Laparoscopic radiofrequency ablation of unresectable hepatic malignancies

BACKGROUND: Radiofrequency ablation (RFA) of hepatic malignancies has been performed successfully via a percutaneous route or at laparotomy. We analyzed the efficacy and utility of laparoscopic intraoperative ultrasound and RFA in patients with unresectable hepatic malignancies. METHODS: Between November 1997 and November 1999, 27 patients with unresectable hepatic malignancies and no evidence of extrahepatic disease were entered in a phase 2 trial of laparoscopic intraoperative ultrasound and RFA. Real-time ultrasonography was used to guide RFA, and lesions were ablated at a temperature of 100 degrees C for 10 min. Overlapping ablations were performed for larger lesions. RESULTS: Additional tumors were identified in 10 (37%) of the 27 study patients by laparoscopy and laparoscopic intraoperative ultrasound despite extensive preoperative imaging. Radiofrequency ablation of 85 hepatic tumors yielded no mortality and only one case of postoperative bleeding. During a mean follow-up period of 14 months, four tumors (4.7%) locally recurred. Of the 27 patients, 11 (41%) remain free of disease at this writing; (22%) are alive with disease; and 10 (37%) have died with disease. CONCLUSION: Laparoscopic RFA and intraoperative ultrasound constitute a safe and accurate method for ablation of unresectable hepatic tumors.     

氩氦刀冷冻消融治疗肝癌

目的观察氩氦刀治疗5 cm以内原发肝癌或肝转移瘤的疗效。方法收集5 cm以内原发肝癌或肝转移瘤患者31例,共39个病灶。所有患者均于CT或超声等影像引导下接受氩氦刀治疗。结果肿瘤消融范围为90%100%,完全消融病灶占69.23%（27/39）。1年和2年存活率分别为90.32%（28/31）、61.29%（19/31）。31例患者均无出血等严重并发症,术中寒战4例（12.90%）;肝区疼痛6例（19.36%）,重度疼痛1例,体表皮肤温度触冰感,CT扫描无出血迹象,生命体征稳定,给予强痛定止痛,效果差,术后2 h疼痛缓解,其余疼痛患者均为中、轻度疼痛,未予处置;术后发热7例（22.58%）,体温37.1238.25℃;无血管、胆管损伤病例;冷冻术后患者的精神状态得到改善,腹部疼痛症状减轻,恢复较快。结论对于不能手术切除的小肝癌和肝转移瘤,氩氦刀消融治疗安全性高、疗效可靠。     

B超引导经皮肝穿刺射频治疗肝癌

目的：探讨B超引导经皮肝穿刺射频（PRFA）治疗肝癌的价值。方法：1999年10月－2000年3月对70例肝癌患者进行了B超引导PRFA治疗,并于治疗后每个月进行肿瘤标记物和B超检查,治疗后1个月复查MRI或CT。结果：患者肝功能分级Child A级53例,B级15例,C级2例,原发性肝癌53例,继发性肝癌17例,原发性小肝癌（小于等于5cm,未手术）21例,其中AFP阳性17例,PRFA术后转阴12例,明显降低4例,未降低1例。MRI显示肿癌完全凝固性坏死16例,根治率76．2％,小肝 癌各组PRFA术后3,6个月生存率均为90．5％－100％,大肝癌各组术后3,6个月生存率分别为66．7％－72．7％和27．6％－72．7％,结论：射频作为肿瘤透热治疗的一种方法,对于肝癌尤其是无手术指征,或有手术指征但位于肝中央区,临近腔静脉或肝门区的小肝癌,PRFA具有微创,时间短,安全方便,疗效可靠,对于大肝癌,PRFA可与肝动脉介入化疗栓塞联合应用,以提高疗效。     

Role of radiofrequency ablation for liver malignancies

Radiofrequency ablation (RFA) is commonly used to treat unresectable malignant liver tumours. It can achieve effective local tumour control and the maximal normal liver parenchyma can be preserved. In recent years, there has been a tremendous expansion in the application of RFA for patients with malignant liver tumours. However, the therapeutic effect of this local ablation treatment needs to be balanced against its risks and possible local failure. The present review focuses on the role of RFA for liver malignancies, with special attention to the indication, approaches, complications, survival benefits, combination therapies and comparison with other treatment modalities. Despite favourable results of most clinical studies of RFA, the associated risks and tumour recurrence of this treatment modality should not be underestimated. Careful patient selection, meticulous RFA techniques, and prompt treatment of residual and recurrent tumours 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 tumours. Nonetheless, more convincing evidence by randomized trials is required for the establishment of a treatment protocol of RFA for patients with liver malignancies.     

Transthoracic hepatic radiofrequency ablation

Background Radiofrequency ablation (RFA) is an alternative for the treatment of unresectable hepatic tumors. Tumors beneath the diaphragmatic dome may be difficult to access by laparoscopy. In these cases, a transthoracic transdiaphragmatic approach for delivering RFA can be used. Methods Three patients with hepatic metastatic disease were treated using a transthoracic transdiaphragmatic approach to deliver RFA therapy for tumors in liver segments 7 and 8. The patients underwent thoracoscopy. The tumors were identified using transdiaphragmatic ultrasound, and transthoracic transdiaphragmatic RFA (TTRFA) was performed. Results In three patients, TTRFA was successfully used to ablate five lesions. There were no perioperative complications, blood loss was minimal, and postoperative hospital stays ranged from 2 to 8 days. There were no recurrences during a follow-up period of 4 to 20 months. Conclusions TTRFA is a viable alternative for hepatic tumors located beneath the dome of the diaphragm that are difficult to access by laparoscopy. Online publication: 13 October 2004     

腹腔镜射频消融术治疗肝血管瘤

目的 :探讨腹腔镜射频消融治疗肝血管瘤的可行性及实用性。方法 :2 5例肝血管瘤患者全麻气管插管后 ,腹腔镜下行射频消融治疗 ,其中 5例同时行胆囊切除术。结果 :患者经治疗均获满意效果 ,术后无残留病灶 ,无明显并发症。结论 :腹腔镜射频消融治疗肝血管瘤安全可行 ,治疗彻底 ,是治疗肝血管瘤的微创新技术。     

经皮肝穿刺射频热凝治疗肝脏恶性肿瘤

目的 探讨经皮肝穿刺射频热凝治疗肝癌的意义。适应证和疗效评价标准。方法 1999年10月-2000年10月,100例肝脏恶性肿瘤患者进行了B超引导经皮肝穿刺射频热凝治疗。患者治疗后每个月进行血清肿瘤标记物检测、B超检查,治疗后1个月复查MRI。结果 患者肝功能ChildA级67例,ChildB级29例,ChildC级4例,原发性肝癌76例,转移性肝癌24例,小肝癌（未手术,肿瘤直径≤5cm)甲胎蛋白阳性者治疗后甲胎蛋白转阴占75.0%(21/28),明显下降占21.4%(6/28)。B超复查肿瘤缩小、MRI或CT提示≤5cm肿瘤完全凝固性坏死率85.9%(61/71)。结论 经皮肝穿刺射频热凝（PRFA）作为肿瘤透热治疗的一种方法,对于小肝癌尤其是无手术指征,或有手术指征但位于肝中央区,临近腔静脉或肝门区的小肝癌,是一种微创、时间短、安全方便、疗效可靠的新方法,对于大肝癌,PRFA可与肝动脉介入化疗栓塞联合应用,提高疗效。     

腹腔镜下冷循环射频消融治疗肝癌

目的探讨腹腔镜下冷循环射频消融在肝癌治疗中的价值. 方法肿瘤位于肝脏脏面不适于在B超引导下进行射频治疗的原发性肝癌12例,转移性肝癌3例,肝癌破裂出血4例,全身麻醉,术中先腹腔镜探查,明确肿瘤位置确定穿刺点,然后在腹腔镜引导下,穿刺肿瘤行射频消融治疗. 结果全组未发生手术并发症.4例肝癌破裂出血停止,术后复查肿瘤缩小,血AFP显著下降.术后1个月32个肝癌病灶,完全消融27个,消融不全5个,完全消融率84.4%(27/32).3个月后CT示9例肿瘤病灶完全坏死,AFP降至正常;6例病灶部分坏死.随访2～18个月,平均8.2月,15例生存,4例死亡(3例肝功能衰竭,1例消化道大出血). 结论腹腔镜引导下冷循环射频消融治疗肝癌比B超引导下射频治疗定位更加准确,治疗效果肯定,手术并发症发生率低.     

Local, intrahepatic, and systemic recurrence patterns after radiofrequency ablation of hepatic malignancies

The objective of this study was to describe the recurrence patterns in patients with unresectable hepatic malignancies treated with radiofrequency ablation (RFA). As RFA is applied more widely to patients with hepatic tumors, a better understanding of the biologic behavior of these tumors and the risk of recurrence, both in the liver and systemically, is needed. A multidisciplinary team evaluated patients referredh for RFA and followed them prospectively to assess local, intrahepatic, and extrahepatic disease recurrence and complication rates. Forty-five patients with 143 lesions and a minimum follow-up of 6 months (median 19.5 months) were treated. Overall, 7.7% of treated lesions had local recurrence. New intrahepatic disease was seen in 49% of patients, and 24% had evidence of new systemic tumor progression. Patients with colorectal metastatic lesions > 4 cm at the time of the first RFA were more likely to present with local recurrence (P = 0.048). Complications occurred in 27% of patients. Although RFA has a satisfactory local failure rate and safety profile, the patient population being treated is at high risk of developing new disease. Multimodality adjuvant therapy will be necessary to realize the full potential of hepatic malignancy control with RFA. Presented in part at the Third Americas Congress of the American Hepato-Pancreato-Biliary Association, Miami, Florida, Feb. 22–25, 2001.     

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.     

经皮肝穿刺射频热凝治疗原发性小肝癌

目的：探讨经皮肝穿刺射频热凝（PRFA）治疗肝癌的效果和适应证。方法：对16例原发性小肝癌患者行PRFA治疗的临床资料进行回顾性分析。结果：16例肝癌的直径均≤3cm。PRFA治疗后甲胎蛋白转阴者占93．3％（14／15）。B超，CT复查肿瘤缩小，并有包膜形成。0．5，1，2年生存率分别为93．8％，100％，100％。结论：PRFA是一种具有微创、时间短、安全方便、疗效可靠的治疗小肝癌的新方法。尤其适于有手术禁忌症，或有手术指征但位于肝中央区、临近腔静脉或肝门区的小肝癌。     

Technical aspects and feasibility of laparoscopic ultrasound navigation in radiofrequency ablation of unresectable hepatic malignancies

PURPOSE: Laparoscopic radiofrequency ablation is safe, practicable, and combines minimally invasive surgery with the advantages of laparotomy. However, application of the laparoscopic freehand puncture is restricted because of capnoperitoneum and the consequent fixation of the needle on two different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve precision. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases. Therefore we present a new navigation tool for laparoscopic interventions. MATERIALS AND METHODS: The US Guide 2000 (Ultra Guide, Tirat Hacarmel, Israel) is an independent navigation system compatible with all ultrasound machines and has six degrees of freedom. After proper evaluation of this system under operating room conditions during transcutaneous radiofrequency ablation, we used this technique in laparoscopic radiofrequency ablation. A special adapter was developed to attach the ultrasound-based navigation system to a laparoscopic ultrasound probe. After calibrating the system with an ultrasound phantom, laparoscopic navigation in a liver organ model was studied. RESULTS: Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Anatomic landmarks in the liver could be safely reached. No interaction between the navigation system and the laparoscopic ultrasound probe or operating instruments was observed. CONCLUSION: Our preliminary results show the feasibility of this technique in laparoscopic radiofrequency ablation. The use of an ultrasound-based laparoscopic inline navigation system offers the possibility of out-of-plane needle placement and could combine the flexibility of freehand puncture with the accuracy of a canal for puncture. This could increase the safety and accuracy of punctures.     

CTAP联合CTA评价肝脏恶性肿瘤射频消融术疗效

目的探讨动脉-间接门静脉造影CT(CTAP)联合肝动脉造影CT(CTA)对评价肝脏恶性肿瘤射频消融疗效的应用价值。方法29例肝恶性肿瘤患者(共34个病灶)经射频消融治疗后行CTAP CTA检查,其中原发性肝癌21例22个病灶、转移癌8例12个病灶。全部病例行CTAP CTA检查,并与同期常规增强CT检查结果比较。结果CTAP CTA观察的34个病灶中,27个(79.5%)病灶在CTAP、CTA及延时各时相均未强化,提示肿瘤完全灭活;6个(17.6%)病灶边缘CTAP未见强化,CTA示局部增强,延时扫描低于正常肝脏密度,判断有肿瘤残存;1个(2.9%)病灶边缘在CTAP呈灌注缺损,在CTA动脉期有轻度强化,并在延时扫描时稍低于正常肝脏密度,怀疑为肿瘤复发,随访6个月无复发迹象,最终诊断为术后反应。最终诊断依据影像学检查并结合肿瘤标志物水平、穿刺活检、3个月以上随访进行综合判断。以最终诊断为金标准,CTAP CTA在诊断肿瘤复发或残余的灵敏度和准确率优于常规CT,其差异有统计学意义,在特异性方面无统计学差异。结论CTAP联合CTA可准确地判断射频消融后肿瘤灭活程度,是评价射频消融疗效的有效方法,优于常规增强CT,有较高临床应用价值。     

Radiofrequency ablation of unresectable hepatic malignancies

Since radiation and chemotherapy have little impact on survival and no prospect for cure, surgery offers the best potentially option in patients with liver tumors. However, a lot of patients with liver tumors is not resectable due to stage combined with health problems, or poor liver function reserve. In this study, our preliminary clinical reports in patients with unresectable liver tumors treatment with RFA have demonstrated radiologic evidence of tumor necrosis and complications. Multielectrode, radiofrequency probes were supplied by RITA Medical Systems (Mountain View, California). This study involved a total of 28 liver tumors in 19 patients (including 17 patients with hepatomas and 2 patients with metastases). The mean age was 68.9 years old. The size of tumor was more than 3 cm in 15 patients. The approaches to the tumor were laparoscopic in 1 patients and open surgical in 18 patients. Hepatic vascular occlusion was combined with RFA in 5 cases. The reasons for unresectable were defined as total bilirubin, ICGR 15, cardiopulmonary function and multiplicity. The efficacy of this RFA therapy was evaluated by preoperative and follow-up CT scans or tumor makers. There tumor necrosis was shown in 15 patients (78.9%). The survival rates at the time up to 12 months were 84.2% in 16 patients. The present study has demonstrated that the RFA is able to provide a safe and effective means in controlling liver tumors.     

Intraoperative magnetic resonance imaging for ablation of hepatic tumors

BACKGROUND: The most significant rise in the use of hepatic ablation has come from image-guided techniques with both computed tomography (CT) and ultrasound (US). The recent development of open-configuration magnetic resonance scanners has opened up an entire new area of image-guided surgical and interventional procedures. Thus the aim of this study was to evaluate the use of intraoperative MRI (iMRI) ablation of hepatic tumors performed by surgeons. METHOD: Percutaneous iMRI hepatic ablation was performed from January 2003 to February 2005 for control of either primary or secondary hepatic disease. RESULTS: Eighteen hepatic ablations were performed on 11 patients with a median age of 71 (range: 51-81) years for metastatic colorectal cancer (n = 6), hepatocellular cancer (n = 2), cholangiocarcinoma (n = 2), and metastatic neuroendocrine (n = 1). Median hospital stay was 1 day, with complications occurring in 2 patients. After a median follow up of 18 months, there have been no local ablation recurrences, 5 patients are free of disease, 4 are alive with disease, 1 has died of disease, and 1 has died of other causes. CONCLUSIONS: Image-guided hepatic ablations represent a useful technique in managing hepatic tumors. Intraoperative MRI represents a new technique with initial success that has been limited to European centers. Further evaluation in U.S. centers has demonstrated iMRI to be useful for certain hepatic tumors that cannot be adequately visualized by US or CT.     

Laparoscopic radiofrequency ablation of hepatic cavernous hemangioma

BACKGROUND: Radiofrequency ablation (RFA), currently used extensively for liver tumors, also has been applied successfully to hepatic cavernous hemangioma (HCH) percutaneously. The aim of this study was to assess the feasibility, safety, and efficacy of laparoscopic RFA for patients with HCHs. METHODS: Between March 2001 and March 2004, 27 patients with symptomatic and rapid-growth lesions were treated by laparoscopic RFA using the RF-2000 generator system. The treatment-related complications were observed. All the patients were followed up with helical computed tomography scans and ultrasonography at regular intervals to assess the therapeutic efficacy of laparoscopic RFA. RESULTS: This study assessed 9 men and 18 women with a mean age of 41.6 +/- 8.3 years. Three additional intrahepatic lesions missed preoperatively were found in three patients on intraoperative ultrasound. A total of 27 patients with 50 liver lesions were treated successfully with laparoscopic RFA. The mean maximum tumor diameter was 5.5 +/- 2.0 cm. The mean length of time for RFA per lesion was 20.7 +/- 11.9 min, and the mean blood loss was 134.4 +/- 88.9 ml. Laparoscopic cholecystectomy was performed simultaneously for gallstones in 13 patients and for abutting of gallbladder from hemangioma in 2 patients. In addition, 3 patients also had a laparoscopic deroofing of simple hepatic cysts. Although postoperative low-grade fever and transient elevation of serum transaminase levels were observed in 13 patients, there were no complications related to laparoscopic RFA. During a median follow-up period of 21 months (range, 12-42 months), complete lesion necrosis was achieved for all the patients. CONCLUSIONS: Laparoscopic RFA therapy is a safe, feasible, and effective treatment option for patients with symptomatic and rapid-growth HCHs located on the surface of the liver or adjacent to the gallbladder. Intraoperative ultrasonography is a useful adjunct for detecting additional liver lesions and offering more accurate targeting for RFA.     

大鼠肝组织冷冻和射频灭活治疗对肺形态学和功能影响的比较实验研究

目的 比较大鼠肝组织冷冻或射频治疗后对肺形态学和功能的影响.方法 SD大鼠随机分成A(n=47)、B(n=32)两组,A组给予冷冻治疗,-196℃液氮浸泡冷冻,治疗时间15～20 s;B组给予射频治疗,功率15 W,时间60～90 s.按预定时间处死.术前、术后1、3、6、24 h ELASA检测血TNF-α,IL-8;同时观察肺组织学表现和早期死亡率.结果 术后,A组血TNF-α,IL-8浓度1 h显著升高,3 h达峰值;B组仅轻微的升高(A与B组相比:P＜0.01).A组光镜下可见肺组织间隔明显增厚,充血,水肿,灶性肺实质出血,大量的中性粒细胞,巨噬细胞浸润;而B组肺部仅有少量的炎细胞浸润.另外,术后48 h内死亡率,A组为25.5%;B组仅为5.4%,差异显著(P＜0.05).结论 相同条件下,冷冻治疗引起了急性肺损伤、高死亡率等并发症,而射频治疗影响轻微.在一定条件下,射频是相对安全的.