in indications and treatment of hepatic hemangiomas. A review

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

Comparative evaluation of percutaneous laser and radiofrequency ablation in patients with HCC smaller than 4 cm

OBJECTIVE

This study was done to compare percutaneous laser ablation (PLA) and radiofrequency thermoablation (RFA) for the treatment of hepatocellular carcinoma (HCC) ≤ 4 cm, in patients with liver cirrhosis.

MATERIALS AND METHODS

Thirty patients with single HCC ≤ 4 cm in diameter were randomly assigned to one of two treatments: 15 patients were treated with PLA, using a multifibre system connected to a neodymium yttrium-aluminium-garnet laser source; 15 patients were treated with RFA, using an expandable needle electrode. Patients were followed up for up to 12 months.

RESULTS

A complete response was obtained in 87 % lesions treated with PLA and in 93 % lesions treated with RFA (p = ns). The overall local recurrence-free survival rates at 3, 6 and 12 months were comparable. However, a higher rate of recurrence was observed in the PLA group for lesions ≥ 21 mm (p = 0.0081). A postablation syndrome was documented in 13 patients (1 PLA; 12 RFA). Tumour necrosis factor-α was significantly higher in the RFA group (p < 0.05).

CONCLUSIONS

RFA is more effective in the treatment of HCC compared to PLA for lesions ≥ 21 mm. However, PLA should be considered a viable treatment option for HCC ≤ 20 mm, in view of the lower incidence of complications.

Radiofrequency ablation for large hepatic hemangiomas: initial experience and lessons

OBJECTIVE

We aimed to assess the feasibility, safety, and efficacy of radiofrequency (RF) ablation for the treatment of large (≥5 cm in greatest diameter) hepatic hemangiomas.

METHODS

Thirty-six patients (15 male, 21 female; mean age 50 years) with 41 hepatic hemangiomas ≥5 cm in diameter were enrolled and treated with RF ablation attributable to the presence of enlargement tendency and/or persistent hemangioma-associated symptoms. Twenty patients had 24 hemangiomas <10 cm, and 16 patients had 17 hemangiomas ≥10 cm. Technical success, complications related to RF ablation, completed ablation, symptom relief, change in size of ablation zone, and recurrence of the residual tumor were analyzed.

RESULTS

Of the 41 hemangiomas with a mean diameter 10 ± 4 cm (range, 5-22 cm), 26 subcapsular lesions were treated with a laparoscopic approach, and 15 lesions located in liver parenchyma underwent a computed tomography-guided percutaneous approach. RF ablation was performed successfully in all patients. There were 62 complications related to the ablation in 22 patients, including 6 of 20 patients with hemangiomas <10 cm and all the 16 patients with hemangiomas ≥10 cm. According to the Dindo-Clavien classification, 2 complications (lower esophageal fistula and acute respiratory distress syndrome, Grade III and Grade IV, respectively) were major in 2 patients with hemangiomas ≥10 cm; all the other were minor in 20 patients (Grade I). All the complications were recovered by conservative treatment. Thirty-eight (93%) of 41 hepatic hemangiomas were ablated completely, including all the 24 lesions <10 cm and 14 of 17 lesions ≥10 cm. All the symptoms related to hemangiomas disappeared (n = 22) or were ameliorated (n = 4) after ablation. The mean diameter of ablation zone was decreased to 6 ± 3 cm (2-12 cm) in a mean follow-up period (X ± SD) of 15 ± 6 months (range, 6-24 months), without recurrence or enlargement of the 3 residual tumors.

CONCLUSION

The present study supports RF ablation as an alternative treatment for hepatic hemangiomas ≥5 cm (but smaller than 10 cm) for the low risk of complications and likelihood of complete ablation, but, in contrast, RF ablation appears to be an inappropriate method for hepatic hemangiomas ≥10 cm because of the high occurrence rate of complications.

Low-dose steroid pretreatment ameliorates the transient impairment of liver regeneration

AIM: To determine if liver regeneration (LR) could be disturbed following radiofrequency (RF) ablation and whether modification of LR by steroid administration occurs.

METHODS: Sham operation, partial hepatectomy (PH), and partial hepatectomy with radiofrequency ablation (PHA) were performed on adult Fisher 344 rats. We investigated the recovery of liver volume, DNA synthetic activities, serum cytokine/chemokine levels and signal transducers and activators of transcription 3 DNA-binding activities in the nucleus after the operations. Additionally, the effects of steroid (dexamethasone) pretreatment in the PH group (S-PH) and the PHA group (S-PHA) were compared.

RESULTS: The LR after PHA was impaired, with high serum cytokine/chemokine induction compared to PH, although the ratio of the residual liver weight to body weight was not significantly different. Steroid pretreatment disturbed LR in the S-PH group. On the other hand, low-dose steroid pretreatment improved LR and suppressed tumor necrosis factor (TNF)-α elevation in the S-PHA group, with recovery of STAT3 DNA-binding activity. On the other hand, low-dose steroid pretreatment improved LR and suppressed TNF-α elevation in the S-PHA group, with recovery of STAT3 DNA-binding activity.

CONCLUSION: LR is disturbed after RF ablation, with high serum cytokine/chemokine induction. Low-dose steroid administration can improve LR after RF ablation with TNF-α suppression.

Oxidative and pre-inflammatory stress in wedge resection of pulmonary parenchyma using the radiofrequency ablation technique in a swine model

Background

Radiofrequency ablation (RFA) is a thermal energy delivery system used for coagulative cellular destruction of small tumors through percutaneous or intraoperative application of its needle electrode to the target area, and for assisting partial resection of liver and kidney. We tried to evaluate the regional oxidative and pre-inflammatory stress of RFA-assisted wedge lung resection, by measuring the MDA and tumor Necrosis Factor Alpha (TNF-α) concentration in the resected lung tissue of a swine model.

Method

Fourteen white male swines, divided in two groups, the RFA-group and the control group (C-group) underwent a small left thoracotomy and wedge lung resection of the lingula. The wedge resection in the RFA-group was performed using the RFA technique whereas in C-group the simple "cut and sew" method was performed. We measured the malondialdehyde (MDA) and TNF-α concentration in the resected lung tissue of both groups.

Results

In C-group the MDA mean deviation rate was 113 ± 42.6 whereas in RFA-group the MDA mean deviation rate was significantly higher 353 ± 184 (p = 0.006). A statistically significant increase in TNF-α levels was also observed in the RFA-group (5.25 ± 1.36) compared to C-group (mean ± SD = 8.48 ± 2.82) (p = 0.006).

Conclusion

Our data indicate that RFA-assisted wedge lung resection in a swine model increases regional MDA and TNF-a factors affecting by this oxidative and pre-inflammatory stress of the procedure. Although RFA-assisted liver resection can be well tolerated in humans, the possible use of this method to the lung has to be further investigated in terms of regional and systemic reactions and the feasibility of performing larger lung resections.

Pringle maneuver exacerbates systemic inflammatory response and multiple-organ injury induced by extended liver radiofrequency ablation

AIM

To assess the systemic inflammatory response (SIR) and the multi-organ damage after large-volume liver radiofrequency ablation (RFA) with or without concurrent Pringle maneuver.

METHODS

Wistar rats were subjected to 30% liver RFA (group RFA), liver RFA under 30-min Pringle maneuver (group RFA + P), Pringle only (group P) or sham operation (group S). Serum levels of interleukin-1α (IL-1α), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), serum biochemical profile, multiple-organ pathology and the activity of nuclear factor-κB (NF-κB) in the liver were assessed post-operatively.

RESULTS

The levels of IL-6 and TNF-α were increased from 1h up to 1w and 6h, respectively, in both RFA groups, while IL-6 was only mildly increased at 3 h in group P. IL-6 was higher in group RFA + P compared to group RFA. Serum biochemical profile was altered more intensely in group RFA + P compared to RFA. There was tissue injury in the non-ablated liver portion as well as in adjacent and remote organs with lesions being more severe in group RFA + P. At 1 h, NF-κB was equally activated in all study groups.

CONCLUSIONS

Extended liver RFA causes SIR and multi-organ injury, which are exacerbated when a concurrent Pringle maneuver is applied.

Large volume hepatic microwave ablation elicits fewer pulmonary changes than radiofrequency or cryotherapy

BACKGROUND

Lung changes after microwave tissue ablation (MTA) of different volumes of liver were compared with hepatic resection, cryotherapy (CRYO) and radiofrequency ablation (RFA).

METHODS

Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33% and 66% of total hepatic volume and lung samples were collected at the time of death. Lung impairment was assessed directly by examining the tissue specimens for the degree of interstitial pneumonia and by comparing the alveolar thickness in the different groups.

RESULTS

All RFA and CRYO rats undergoing 66% of ablations died, but the MTA group had no fatalities. Following 66% RFA or CRYO ablations, the animals had a significantly increased thickness of the alveolar septa compared to 15% or 33% ablations and to 66% ablations in the MTA group.

CONCLUSIONS

Large volume MTA is associated with a significant reduction in consequent lung damage and is well tolerated compared to RFA and CRYO.

Changes in interleukin-1β and 6 after hepatic microwave tissue ablation compared with radiofrequency, cryotherapy and surgical resections

BACKGROUND

Cytokine changes after microwave tissue ablation (MTA) were compared with hepatic resection, cryotherapy (CRYO), and radiofrequency ablation (RFA). Cytokine production was measured at various ablation volumes for each modality and correlated with the transitional inflammatory zone produced by the ablation techniques.

METHODS

Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33%, or 66% of the total hepatic volume. Serum samples were collected preoperatively and at 1, 3, 6, 24, and 48 hours after surgery and analyzed for pro-inflammatory cytokines interleukin (IL)-1β and IL-6.

RESULTS

Significantly higher levels of both cytokines were present after CRYO and RFA compared with MTA, hepatic resection, or controls (P < .001). All animals survived except those undergoing RFA or CRYO of 66% of the hepatic volume, which died within 6 hours. Transitional zones produced after RFA were larger than those after CRYO or MTA, but no correlation was present with the amount of cytokines.

CONCLUSIONS

Large-volume MTA is associated with a significant decreased cytokine response and is well tolerated compared with RFA and CRYO.

Combined resection and radiofrequency ablation for multifocal hepatocellular carcinoma: Prognosis and outcomes

AIM: To analyze the combined treatment of resection and intraoperative radiofrequency ablation (RFA) for multifocal hepatocellular carcinoma in terms of prognosis and surgical outcomes.

METHODS: This study was a retrospective case comparison study using prospectively collected data. The study covered the period from April 2001 to December 2006. The data of 200 patients with histologically confirmed hepatocellular carcinoma were reviewed. Nineteen patients (17 men and 2 women) having received resection in combination with RFA were chosen as subjects of the study (the combination group). Fifty-four patients (43 men and 11 women) having received resection alone were selected for comparison (the resection group). The two groups matched tumor number and tumor size, and all the patients in the two groups displayed no tumor rupture, major vascular involvement and distant metastasis. Their demographics, preoperative assessment, disease recurrence patterns, overall survival and disease-free survival were compared.

RESULTS: In the combination group, the median age was 65 years (range, 34-77 years), the median tumor number was 3 (range, 2-9), and the median tumor size was 6 cm (range, 1.2-14 cm). In the resection group, the median age was 51.5 years (range, 27-80 years, P = 0.003), the median tumor number was 3 (range, 2-9, P = 0.574), and the median tumor size was 6 cm (range, 1-14 cm, P = 0.782). The two groups were similar in characteristics of tumors and comorbidities, and had comparable results in preoperative liver function tests. All patients had Child-Pugh class A status. Bilobar involvement occurred in 14 patients (73.6%) in the combination group and 3 patients (5.5%) in the resection group (P = 0.04). Six patients (32%) in the combination group and 35 patients (65%) in the resection group underwent major hepatectomy. Thirteen patients (68%) in the combination group and 19 patients (35%) in the resection group underwent minor hepatectomy (P = 0.012). The combination group had fewer major resections (32% vs 65%, P = 0.012), less blood loss (400 vs 657 mL, P = 0.007), shorter operation time (270 vs 400 min, P = 0.001), and shorter hospital stay (7 vs 8.5 d, P = 0.042). The two groups displayed no major differences in surgical complications (15.8% vs 31.5%, P = 0.24), disease recurrence (63.2% vs 50%, P = 0.673), hospital mortality (5.3% vs 5.6%, P = 1), and overall survival (53 vs 44.5 mo, P = 0.496).

CONCLUSION: Safe and effective for selected patients with multifocal hepatocellular carcinoma, the combination of resection and intraoperative RFA widens the applicability of surgical intervention for the disease.

Tolerance of radiofrequency ablation by patients of hepatocellular carcinoma

BACKGROUND

Radiofrequency ablation (RFA) is currently an effective method for ablation of hepatocellular carcinoma (HCC). Early reports have indicated that RFA is safe and virtually free from major complications. Unlike partial hepatectomy for HCC on patients with cirrhosis, there are no data on the safety limit of RFA. However, information is vital for selection of appropriate patients for the procedure. In this study, we analyzed results from use of RFA on HCC patients and determined the lower limit of liver function with which HCC patients can tolerate RFA.

METHOD

Preoperative variables of 310 patients who underwent RFA for HCC were analyzed to identify the risk factors in RFA intolerance in terms of morbidity associated with stress-induced complications.

RESULTS

Thirty-nine (12.6%) patients developed intolerance of RFA. Postoperative morbidity was mainly because of intractable ascites (n = 13), hyperbilirubinemia (n = 10), massive pleural effusion (n = 7), and other complications (n = 14). Multivariate analysis revealed that serum albumin level (P = 0.001), serum bilirubin level (P = 0.000), tumor number (P = 0.002), and RFA duration (P = 0.017) all played a role in this issue.

CONCLUSIONS

Simple data such as serum bilirubin, serum albumin level, and tumor number can be used to predict HCC patients' tolerance of RFA. Avoidance of excessive RFA time and careful monitoring of patients at risk are important means of reducing the postoperative morbidity rate.

Immunoregulatory effects of liver ablation therapies for the treatment of primary and metastatic liver malignancies

Ablation of liver tissue produces in situ tumoural antigens and elicits specific immune responses. The aim of this review is to examine the available data about the local and systemic responses produced and to compare differences between the methods available. A literature search was undertaken for all papers focusing on immune responses following ablative therapy of the liver, including experimental and clinical studies. Following ablative procedures, the cellular response is elicited by the presentation of antigens by dendritic cells to specific CD4(+) T cells, which in turn stimulate natural killer or CD8(+) cytotoxic cells. The local release of intracellular debris activates Kupffer cells to produce cytokines, which, in the immediate vicinity, activate monocytes/macrophages or specific T cells that respond and produce systemic reactions such as fever, thrombocytopaenia or shock. The immune responses elicited by cryotherapy, both cellular and cytokine, seem far greater than those produced by radiofrequency or microwave ablation, probably as a consequence of the peculiar mechanism of cell death of the former (disruptive necrosis). This mechanism is considered central to the pathogenesis of cryoshock. Ablative techniques stimulate the immune system and provide an easy way to achieve in vivo vaccination against tumoural antigens. Immunomodulatory approaches have the potential to augment the initial immune stimulation and this combined approach could pave the way to a more selective and specific method of treating liver tumours.

Ferucarbotran expands area treated by radiofrequency ablation in rabbit livers

BACKGROUND AND AIM

Several studies have examined the factors involved with expansion of the coagulation volume following radiofrequency ablation (RFA). Ferucarbotran contains superparamagnetic iron oxide that generates heat in a radiofrequency electric field and may have an effect on the area affected by RFA. We attempted to determine whether ferucarbotran administration expands radiofrequency-ablated volume using a rabbit model.

METHODS

A total of 15 male Japanese white rabbits (16 weeks old) were used and divided into three groups of five each. A 1-mL saline solution was given intravenously into a dorsal ear vein in the control group, whereas 1 mL ferucarbotran solution (0.016 mL/kg bodyweight) was given to the common-dose group and 1 mL of a twofold concentrated ferucarbotran solution (0.032 mL/kg bodyweight) was given to the high-dose group. RFA was performed with a cool-tip electrode 4 h after the administration and immediately thereafter the rabbits were killed, and the volume of the ablated area measured using magnetic resonance imaging (MRI). Following the MRI analysis, the rabbit's livers were resected, and the maximum short axis diameter of the ablated area in each was measured.

RESULTS

None of the rabbits died during the RFA procedure. The volume of the ablated area estimated on MR images in the ferucarbotran-administered groups was larger than that in the control group. Further, our macroscopic assessment showed that the maximum short axis diameter had a tendency to increase with ferucarbotran administration.

CONCLUSION

Ferucarbotran may expand the area treated by RFA.