Long-term Follow-up Outcome of Patients Undergoing Radiofrequency Ablation for Unresectable Hepatocellular Carcinoma

The long-term outcome of radiofrequency thermal ablation (RFA) for unresectable hepatocellular carcinoma (HCC) has not been reported. This study was performed to evaluate the long-term survival of patients with unresectable HCC after RFA and to identify possible factors that might affect survival. In this prospective study, 65 patients with unresectable HCC who underwent RFA were followed. A total of 84 RFA operations were performed percutaneously (n = 49), laparoscopically (n = 20), or by open surgery (n = 15), to ablate 191 tumors. Twenty-two patients died within 16 months; otherwise, the follow-up period was at least 16 months, up to 71 months, with median 20.0 months and mean (± standard deviation) 24.8 ± 18.4 months for all patients. Local tumor recurrence developed in 12 of 191 tumors (6.3%) in 11 of 84 operations (13.1%), or 11 of 65 patients (16.9%). New liver and/or extrahepatic recurrence developed in 48 operations (57.1%). The overall median, mean, and 5-year survivals were 40.0 months, 33.7 ± 2.9 months, and 39.9%. The disease-free survivals were 16.0 month, 32.9 ± 3.0 months, and 27.9%. Factors that had a significant effect on survival outcome after RFA were TNM cancer stage and the operative approach method employed for RFA. Age, gender, race, etiology, alpha-fetoprotein, previous or subsequent treatment, and liver function (Child-Pugh class) did not affect survival. For patients with unresectable HCC, RFA is an effective and repeatable local treatment that can afford long-term survival, although often with disease recurrence.     

Endoscopic versus Open Radiofrequency Ablation for Treatment of Small Hepatocellular Carcinoma

Background

Surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is associated with superior oncological outcome in comparison with percutaneous RFA. The present study aimed to retrospectively evaluate the relative perioperative safety and postoperative outcome of the laparoscopic or thoracoscopic approach versus the open approach to RFA for small HCC.

Methods

A retrospective analysis was performed in 55 consecutive patients who underwent open (n = 32) or laparoscopic/thoracoscopic (LTS) RFA (n = 23) for primary unresectable HCC between January 2005 and December 2010. Baseline characteristics, survival/recurrence rates, and complications after treatment were compared between the two groups.

Results

There was a trend showing that LTS RFA was performed for tumors located in the anterior segment (e.g., segments III, V, VIII). The LTS RFA group had a significantly lower intraoperative blood loss, shorter operative time, and shorter postoperative hospital stay, compared with the open RFA group. No major postoperative complications occurred in patients who underwent LTS RFA. No significant differences in overall survival, recurrence-free survival and local recurrence rates were observed between the two groups.

Conclusions

In consideration of operative invasiveness and postoperative recovery, LTS RFA is superior to the open approach in patients with small HCC. Moreover, the surgical outcome did not differ between the two approaches. Laparoscopic/thorascopic RFA can be considered to be a useful procedure for ablation therapy.     

Radiofrequency ablation for unresectable tumors of the liver

Surgical resection of primary or metastatic tumors of the liver offers patients the best long-term survival. Liver resections may not be appropriate in patients with bilobar metastases, liver dysfunction, or severe comorbidities. Radiofrequency ablation (RFA) is a technique used to destroy unresectable hepatic tumors through thermocoagulation. We retrospectively reviewed a consecutive series of patients undergoing RFA with unresectable hepatic tumors for local recurrence and overall survival. Under an Institutional Review Board-approved protocol, all patients treated with RFA at the University of Alabama at Birmingham from September 1, 1998, to June 15, 2005, were identified. During this time period, 189 lesions in 107 patients were treated with RFA. Patients' charts were retrospectively reviewed. Data is presented as mean +/- SEM. Significance is defined as P < 0.05. Patient demographics revealed 62 per cent males and 38 per cent females with a mean age of 59 (+/- 1) years. Hepatocellular carcinoma (HCC) represented 54 per cent of the tumors treated. Metastatic colorectal cancer represented 22 per cent and the remaining 24 per cent were other metastatic tumors. Overall recurrence rates for all tumors after RFA was 53 per cent. Local recurrence rates for HCC, colorectal cancer, and other metastatic lesions were 27.6 per cent, 29.1 per cent, and 52 per cent, respectively. The morbidity rate for the procedure was 11 per cent. There was one mortality (0.9%) related to RFA. Laparoscopic RFA for HCC in Childs-Pugh Class C cirrhotics (n = 6) resulted in 50 per cent of patients being transplanted with no evidence of disease at a mean follow-up period of 14 months. RFA is a safe and effective way for treating HCC and other unresectable tumors in the liver that are not eligible for hepatic resection. More effective control of systemic recurrence will dictate survival in the majority of patients with metastatic cancers. Local ablation for HCC in cirrhotic patients may be an effective bridge to transplantation. Liver transplantation may still be the most effective long-term treatment for localized HCC.     

Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis

OBJECTIVE: To determine the treatment efficacy, safety, local tumor control, and complications related to radiofrequency ablation (RFA) in patients with cirrhosis and unresectable hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: Most patients with HCC are not candidates for resection because of tumor size, location, or hepatic dysfunction related to cirrhosis. RFA is a technique that permits in situ destruction of tumors by means of local tissue heating. METHODS: One hundred ten patients with cirrhosis and HCC (Child class A, 50; B, 31; C, 29) were treated during a prospective study using RFA. Patients were treated with RFA using an open laparotomy, laparoscopic, or percutaneous approach with ultrasound guidance to place the RF needle electrode into the hepatic tumors. All patients were followed up at regular intervals to detect treatment-related complications or recurrence of disease. RESULTS: All 110 patients were followed up for at least 12 months after RFA (median follow-up 19 months). Percutaneous or intraoperative RFA was performed in 76 (69%) and 34 patients (31%), respectively. A total of 149 discrete HCC tumor nodules were treated with RFA. The median diameter of tumors treated percutaneously (2.8 cm) was smaller than that of lesions treated during laparotomy (4.6 cm). Local tumor recurrence at the RFA site developed in four patients (3.6%); recurrent HCC subsequently developed in other areas of the liver in all four. New liver tumors or extrahepatic metastases developed in 50 patients (45. 5%), but 56 patients (50.9%) had no evidence of recurrence. There were no treatment-related deaths, but complications developed in 14 patients (12.7%) after RFA. CONCLUSIONS: In patients with cirrhosis and HCC, RFA produces effective local control of disease in a significant proportion of patients and can be performed safely with minimal complications.     

Analysis of Recurrence Pattern and Its Influence on Survival Outcome After Radiofrequency Ablation of Hepatocellular Carcinoma

Background Radiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients. Aim of Study To evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA. Patients and Methods From April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (n = 101), laparoscopic (n = 17), or open approaches (n = 91). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients. Results The mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26 months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child–Pugh grade (risk ratio [RR] = 2.918, 95% confident interval [CI] 1.704–4.998, p = 0.000), tumor size (RR = 1.231, 95% CI 1.031–1.469, p = 0.021), and pattern of recurrence (risk ratio [RR] = 1.464, 95% CI 1.156–1.987, P = 0.020) were identified as independent prognostic factors for overall survival. Conclusion The tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.     

Surgery After Downstaging of Unresectable Hepatic Tumors With Intra-Arterial Chemotherapy

Background: This retrospective study was performed to assess the outcome among patients who underwent hepatic resection or tumor ablation after hepatic artery infusion (HAI) therapy downstaged previously unresectable hepatocellular carcinoma (HCC) or liver metastases from colorectal cancer (CRC).Methods: Between 1983 and 1998, 25 patients with HCC and 383 patients with hepatic CRC metastases were treated with HAI therapy for unresectable liver disease. We retrospectively reviewed the records of 26 (6%) of these patients who underwent subsequent surgical exploration for tumor resection or ablation.Results: At a median of 9 months (range 7–12 months) after HAI treatment, four patients (16%) with HCC underwent exploratory surgery; two underwent resection with negative margins, and the other two were given radiofrequency ablation (RFA) because of underlying cirrhosis. At a median postoperative follow-up of 16 months (range 6–48 months), all four patients were alive with no evidence of disease. At a median of 14.5 months (range 8–24 months) after HAI therapy, 22 patients with hepatic CRC metastases underwent exploratory surgery; 10 underwent resection, 6 underwent resection and RFA or cryotherapy, and 2 underwent RFA only. At a median follow-up of 17 months, 15 (83%) of the 18 patients with CRC who had received surgical treatment had developed recurrent disease; the other 3 died of other causes (1 of postoperative complications) within 7 months of the surgery. One patient in whom disease recurred underwent a second resection and was disease-free at 1 year follow-up.Conclusions: Hepatic resection or ablation after tumor downstaging with HAI therapy is a viable option for patients with unresectable HCC. However, given the high rate of recurrence of metastases from CRC, hepatic resection or ablation after downstaging with HAI should be used with caution.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16–19, 2000.     

Early and late complications after radiofrequency ablation of malignant liver tumors in 608 patients

BACKGROUND: Radiofrequency ablation (RFA) has become a common treatment of patients with unresectable primary and secondary hepatic malignancies. We performed this prospective analysis to determine early (within 30 days) and late (more than 30 days after) complication rates associated with hepatic tumor RFA. METHODS: All patients treated between January 1, 1996 and June 30, 2002 with RFA for hepatic malignancies were entered into a prospective database. Patients were evaluated during RFA treatment, throughout the immediate post RFA course, and then every 3 months after RFA to assess for the development of treatment-related complications. RESULTS: A total of 608 patients, 345 men (56.7%) and 263 women (43.3%), with a median age of 58 years (range 18-85 years) underwent RFA of 1225 malignant liver tumors. Open intraoperative RFA was performed in 382 patients (62.8%), while percutaneous RFA was performed in 226 (37.2%). The treatment-related mortality rate was 0.5%. Early complications developed in 43 patients (7.1%). Early complications were more likely to occur in patients treated with open RFA (33 [8.6%] of 382 patients) compared with percutaneous RFA (10 [4.4%] 226 patients, P < 0.01), and in patients with cirrhosis (25 [12.9%] complications in 194 patients) compared with noncirrhotic patients (31 [7.5%] complications in 414 patients, P < 0.05). Late complications arose in 15 patients (2.4%) with no difference in incidence between open and percutaneous RFA treatment. The combined overall early and late complication rate was 9.5%. CONCLUSIONS: Hepatic tumor RFA can be performed with low mortality and morbidity rates. Though relatively rare, late complications can develop and physicians performing hepatic RFA must be cognizant of these delayed treatment-related problems.     

Radiofrequency ablation for unresectable hepatic tumors

BACKGROUND: Radiofrequency ablation (RFA) is a relatively new treatment for unresectable hepatic tumors. The purpose of this analysis was to examine the frequency of complications and local recurrence associated with RFA. METHODS: Patients who underwent RFA of hepatic tumors with curative intent were included in this study. At laparotomy, RFA was performed using intraoperative ultrasound guidance. Computed tomography scans were obtained in the immediate postoperative period and every 3 to 6 months thereafter. RESULTS: Forty patients underwent RFA for 122 hepatic tumors. Thirty-one patients had metastatic lesions from colorectal cancer; 9 had other liver tumors. Complications occurred in 8 patients. With 9.5 months median follow-up, 6 patients had local recurrence of their ablated tumors. CONCLUSIONS: Our initial experience shows that RFA can effectively eradicate unresectable hepatic tumors. The rate and severity of complications appear acceptable. However, further study is necessary to assess long-term recurrence rates and effect on overall survival.     

Local Recurrences After Intraoperative Radiofrequency Ablation of Liver Metastases: A Comparative Study with Anatomic and Wedge Resections

Background The indications and results of intraoperative radiofrequency ablation (RFA) of liver metastases (LMs) are not well defined in the literature and have never been compared with those of hepatectomy. The aim of the study was to appreciate the local recurrence rate of RFA in comparison with anatomic and wedge resection.Methods Eighty-eight patients with technically unresectable LMs were treated with curative intent. The LMs were treated by anatomic resection (40 patients, 213 LMs) when large, by wedge resection (64 patients, 99 LMs) when peripheral and small, and by RFA (88 patients, 227 LMs) when central and small. The median follow-up was 27.6 months (range, 15–74 months), and a total of 539 LMs were treated (median of 5 per patient).Results The local recurrence rates were 5.7% for the 227 RFAs, 7.1% for the 99 wedge resections, and 12.5% for the 40 anatomic resections (P = .216). Local recurrence rates after RFA were correlated with LMs larger than 30 mm (P < .001) and with LMs in direct contact with large vessels (P < .001).Conclusions RFA is as efficient and safe as wedge or anatomic resections in terms of local control.     

Laparoscopic radiofrequency ablation of unresectable liver malignancies: feasibility and clinical outcome

Radiofrequency ablation (RFA) is a safe and effective treatment in patients with unresectable liver malignancies. Since there is little information on its optimal approach, the feasibility, clinical outcome, and efficacy of laparoscopic RFA need further investigation. Twenty-three consecutive patients with unresectable hepatic malignancies were treated with RFA. RFA was performed percutaneously in 5 patients (5 tumors; median maximum diameter of 25 mm [range, 20-73]), via laparotomy in 9 (28 tumors; median maximum diameter of 38 mm [5-90]), and via laparoscopy in 9 (16 tumors; median maximum diameter of 35 mm [8-58]). Mortality and intraoperative complication rates were 0. In the laparoscopy and laparotomy groups, mean blood loss was 13 mL versus 421 mL and mean hospital stay was 5.7 versus 11.2 days, respectively (P = 0.0008 and P = 0.04). Postoperative complications occurred in one patient after laparoscopic RFA and in three after RFA via laparotomy. After a median follow-up of 12.2 months, local recurrence occurred in 2 patients (laparoscopic RFA, 1; percutaneous RFA, 1), and new hepatic tumors developed in 7 (laparoscopic RFA, 2/9; RFA via laparotomy, 5/9). Laparoscopic RFA is a safe and feasible treatment modality to achieve tumor destruction in selected patients with unresectable hepatic malignancies.     

Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies

BACKGROUND: The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA. PATIENTS AND METHODS: Patients with hepatic malignancies were entered into two consecutive prospective, nonrandomized trials. The liver tumors were treated intraoperatively with cryoablation or RFA; intraoperative ultrasonography was used to guide placement of cryoprobes or RFA needles. All patients were followed up postoperatively to assess complications, treatment response, and local recurrence of malignant disease. RESULTS: Cryoablation was performed on 88 tumors in 54 patients, and RFA was used to treat 138 tumors in 92 patients. Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation (40.7% complication rate). In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01). CONCLUSIONS: RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA.     

Intraoperative Ablation for Small HCC not Amenable for Percutaneous Radiofrequency Ablation in Child A Cirrhotic Patients

Background

Radiofrequency ablation (RFA) was initially started by radiologists as a percutaneous treatment, but surgeons started to use RFA by surgical approach for patients with tumors at locations difficult for the percutaneous procedure. The aim was to evaluate the results of intraoperative RFA for small hepatocellular carcinomas (HCCs) (<3 cm) in locations difficult for a percutaneous approach.

Methods

Two hundred forty-seven patients with small solitary HCC (<3 cm) were treated; 196 via percutaneous RFA while 51 patients presented at sites not amenable for percutaneous route. Twenty-seven out of 51 patients underwent surgical resection, while 24/51 patients underwent intraoperative RFA.

Results

The location and depth of the tumor from the liver capsule was the only significant factors in the choice of the surgeon between resection and RFA. RFA was successful in all tumors (complete ablation rate of 100 %). In the surgery group, all patients achieved R0 resection. Complication rate was comparable (p?=?1.0). After a median follow-up of 37 months (range, 10–45 months), no tumors showed neither local progression nor local recurrence and no significant difference was observed between two groups as regards early recurrence and number of de novo lesions (p?=?0.49). One-year and 3-year survival rates were 93 % and 81 %, respectively, in the resection group comparable to the corresponding rates of 92 % and 74 % in the RFA group (p?=?0.9).

Conclusion

For small HCC in locations difficult for a percutaneous approach, intraoperative RFA can be an alternative option for deep-seated tumors necessitating more than one segmentectomy achieving similar tumor control, and overall and disease-free survival.     

Long-term outcomes after hepatic resection combined with radiofrequency ablation for initially unresectable multiple and bilobar liver malignancies

Background

Hepatic resection (HRE) combined with radiofrequency ablation (RFA) offers a surgical option to a group of patients with multiple and bilobar liver malignancies who are traditionally unresectable for inadequate functional hepatic reserve. The aims of the present study were to assess the perioperative outcomes, recurrence, and long-term survival rates for patients treated with HRE plus RFA in the management of primary hepatocellular carcinoma (HCC) and metastatic liver cancer (MLC).

Methods

Data from all consecutive patients with primary and secondary hepatic malignancies who were treated with HRE combined with RFA between 2007 and 2013 were prospectively collected and retrospectively reviewed.

Results

A total of 112 patients, with 368 hepatic tumors underwent HRE combined with ultrasound-guided RFA, were included in the present study. There were 40 cases of HCC with 117 tumors and 72 cases of MLC with 251 metastases. Most cases of liver metastases originated from the gastrointestinal tract (44, 61.1%). Other uncommon lesions included breast cancer (5, 6.9%), pancreatic cancer (3, 4.2%), lung cancer (4, 5.6%), cholangiocarcinoma (4, 5.6%), and so on. The ablation success rates were 93.3% for HCC and 96.7% for MLC. The 1-, 2-, 3-, 4-, and 5-y overall recurrence rates were 52.5%, 59.5%, 72.3%, 75%, and 80% for the HCC group and 44.4%, 52.7%, 56.1%, 69.4%, and 77.8% for the MLC group, respectively. The 1-, 2-, 3-, 4-, and 5-y overall survival rates for the HCC patients were 67.5%, 50%, 32.5%, 22.5%, and 12.5% and for the MLC patients were 66.5%, 55.5%, 50%, 30.5%, and 19.4%, respectively. The corresponding recurrence-free survival rates for the HCC patients were 52.5%, 35%, 22.5%, 15%, and 10% and for the MLC patients were 58.3%, 41.6%, 23.6%, 16.9%, and 12.5%, respectively.

Conclusions

HRE combined with RFA provides an effective treatment approach for patients with primary and secondary liver malignancies who are initially unsuitable for radical resection, with high local tumor control rates and promising survival data.     

The laparoscopic approach for radiofrequency ablation of hepatocellular carcinoma—indication, technique and results

Background

The therapeutic regimen for patients suffering of HCC in liver cirrhosis must pay attention to the underlying liver disease. Surgical resection is often limited by liver function and transplantation, as an optimal therapy for many early diagnosed HCC, by the availability of organs. Due to three prospective, randomized trials radiofrequency ablation (RFA) is the standard method of local ablation. RFA compared with resection for HCC in liver cirrhosis yields similar results concerning overall survival but a lower rate of complications. The laparoscopic approach may be advantageous concerning the major drawback of RFA which is still the rate of local failure as shown by a meta-analysis of local recurrences.

Method

Indication for RFA was HCC in liver cirrhosis either as a definite therapy or as a bridging procedure for transplantation if the expected waiting time exceeded 6 months. Laparoscopic ultrasound, standardized algorithm of laparoscopic RFA procedure, track ablation and a Trucut biopsy were performed. The postoperative follow-up was done according to institutional standards. Patient data and parameters of laparoscopic RFA were prospectively documented, analyzed and compared with the results of previously published series found in a Medline search.

Results

34 patients were treated by laparoscopic RFA. The average time of follow-up was 36.9?±?28.3 months. There was no procedure-related mortality or surgical complications. An upstaging of the tumor stage by laparoscopic ultrasound was achieved in 32 % of the patients. The overall survival of these patients was 44.7?±?6.9 months. The intrahepatic recurrence rate was 61.8 % based on the number of patients treated. The results have been analyzed and compared with six independent papers identified in a Medline search that report on the treatment of patients with HCC in a liver cirrhosis by laparoscopic RFA with a mean follow-up of 12 or more months.

Conclusions

Laparoscopic RFA is a feasible and reliable therapy for unresectable HCCs in patients with cirrhosis. The laparoscopic RFA combines the advantage of a minimally invasive procedure concerning liver dysfunction with the ability of an accurate intraoperative staging by laparoscopic ultrasound.     

Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases

OBJECTIVE: To examine recurrence and survival rates for patients treated with hepatic resection only, radiofrequency ablation (RFA) plus resection or RFA only for colorectal liver metastases. SUMMARY BACKGROUND DATA: Thermal destruction techniques, particularly RFA, have been rapidly accepted into surgical practice in the last 5 years. Long-term survival data following treatment of colorectal liver metastasis using RFA with or without hepatic resection are lacking. METHODS: Data from 358 consecutive patients with colorectal liver metastases treated for cure with hepatic resection +/- RFA and 70 patients found at laparotomy to have liver-only disease but not to be candidates for potentially curative treatment were compared (1992-2002). RESULTS: Of 418 patients treated, 190 (45%) underwent resection only, 101 RFA + resection (24%), 57 RFA only (14%), and 70 laparotomy with biopsy only or arterial infusion pump placement ("chemotherapy only," 17%). RFA was used in operative candidates who could not undergo complete resection of disease. Overall recurrence was most common after RFA (84% vs. 64% RFA + resection vs. 52% resection only, P < 0.001). Liver-only recurrence after RFA was fourfold the rate after resection (44% vs. 11% of patients, P < 0.001), and true local recurrence was most common after RFA (9% of patients vs. 5% RFA + resection vs. 2% resection only, P = 0.02). Overall survival rate was highest after resection (58% at 5 years); 4-year survival after resection, RFA + resection and RFA only were 65%, 36%, and 22%, respectively (P < 0.0001). Survival for "unresectable" patients treated with RFA + resection or RFA only was greater than chemotherapy only (P = 0.0017). CONCLUSIONS: Hepatic resection is the treatment of choice for colorectal liver metastases. RFA alone or in combination with resection for unresectable patients does not provide survival comparable to resection, and provides survival only slightly superior to nonsurgical treatment.     

Radiofrequency Ablation of Unresectable Primary and Metastatic Hepatic Malignancies: Results in 123 Patients

OBJECTIVE: To describe the safety and efficacy of radiofrequency ablation (RFA) to treat unresectable malignant hepatic tumors in 123 patients. BACKGROUND: The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, or multifocality or inadequate functional hepatic reserve. Local application of heat is tumoricidal; therefore, the authors investigated a novel RFA system to treat patients with unresectable hepatic cancer. PATIENTS AND METHODS: Patients with hepatic malignancies were entered into a prospective, nonrandomized trial. The liver tumors were treated percutaneously or during surgery under ultrasound guidance using a novel LeVeen monopolar array needle electrode and an RF 2000 generator. All patients were followed to assess complications, treatment response, and recurrence of malignant disease. RESULTS: RFA was used to treat 169 tumors (median diameter 3.4 cm, range 0.5 to 12 cm) in 123 patients. Primary liver cancer was treated in 48 patients (39.1%), and metastatic liver tumors were treated in 75 patients (60.9%). Percutaneous and intraoperative RFA was performed in 31 patients (35.2%) and 92 patients (74.8%), respectively. There were no treatment-related deaths, and the complication rate after RFA was 2.4%. All treated tumors were completely necrotic on imaging studies after completion of RFA treatments. With a median follow-up of 15 months, tumor has recurred in 3 of 169 treated lesions (1.8%), but metastatic disease has developed at other sites in 34 patients (27.6%). CONCLUSIONS: RFA is a safe, well-tolerated, and effective treatment to achieve tumor destruction in patients with unresectable hepatic malignancies. Because patients are at risk for the development of new metastatic disease after RFA, multimodality treatment approaches that include RFA should be investigated.     

Combined Resection and Radiofrequency Ablation for Advanced Hepatic Malignancies: Results in 172 Patients

Background: Resection combined with radiofrequency ablation (RFA) is a novel approach in patients who are otherwise unresectable. The objective of this study was to investigate the safety and efficacy of hepatic resection combined with RFA.Methods: Patients with multifocal hepatic malignancies were treated with surgical resection combined with RFA. All patients were followed prospectively to assess complications, treatment response, and recurrence.Results: Seven hundred thirty seven tumors in 172 patients were treated (124 with colorectal metastases; 48 with noncolorectal metastases). RFA was used to treat 350 tumors. Combined modality treatment was well tolerated with low operative times and minimal blood loss. The postoperative complication rate was 19.8% with a mortality rate of 2.3%. At a median follow-up of 21.3 months, tumors had recurred in 98 patients (56.9%). Failure at the RFA site was uncommon (2.3%). A combined total number of tumors treated with resection and RFA >10 was associated with a faster time to recurrence (P = .02). The median actuarial survival time was 45.5 months. Patients with noncolorectal metastases and those with less operative blood loss had an improved survival (P = .03 and P = .04, respectively), whereas radiofrequency ablating a lesion >3 cm adversely impacted survival (HR = 1.85, P = .04).Conclusions: Resection combined with RFA provides a surgical option to a group of patients with liver metastases who traditionally are unresectable, and may increase long-term survival.     

Predictors of survival after laparoscopic radiofrequency thermal ablation of hepatocellular cancer

Background Most patients with hepatocellular carcinoma (HCC) are not candidates for hepatic resection or liver transplantation. Radiofrequency ablation (RFA) provides local control for unresectable HCC with minimal morbidity. The aim of this prospective study is to determine factors predicting survival in patients with HCC undergoing RFA.Methods Sixty-six consecutive patients with HCC who were not candidates for a curative liver resection and were free of extrahepatic disease underwent laparoscopic RFA. The relationship between demographic, clinical, laboratory, and surgical parameters and survival was assessed using univariate Kaplan-Meier survival and multivariate Cox proportional hazards model.Results The median Kaplan-Meier survival for all patients was 25.3 months after RFA. Although alfa fetal protein (AFP), bilirubin, ascites, and Child class were statistically significant predictors of survival by univariate analysis, only the Child class and AFP were independent predictors by multivariate analysis.Conclusions This study determines which patients do best after RFA and shows that RFA can provide significant survival for patients with unresectable HCC while also forming a bridge to liver transplantation. RFA has become the first line of treatment in the management of these patients.Paper presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, USA, March 31–April 3, 2004     

Intraoperative Iatrogenic Rupture of Hepatocellular Carcinoma

Intraoperative iatrogenic rupture of hepatocellular carcinoma (HCC), which can occur during hepatic resection when large tumors are being mobilized, may adversely affect the operative outcome. Little information is available in the literature on this serious intraoperative complication. The aim of the present study is to document iatrogenic rupture of HCC as a serious complication during hepatic resection and its effects on the operative and long-term outcomes of patients with this complication. A retrospective study was performed on all patients with intraoperative iatrogenic rupture of HCC during hepatic resection from 1989 to 1997, and the operative and long-term survival outcomes were compared with those of patients without the complication. Among 194 patients who underwent hepatic resection for a large HCC (> or =5 cm) during the study period, 8 (4.1%) had intraoperative iatrogenic rupture of the tumor. When compared with 186 patients with similar clinical parameters but without intraoperative rupture, patients with intraoperative rupture had significantly more intraoperative blood loss (median 5.7 vs. 2.0 L;p = 0.01) and blood transfusion requirement (median 3.1 vs 0.9 L; p = 0.02). On follow-up, patients in the intraoperative rupture group had a significantly higher intraperitoneal extrahepatic recurrence rate (33.3% vs. 2.9%; p =0.02) and significantly shorter survival (median 11.5 vs. 37.9 months,p = 0.04) when compared with patients without the complication. Intraoperative iatrogenic rupture is a serious complication of hepatic resection for HCC because it is associated with increased intraoperative blood loss, increased incidence of intraperitoneal extrahepatic recurrence, and short survival. Extreme care should be taken during mobilization of the tumor, and an alternative operative approach in the presence of a difficult hepatic resection of a large HCC may be required to avoid the complication.     

Clinical short-term results of radiofrequency ablation in primary and secondary liver tumors.

BACKGROUND: Radiofrequency ablation (RFA) is emerging as a new therapeutic method for management of solid tumors. We report here our experience in the use of this technique for management of primary and secondary unresectable liver cancers. METHODS: Thirty-five patients with liver cancers were considered not suitable for curative resection at presentation: 8 with primary hepatocellular carcinoma ([HCC] 6 HCC and 2 fibrolamellar); 27 with metastatic liver cancer (17 colorectal carcinoma and 10 others). They were treated either with radiofrequency heat ablation (Radionics Europe N.V., Wettdren, Belgium) alone percutaneously and/or intraoperatively or in conjunction with surgical resections. The quality of RFA was based on the subjective feeling of whether the tumor was completely destroyed or not. The effectiveness of RFA was assessed according to clinical findings, radiographic images, and tumor markers at follow-up. RESULTS: In 8 primary liver cases, 4 patients with a high level of alpha fetoprotein (AFP) benefited from the RFA with a 83.3% to 99.7% reduction of AFP. One with fibrolamellar hepatocellular carcinoma died 2 months after an incomplete percutaneous RFA from recurrence. The rest all had stable disease at the time of follow-up (mean 10.4 months). In patients with colorectal liver metastases, there were 4 deaths: 1 patient died postoperatively on the 30th day from a severe chest infection having shown a considerable reduction of carcinoembryonic antigen level (CEA, 8 versus 36 microg/L); 3 died from local and systemic disease, 1 at 12 months and 2 at 1 month, having had an incomplete RFA. The others had stable disease at follow-up (mean 7.6 months). Five patients underwent liver resections successfully with the application of RFA for residual lesions in the remaining contralateral lobe. In 10 patients with other liver tumors, 7 patients had stable disease at follow-up (mean 13.4 months); 1 patient had evidence of local and systemic recurrence 10 months after surgical resections with the intraoperative RFA and 2 patients died of systemic recurrence of disease 3 and 6 months after RFA alone. Two patients had liver resections in conjunction with the intraoperative RFA. The mean follow-up in our series was 8.5 months. CONCLUSION: Radiofrequency heat ablation is useful as a primary treatment for unresectable liver cancers. The procedure can be used to treat the small residual tumor load in the contralateral lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy seems to increase surgical resectability in patients judged unresectable.