肝癌射频消融治疗后并发症的影像学表现及治疗

射频热消融（radiofrequency ablation,RFA）治疗肝细胞癌在临床上使用日趋广泛,但RFA治疗后仍会出现一些并发症,主要包括局部感染（脓肿形成）和局部出血,以及胆管损伤、接地板烧伤和胸部及小肠的并发症。射频治疗的并发症不能忽视,合理控制RFA治疗的适应证及早期发现并发症,并早期处理是必要的。避免并发症的发生有三个主要策略,首要策略是不给可能发生并发症的患者做该治疗;第二种策略是早期发现RFA治疗后的并发症;最后一种策略是对并发症的合理的处治。     

Percutaneous radiofrequency ablation of hepatocellular carcinoma in the presence of portal vein thrombosis

Portal vein thrombosis (PVT) may not be an absolute contraindication for hepatic radiofrequency ablation (RFA). Although the data are sparse, PVT is commonly considered a contraindication to RFA. PVT has actually been described as a complication following RFA. RFA was used to treat a 3.9×2.9 cm primary hepatocellular carcinoma (HCC) in a patient with concomitant PVT without complication. RFA can be safely performed in this setting but further studies could clarify this issue.     

重复射频消融治疗原发性肝癌的临床疗效观察

目的评价经皮肝穿刺重复射频消融治疗原发性肝癌的临床疗效。方法将88例原发性肝癌患者按单次射频消融及重复射频消融的方法分为2组,观察每组肿瘤完全消融率、肿瘤复发率及不良反应的发生情况。结果2组均未发生出血、胆漏等严重的不良反应。单次射频消融组肿瘤的完全消融率为62．5％,重复射频消融组为87．5％,2组间比较差异有统计学意义（P〈O．05）;单次射频消融组肿瘤的复发率为20．0％,重复射频消融组为4．2％,2组间比较差异有统计学意义（P〈O．05）。结论重复射频消融可有效提高原发性肝癌的临床治疗效果。     

经皮门静脉栓塞治疗肝癌的临床应用

目的探讨经皮选择性门静脉右支栓塞(PVE)在肝癌治疗中的应用价值。方法12例无手术切除指征的中晚期肝癌患者,在电视透视引导下经导管行经皮穿肝或穿脾行PVE。栓塞前、后用CT测量左侧肝叶的体积,并测量栓塞前后的门静脉压力、肝功能。结果12例患者均成功行经皮PVE,栓塞术后左肝叶代偿增生明显,其中3例PVE后顺利实行右肝切除术。PVE后未出现门静脉高压,肝功能损害轻,均未发现并发症。结论经皮选择性PVE能诱导非栓塞侧肝叶代偿性增生及栓塞侧肝叶萎缩,增加肿瘤手术切除机会,提高手术切除的安全性,对于无法手术切除的肝癌患者重新获得手术切除的机会,具有潜在的临床应用价值。     

Combined versus single locoregional therapy in the treatment of unresectable hepatocellular carcinoma

Introduction

Surgical and locoregional therapies are different options in HCC treatment, several locoregional techniques are used.

Purpose

This study aimed to assess the effectiveness of transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and combined therapy, in HCC management.

Materials and methods

The study was conducted at our University Hospital, from August 2011 to February 2013. It included 60 patients with HCC (40 males and 20 females, age ranged between 45 and 70 years). Patients were classified into 3 groups, group 1 treated with TACE, group 2 with RFA, and group 3 with both techniques. Response was assessed by triphasic CT and alpha fetoprotein. Patients were classified into good and poor responders after one and six months and one year. Patients’ survival and incidence of recurrence were recorded.

Results

The percentage of good responders was greater with combined therapy than with TACE and RFA (90%, 70%, and 60% respectively). The overall survival was 75% and the recurrence free survival was 60% in TACE, 90%, and 45% in RFA and 95% and 90% in combined therapy respectively.

Conclusion

Combined therapy is superior regarding good response, overall survival, and free recurrence survival than either TACE or RFA alone.     

Comparison of two different thermal techniques for the treatment of hepatocellular carcinoma

Purpose

To compare the safety and efficacy of radiofrequency ablation (RFA) and microwave ablation (MWA) in treating hepatocellular carcinoma (HCC) while conforming to the Milan criteria.

Materials and methods

The study was approved by the Institutional Review Board, and informed consent was waived due to the retrospective study design. One hundred ninety-eight patients met the inclusion criteria and were included in the study. Eighty-five patients with 98 lesions received RFA, and 113 patients with 131 lesions underwent MWA. Complete ablation rates, local recurrence rates, disease-free survival rates, cumulative survival rates, and major complications were compared between the two treatment groups.

Results

Complete ablation rates were 99.0% for RFA and 98.5% for MWA (P = 1.000). Local recurrence rates were 5.2% for RFA and 10.9% for MWA (P = 0.127). Disease-free survival rates at 1, 2, 3, and 4 years were 80.3%, 61.8%, 39.5%, and 19.0% in the RFA group and 75.0%, 59.4%, 32.1%, and 16.1% in the MWA group, respectively (P = 0.376). Cumulative survival rates at 1, 2, 3, and 4 years were 98.7%, 92.3%, 82.7%, and 77.8% in the RFA group and 98.0%, 90.7%, 77.6%, and 77.6% in the MWA group, respectively (P = 0.729). Major complication rates were 2.4% and 2.7% in the RFA group and the MWA group, respectively (P = 1.000). There were no patient deaths due to treatment.

Conclusion

RFA and MWA have the same clinical value in treating HCC conforming to the Milan criteria. RFA and MWA are both safe and effective techniques for HCC as clinical application.     

腹腔镜射频消融治疗原发性肝癌的研究

目的：评价腹腔镜射频消融（RFA）治疗原发性肝癌的可行性、安全性及疗效。方法：51例原发性肝癌在全麻下行腹腔镜RFA治疗,共72个瘤体,平均最大肿瘤直径（3．4±1．0）cm。合并肝硬化49例、慢性结石性胆囊炎5例,糖尿病4例,凝血功能障碍10例。结果：51例均顺利完成腹腔镜RFA治疗,12例行腹腔镜胆囊切除术。未出现严重并发症。肿瘤完全坏死率为95．8％。随访12～58个月（平均35个月）,6例发现肝内新病灶,11例射频治疗部位复发,再次采用经皮RFA治疗9例,12例死于肿瘤复发或肝功能衰竭。结论：腹腔镜RFA治疗原发性肝癌安全可行,治疗效果可靠,但应选择瘤体位于肝脏表面或临近胆囊而且不宜手术切除的病例进行治疗。     

原发性肝癌合并门静脉癌栓的经动脉化疗栓塞治疗

目的分析经导管肝动脉化疗栓塞术(TACE)对肝癌并门静脉癌栓(PVTT)患者的治疗作用。方法对106例肝癌并门静脉癌栓患者行TACE治疗。治疗前后观察肝癌病灶及门静脉癌栓的变化。结果23例肿瘤缩小50%以上,50%以下的有25例,不变的有44例,增大12例。门静脉癌栓14例消失,39例缩小,51例不变。2例术后1周内死亡。结论TACE治疗肝癌并门静脉内癌栓可取得良好效果。     

Carbon dioxide microbubbles-enhanced sonographically guided radiofrequency ablation: treatment of patients with local progression of hepatocellular carcinoma

Purpose The aim of our study was to evaluate the usefulness of percutaneous radiofrequency ablation (RFA) using CO₂ microbubbles-enhanced sonography for patients with local tumor progression of hepatocellular carcinoma (HCC). Materials and methods The tumors of 14 patients with local progression of HCC were treated with CO₂ microbubbles-enhanced RFA ablation via a catheter that had been placed in the hepatic artery. We assessed tumor detectability and technical effectiveness. The mean follow-up period was 14.1 months. Results Only 6 of the tumors could be found on conventional sonography, whereas 14 tumors were detected on CO₂ microbubbles-enhanced sonography. These 14 lesions were successfully treated with RFA guided by CO₂ microbubbles-guided sonography. Technical effectiveness was complete in all patients. No serious complications were observed, and there was no local tumor progression during the follow-up period. Conclusion RFA guided by CO₂ microbubbles-guided sonography is a feasible technique for treating local progression of HCC lesions that cannot be adequately depicted by conventional sonography.     

Radiofrequency thermal ablation for pain control in patients with single painful bone metastasis from hepatocellular carcinoma

Objective

The aim of this study was to assess the safety and the efficacy of radiofrequency thermal ablation (RFA) for pain relief and analgesics use reduction in two patients with painful bone metastases from hepatocellular carcinoma (HCC).

Materials and methods

Two patients with lytic metastases from HCC located at the left superior ileo-pubic branch and at the middle arch of VII rib, performed RFA displacing a LeVeen Needle (3.5 and 4.0 cm diameter) under US (ultrasonography) and fluoroscopic guidance.Two methods were used to determine the response of both patients: the first method was to measure patient's worst pain with a Brief Pain Inventory (BPI) 1 day after the procedure, every week for 1 month, and thereafter at week 8 and 12 (total follow-up 3 months); the second method was to evaluate patient's analgesics use recorded at week 1, 4, 8 and 12.Analgesic medication use was translated into a morphine-equivalent dose.

Results

The RFA were well tolerated by the patients who did not develop any complication. Both patients obtained substantial reduction of pain, which decreased from a mean score of 8 to approximately 2 in 4 weeks. In both patients we observed a reduction in the use of morphine dose-equivalent after a peak at week 1.CT (computed tomography) imaging, performed at 1 month after RFA, demonstrated that both procedures were technically successful and safe because consistent necrosis and no evidence for complications were observed.

Conclusion

RFA provides a potential alternative method for palliation of painful osteolytic metastases from HCC; the procedure is safe, and the pain relief is substantial.     

超声引导下射频消融治疗肝癌安全性与疗效分析

目的探讨超声引导下射频消融方法治疗肝癌的安全性与临床效果。方法选取我院2010年7月-2013年7月收治的35例肝癌患者,共61个病灶实施超声引导下经皮射频消融治疗,观察患者并发症情况及肿瘤消融情况,对比分析治疗前后的甲胎蛋白值、肿瘤大小及瘤体内的血供情况。结果所有病灶均消融成功,无严重并发症发生。经过4-15个月随访,复发13例,均给予再次射频消融。结论经皮射频消融治疗肝癌是一种安全、有效的热消融治疗技术,值得临床推广应用。     

经导管肝动脉栓塞化疗联合华蟾素门静脉灌注治疗中期原发性肝癌疗效研究

目的探讨经导管肝动脉栓塞化疗(TACE)联合华蟾素门静脉灌注治疗中期原发性肝癌患者的临床疗效与预后。方法选取自2011年2月至2013年11月收治的中期原发性肝癌患者79例,其中,单独应用TACE的患者40例(单独组),联合应用TACE与华蟾素门静脉灌注的患者39例(联合组)。比较两组患者存活与门静脉侵犯情况,并分析其影响因素。结果单独组与联合组患者的1年存活率分别为62.5%(25/40)与82.1%(32/39),2年存活率分别为22.5%(9/40)与35.9%(14/39),3年存活率分别为7.5%(3/40)与17.9%(7/39);中位存活时间分别为15.0个月与18.0个月;门静脉癌栓发生率分别为82.5%(33/40)与61.5%(24/39)。两组比较,差异均有统计学意义(P<0.05)。华蟾素门静脉灌注、ChildPugh分级、甲胎蛋白水平及肿瘤大小是影响患者预后的独立危险因素。结论 TACE联合华蟾素门静脉灌注治疗可明显改善中期原发性肝癌患者的预后,值得临床推广。     

伴门静脉癌栓肝癌的不同靶区适形放疗临床分析

目的比较原发性肝癌伴门静脉癌栓不同肿瘤靶区三维适形放射治疗联合介入的临床疗效。方法30例原发性肝癌伴门静脉癌栓患者，采用三维适形放射治疗联合肝动脉化疗栓塞（TACE）进行治疗，根据肿瘤靶区分为2组：肿瘤靶区包括肝内原发肿瘤＋静脉癌栓者为A组（15例），肿瘤靶区只包括静脉癌栓而不包括肝原发灶者为B组（15例）。2组病例均于TACE 1～2次后开始放疗。结果A、B两组治疗有效率分别为33．3％和53．3％，1、2年生存率分别为26．7％、6．7％和40．0％、13．3％，两组差异均无统计学意义（P〉0．05）。A组放射反应发生率明显高于B组（P〈0．05）。结论对于晚期肝癌伴门静脉癌栓，特别是肝内多发或大病灶、肝功能差的患者，在联合TACE有效治疗下，对静脉癌栓的局部放射治疗仍能取得较好疗效。     

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.     

Treatment response assessment of radiofrequency ablation for hepatocellular carcinoma: usefulness of virtual CT sonography with magnetic navigation

Purpose

Virtual CT sonography using magnetic navigation provides cross sectional images of CT volume data corresponding to the angle of the transducer in the magnetic field in real-time. The purpose of this study was to clarify the value of this virtual CT sonography for treatment response of radiofrequency ablation for hepatocellular carcinoma.

Patients and methods

Sixty-one patients with 88 HCCs measuring 0.5–1.3 cm (mean ± SD, 1.0 ± 0.3 cm) were treated by radiofrequency ablation. For early treatment response, dynamic CT was performed 1–5 days (median, 2 days). We compared early treatment response between axial CT images and multi-angle CT images using virtual CT sonography.

Results

Residual tumor stains on axial CT images and multi-angle CT images were detected in 11.4% (10/88) and 13.6% (12/88) after the first session of RFA, respectively (P = 0.65). Two patients were diagnosed as showing hyperemia enhancement after the initial radiofrequency ablation on axial CT images and showed local tumor progression shortly because of unnoticed residual tumors. Only virtual CT sonography with magnetic navigation retrospectively showed the residual tumor as circular enhancement. In safety margin analysis, 10 patients were excluded because of residual tumors. The safety margin more than 5 mm by virtual CT sonographic images and transverse CT images were determined in 71.8% (56/78) and 82.1% (64/78), respectively (P = 0.13). The safety margin should be overestimated on axial CT images in 8 nodules.

Conclusion

Virtual CT sonography with magnetic navigation was useful in evaluating the treatment response of radiofrequency ablation therapy for hepatocellular carcinoma.     

Ultrasound-guided percutaneous thermal ablation of hepatocellular carcinoma using microwave and radiofrequency ablation

AIM: To investigate the therapeutic efficacy of thermal ablation for treatment of hepatocellular carcinoma (HCC) using microwave and radiofrequency (RF) energy application. MATERIALS AND METHODS: A total of 190 nodules in 97 patients (84 male, 13 female; mean age 53.4 years, range 24-74 years) with HCC were treated with microwave or RF ablation in the last 4 years. The applicators were introduced into the tumours under conscious analgesic sedation by intravenous administration of fentanyl citrate and droperidol and local anaesthesia in both thermal ablation procedures. The patients were then followed up with contrast-enhanced computed tomography (CT) to evaluate treatment response. Survival was analysed using the Kaplan-Meier method. RESULTS: Complete ablation was obtained in 92.6% (176/190) nodules. The complete ablation rates were 94.6% (106/112) in microwave ablation and 89.7% (70/78) in RF ablation. The complete ablation rates in tumours/=4.0 cm were 93.1, 93.8 and 86.4%, respectively. Local recurrence was found in 9.5% nodules and the rates in tumours/=4.0 cm in diameter were 3.4, 9.9 and 31.8%, respectively. In the follow-up period, 7.1% nodules ablated by microwave and 12.8% by RF presented local recurrence. The 1, 2 and 3-year distant recurrence-free survivals were 47.2, 34.9 and 31.0%, respectively. Estimated mean survival was 32 months, and 1, 2 and 3-year cumulative survivals were 75.6, 58.5, and 50.0%, respectively. One and 2 years survivals of Child-Pugh class A, B and C patients were 83.8 and 70.4%, 78.2 and 53.2%, 36.3 and 27.3%, respectively. CONCLUSION: Thermal ablation therapy by means of microwave and RF energy application is an effective and safe therapeutic technique for hepatocellular carcinoma. Large tumours can be completely ablated, but have a significantly higher risk of local recurrence at follow-up.     

无水酒精注射术联合射频消融术与单纯射频消融术治疗小肝癌的疗效比较

目的比较无水酒精注射术（PEI）联合射频消融术（RFA）治疗方案与单纯RFA治疗小肝癌的疗效。方法回顾分析我院2006年1月～2008年1月进行的68例小肝癌射频消融治疗患者的临床资料。68例中37例行PEI联合RFA术,31例行单纯RFA术。比较两组肿瘤完全消融率,复发率,复发时间,术后1、2、3年生存率等情况。结果 PEI联合RFA组肿瘤完全消融率91.89%,局部复发率10.81%,局部复发时间（14.22±3.48）月,1、2、3年的生存率分别为89.19%、81.08%和72.97%。单纯RFA组肿瘤完全消融率70.97%,局部复发率32.26%,局部复发时间（9.15±2.68）月,1、2、3年的生存率87.10%、77.42%和48.39%。PEI联合RFA组在肿瘤完全消融率、局部复发率、复发时间、术后3年生存率方面好于单纯RFA组。结论 PEI联合RFA治疗小肝癌疗效优于单纯RFA治疗,在小肝癌的治疗中有重要临床应用价值。     

The efficacy of intraperitoneal saline infusion for percutaneous radiofrequency ablation for hepatocellular carcinoma

Objective

To evaluated the efficacy and safety of radiofrequency ablation (RFA) with intraperitoneal saline infusion.

Background

Ultrasound-guided RFA is not always feasible due to the tumor location, possible adjacent tissue damage or poor sonographic identification.

Patients and methods

Ultrasound-guided RFA with intraperitoneal saline infusion was performed in 116 patients between June 2001 and March 2008.

Results

The overall technical feasibility of the intraperitoneal saline infusions was 90.5% (105 patients). The purposes of the intraperitoneal saline infusion were achieved in 100 patients (86.2%) by visualizing the tumor located in hepatic dome (47 patients), prevent adjacent organ damage (42 patients) and withdrawing overlying omentum (10 patients). Complete ablation of tumor was accomplished in 102 patients (87.9%). Complications associated with the treatment occurred in seven patients (6.0%). There was no case of adverse event directly related to intraperitoneal saline infusion.

Conclusions

Intraperitoneal saline infusion is an effective and safe procedure that can be used to overcome the current limitations of ultrasound-guided RFA.     

不完全射频消融对兔VX2肝癌MMP-9表达的影响

目的研究不完全射频消融（RFA）治疗对兔VX2肝癌模MMP-9蛋白表达的影响。 方法建立新西兰白兔的VX2肝癌模型,将30只兔VX2肝癌模型分为2组,即对照组和实验组,每组15只,对照组只做开关腹,而不进行RFA;实验组进行开腹消融,消融范围为肿瘤组织的75%;在实验组中设立RFA后快速进展亚组,定义为实验结束时肿瘤的倍增率大于对照组。对比其RFA后的VX2肝癌的体积变化、残留VX2肝癌基质金属蛋白酶-9（MMP-9）的表达情况。 结果对照组和实验组治疗后肿瘤体积分别为（7 862±1 304）mm³和（6 996±709）mm³,肿瘤的倍增率分别为（291±49）和（232±16）,差异有统计学意义（P < 0.05）。对照组和实验组MMP-9阳性表达率为52.1%和46.3%,差异均有统计学意义（P < 0.05）;实验组中3只实验兔肿瘤倍增率及MMP-9表达率明显高于实验组,属于RF后快速进展亚组,差异有统计学意义（P < 0.05）。 结论部分性消融对大多数肝细胞癌具有一定疗效,但对于少数肿瘤可能加速其生长,而MMP-9的过表达可能是促进残留癌快速进展的原因。     

Radiofrequency ablation of hepatocellular carcinoma: long-term outcome and prognostic factors

PURPOSE: To investigate the efficacy of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC), and the prognostic factors for post-RFA survival rate. METHODS: From 1999 to 2006, 266 patients with 392 HCCs underwent ultrasound guided RFA treatment. They were 216 males and 50 females, average age 59.4+/-15.4 years (24-87 years). The HCC were 1.2-6.7 cm in diameters (average 3.9+1.3 cm). There were 158 patients with single tumor, and the rest had multiple (2-5) tumors. Univariate and multivariate analysis with 19 potential variables were examined to identify prognostic factors for post-RFA survival rate. RESULTS: The overall post-RFA survival rates at 1st, 3rd, and 5th year were 82.9%, 57.9% and 42.9%, respectively. In the 60 patients with stage I HCC (AJCC staging), the 1-, 3-, 5-year survival rate were 94.8%, 76.4% and 71.6%, significantly higher than the 148 patients with stage II-IV tumors (81.8%, 57.6% and 41.2%, P=0.006). For the 58 patients with post-surgery recurrent HCC, the survival rates were 73.2%, 41.9% and 38.2% at the 1st, 3rd, and 5th year, which were significantly lower than those of stage I HCC (P=0.005). Nine potential factors were found with significant effects on survival rate, and they were number of tumors, location of tumors, pre-RFA liver function enzymes, Child-Pugh classification, AJCC staging, primary or recurrent HCC, tumor pathological grading, using mathematical protocol in RFA procedure and tumor necrosis 1 month after RFA. After multivariate analysis, three factors were identified as independent prognostic factors for survival rate, and they were Child-Pugh classification, AJCC staging and using mathematical protocol. CONCLUSION: Identifying prognostic factors provides important information for HCC patient management before, during and after RFA. This long-term follow-up study on a large group of HCC patients confirmed that RFA could not only achieve favorable outcome on stage I HCC, but also be an effective therapy for stage II-IV or recurrent HCC.