Laparoscopic microwave ablation of liver tumors: our experience

BACKGROUND/AIMS: Microwave ablation is the most recent development in the field of tumor ablation and is a well established and safe local ablative method available for liver tumors (both primary and secondary tumors). The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. Laparoscopic technique has the advantages of accurate tumor staging, better tolerability and low cost. It can be performed in tumors which are close to the vital organs. The aim of this study was to evaluate the feasibility and safety of laparoscopic microwave ablation of liver tumors. METHODOLOGY: During January 2001 to December 2005, 57 patients with liver tumors were treated with laparoscopic microwave ablation in the department of Surgical Oncology. There were 34 male and 23 female patients. Out of 57 patients, 11 patients had hepatocellular carcinoma and 46 patients had secondaries in the liver. The most common source of secondaries was colorectal cancers. Laparoscopic microwave ablation of tumors was performed in these patients. RESULTS: During the study period, 57 patients with no evidence of extrahepatic disease underwent laparoscopic microwave ablation of unresectable hepatic tumors. No major intraoperative complications occurred. Postoperatively all the patients did well. Four patients developed liver abscess at the ablation area. Two patients required percutaneous aspiration of the liver abscess. No other major complications occurred. Follow-up CT scan shows complete necrosis of the tumors. Patients were followed-up at regular intervals. CONCLUSIONS: Laparoscopic microwave ablation is a feasible and safe alternative to open microwave ablation of the liver tumors. It carries all the advantage of minimal invasive surgery. In experienced hands, microwave ablation using laparoscopic technique can be done safely and effectively.     

原发性肝癌外科治疗的理性思考

全球肝细胞癌（hepatocellular carcinoma,HCC）的发病率一直呈上升趋势,肝切除仍然是HCC患者的首选治疗。有临床症状肝癌患者的可切除率为20％～30％。大型肝切除术不输血是肝切除术的一个进展。原位肝移植应遵照米兰标准执行,并应把肝移植数量控制在肝切除数量的10％以下。HCC的微创治疗,包括经皮射频消融、经皮微波凝固治疗、冷冻治疗、高强度聚焦超声热疔等,一直在临床应用。芮静安提出的“120”肝外科技术适用于城市和农村的医院。未来,HCC患者治疗后的无瘤生存率将会提高。     

经皮B超引导下微波消融术治疗肝脏巨大血管瘤的可行性、安全性及疗效分析

目的评估微波消融治疗肝脏巨大血管瘤(直径≥10 cm)的可行性、安全性和有效性。方法 2013年12月到2016年6月间,12例肝脏巨大血管瘤(≥10 cm)患者共13个肿瘤接受超声引导下经皮穿刺微波消融治疗。观察治疗相关并发症。所有患者均在术后1个月通过磁共振或增强计算机成像(CT)随访,评估消融治疗效果。结果 12例患者中男性4例,女性8例,平均年龄(41±10)岁。除1例同时存在2枚直径≥10 cm的肝血管瘤,其他患者均只有1枚直径≥10cm。肿瘤最大直径平均(11.7±1.6)cm。13枚巨大血管瘤初始共接受17次微波消融治疗(4例采取有计划2次消融),单枚血管瘤的消融平均时间(39.0±14.4)min。术后2例患者出现急性非少尿型肾功能不全,无腹腔内出血、肝功能衰竭等并发症发生。平均随访时间20.7个月,9例患者10个巨大血管瘤完全坏死,体积显著缩小,一次性完全消融10/13枚。1例术后残留者因生长速度较快,于术后第5个月实施二次微波消融,复查完全坏死,故总体完全消融11/13枚。另外2例因残留体积较小而定期复查,未予任何有创治疗。结论影像引导下微波消融肝脏巨大血管瘤安全、可行,且操作简单、快捷、恢复迅速、损伤轻微,无远期并发症,因而有潜力成为肝脏巨大血管瘤的一线治疗方式。     

Current status of hepatic resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide. For this disease, a variety of therapeutic measures have been applied, including hepatic resections, total hepatectomy followed by allografting, transarterial chemoembolization, and percutaneous tumor ablative therapy by ethanol, microwave coagulation, and radiofrequency ablation. This article focuses on the current status of hepatic resections for HCC.     

大肝癌的消融治疗

肝癌是我国最常见的恶性肿瘤之一,当单个肿瘤直径大于5 cm时定义为大肝癌。大肝癌具有肿瘤恶性程度高、易出现肿瘤转移和血管浸润等特点,增加了治疗的难度。外科切除是大肝癌首选的治疗方案,但仅有20%~30%的患者符合手术治疗要求。对于不可切除的大肝癌国内外指南推荐经肝动脉化疗栓塞术(TACE)作为治疗方案,TACE可以控制肿瘤进展并延长患者生存时间,但反复多次的TACE治疗疗效有限,且对患者肝功能造成严重损害,单独的TACE治疗已无法满足临床需求。随着肿瘤消融技术如射频、微波和冷冻消融等不断发展,TACE联合肿瘤消融治疗已成为大肝癌治疗中的一个重要治疗手段。然而目前国内外关于大肝癌消融治疗的疗效仍有较多的争议,因此如何选择合适的消融时机,减少消融术后残留,降低消融术后肿瘤的复发,最终使患者生存获益是目前临床和科研仍需继续探讨的难题。针对以上内容,综述并分析了大肝癌消融治疗的现况、困境及未来发展趋势。     

射频治疗原发性肝癌

射频消融是治疗原发性肝癌的新方法,其治疗小肝癌的价值已得到公认。近年其设备及治疗方法均有长足进步。多数学者主张,射频消融与其他疗法,如经导管动脉化学灌注栓塞治疗、氩氦刀冷冻消融、瘤内注射无水乙醇等联合,可用于治疗大肝癌。     

Hepatic volumetry to predict adverse events in percutaneous ablation of hepatocellular carcinoma

BACKGROUND/AIMS: This study aimed to clarify the relation of hepatic volumetry to adverse events after percutaneous transhepatic ablation for hepatocellular carcinoma. METHODOLOGY: One hundred and forty-nine patients with hepatocellular carcinoma who underwent percutaneous ablation sessions with complete ablation of cancer nodules, underwent volume measurement of the entire liver, tumor, and ablated area using computed tomography. The parenchymal ablation rate was calculated: (ablated volume-tumor volume)/(entire liver volume-tumor volume) x 100 (%). Other clinical parameters were also analyzed to determine their relationship to adverse events. RESULTS: The median adjusted liver volume was 591 mL/body surface area (m2) (range: 300 to 1197 mL/m2). The median parenchymal ablation rate was 2.3% (range: 0.2% to 20.2%). Adverse events were observed in 17 patients after percutaneous ablation: liver abscess in 3, hepatic infarction in 3, portal vein thrombus in 3, hemobilia in 1, pleural effusion and/or ascites in 6, and gastric ulcer in 1. Multivariate analysis showed that Child B or C (P = 0.0009), adjusted liver volume < 600 mL/m2 (P = 0.0004), and parenchymal ablation rate > 5% (P = 0.0320) were independent risk factors for adverse events. CONCLUSIONS: Measurement of liver volume and parenchymal ablation rate are useful to predict the presence of percutaneous ablation-related adverse events.     

肝肿瘤的微波消融治疗

随着健康查体及医学影像技术的广泛应用,肝肿瘤的检出率逐年攀高。手术是肝脏肿瘤治疗的标准方法,但其较高的并发症及死亡率促进了微创热消融技术在过去20年间的快速发展。微波消融作为一种极具前景的热消融技术,随着消融设备及影像引导策略的不断完善,其临床疗效也得到极大提高。本文着重探讨微波消融技术在肝脏肿瘤中的应用现状及其临床疗效及安全性,介绍目前可用的微波消融设备,并与肝脏肿瘤其他治疗方法进行比较。此外,本文还介绍了微波消融领域的前沿技术及联合治疗方法,从而为实现微波精准消融及进一步提高微波消融疗效奠定基础。     

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma ≤ 4 cm

AIM: To determine which treatment modality--hepatectomy or percutaneous ablation--is more beneficial for patients with small hepatocellular carcinoma (HCC) (< or =4 cm) in terms of long-term outcomes. METHODS: A retrospective analysis of 149 patients with HCC < or =4 cm was conducted. Eighty-five patients underwent partial hepatectomy (anatomic in 47 and non-anatomic in 38) and 64 underwent percutaneous ablation (percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6). The median follow-up period was 69 mo. RESULTS: Hepatectomy was associated with larger tumor size (P<0.001), whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy (P<0.0001). Survival was better following hepatectomy (median survival time: 122 mo) than following percutaneous ablation (median survival time: 66 mo; P=0.0123). When tumor size was divided into < or =2 cm vs >2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors>2 cm (P=0.0001). The Cox proportional hazards regression model revealed that hepatectomy (P=0.006) and tumors < or =2 cm (P=0.017) were independently associated with better survival. CONCLUSION: Hepatectomy provides both better local control and better long-term survival for patients with HCC < or =4 cm compared with percutaneous ablation. Of the patients with HCC < or =4 cm, those with tumors >2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.     

经皮微波消融术治疗的肝海绵状血管瘤患者血红蛋白尿发生及其处理*

目的 探讨经皮微波消融术治疗肝海绵状血管瘤（HCHs）患者的疗效,并探讨术后血红蛋白尿发生及处理方法。方法 2012年2月~2017年12月我院诊治的HCHs患者54例,病灶数80个。采用在超声引导下经皮微波消融术治疗。采用联苯胺试验检测血红蛋白尿。术后随访6~12 m。结果 在54例HCHs患者的80个病灶中,经皮微波消融术治疗后, 78个肿瘤完全被消除,2例被大部分消融;术后6~12个月对患者进行超声造影和CT检查随访,所有患者血管瘤均缩小,其中瘤体完全消失者41例（75.9%）,瘤体缩小超50%者8例（14.8%）,瘤体缩小大于25%但小于50%,但未见肿瘤复发者4例（7.4%）,瘤体缩小小于25%,但是未见肿瘤复发者1例（1.9%）;术中未出现严重的肝肾功能损害,术后3~4 h有8例（14.8%）患者出现血红蛋白尿,经水化和碱化尿液处理2 d后,尿色恢复正常;2例（3.7%）出现腹水,经内科综合治疗后消退;5例（9.3%）出现右上腹轻微的疼痛,未经干预自行缓解;7例（12.3%）出现恶心呕吐,经止吐处理后缓解。结论 经皮微波消融术是一种疗效确切、创伤小的治疗HCHs患者的方法,选择合适的患者进行治疗,可以达到微创治疗的目的。对少数发生的血红蛋白尿,经对症处理,预后良好,但应总结其发生的原因,予以避免。     

经皮热消融治疗疑难部位肝肿瘤引导技术的临床应用进展

肝肿瘤热消融技术日趋成熟,已成为仅次于外科手术的常用治疗手段。邻近肝门、肝内重要管道、胆囊、膈肌和胃肠道等部位的肝肿瘤,由于操作难度大、并发症发生率高,是经皮热消融治疗的相对禁忌证。近年来随着经皮引导技术和消融设备技术的不断进步,疑难部位的肝肿瘤可以进行经皮热消融治疗,并取得可靠疗效。本文就经皮热消融治疗疑难部位肝肿瘤引导技术的临床应用进行综述。     

肝门区域微波凝固消融的可靠性与安全性探讨

目的探讨经皮微波凝固消融（PMCT）治疗肝门区域肝癌的可靠性与安全性。方法将12只健康狗随机分为A、B组，各6只，经皮穿刺，于肝门区行PMCT，之后3d（A组）和4周（B组）处死、取肝，观察消融靶区和Ghsson管道系统一级分支的病理变化。结果术后Glisson管道系统一级分支周围的肝组织均坏死；门静脉血管壁在肉眼及镜下观察可见轻度损伤，但恢复良好；胆管结构未见不可恢复的破坏；肝脏功能的损伤表现为可逆性。结论PMCT可完全灭活肝门区域大血管周围的肝组织，Glisson管道系统及肝脏功能未出现严重不可逆的损伤，是一种疗效可靠且安全的治疗肝门区域肿瘤的方法。     

Percutaneous and laparoscopic approaches of radiofrequency ablation treatment for liver cancer

Background/Purpose. Radiofrequency ablation (RFA) and microwave coagulation therapy (MCT) have been gaining acceptance as a standard method in the management strategy of liver cancer, for reasons of minimally invasive techniques and effective results. We present our experience of RFA and MCT in patients with liver cancer, and analyze retrospectively the advantages and disadvantages of both of the percutaneous and laparoscopic approaches. Methods. Thirty-two consecutive patients (23 men and 9 women) with 19 hepatocellular carcinomas (HCC), 12 metastatic liver cancers, and recurrent cholangiocellular carcinoma (CCC), were enrolled in this study. Out of these 32 patients, as a prior laparotomy, 19 underwent hepatectomy, colectomy, gastrectomy or cholecystectomy, and 15 were treated with the laparoscopic approach, 17 treated with the percutaneous approach, and 2 treated with the combined approach of those two. All of these procedures were carried out under general anesthesia with ultrasound guidance. Seven and 30 days after these procedures, an assessment helical computed tomography was done. Results. No sign of the residual tissues was noted in all patients except only one case. Conclusions. The percutaneous approach was thought to be a more practical and less invasive method regardless previous laparotomy. For the laparoscopic approach, tumors located at the hepatic surface or margin were preferable candidates.     

Major complications of ultrasound-guided percutaneous radiofrequency ablations for liver malignancies: Single center experience

Background and Aim:  Despite radiofrequency ablation (RFA) for malignant liver nodular lesions having promising therapeutic effects, the trade-off between the risks and benefits must be acceptable. This study analyzed the major complications of ultrasound (US)-guided percutaneous RFA procedures encountered at a single center, by a single physician.
Methods:  A total of 104 patients (total 183 tumors) underwent 172 US-guided percutaneous RFA sessions between May 2003 and March 2006. The definition of major complications was according to the standardized Society of Interventional Radiology grading system (classification C-E).
Results:  Eighty-six patients had hepatocellular carcinoma (HCC) and 18 patients had hepatic metastatic tumors. Nine major complications occurred from 172 RFA sessions (9/172, incidence of 5.2% per session); namely, two cases of transient liver function impairment, two cases of infection (liver abscess and septicemia), two cases of tumor seeding along the ablated track, one case of colon perforation, one case of acalculous cholecystitis and, lastly, a case of hemocholecyst. We further analyzed the possible risk factors precipitating these complications, and found that only tumor size (Pearson's correlation coefficient, 0.324; P  < 0.05) and baseline liver function reserve (compensated 0%, 0/148 vs decompensated 8.3%, 2/24; P  = 0.019) were significant factors for the complication of transient liver function impairment.
Conclusion:  Radiofrequency ablation for liver malignancy is a safe procedure with acceptable incidence of complications. Decompensated baseline liver function reserve and large tumor size are precipitating factors for transient liver function impairment after RFA and warrant a close follow up.     

Ablative strategies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is the most common primary liver cancer and is the fifth leading cause of cancer death worldwide and the third leading cause of all diseases worldwide. Liver transplantation, surgical resection and ablation are the three main curative treatments for HCC. Liver transplantation is the optimal treatment option for HCC, but its usage is limited by the shortage of liver sources.Surgical resection is considered the first choice for early-stage HCC, but it does not apply t...     

Local injection therapy for hepatocellular carcinoma

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world and ranks the third most common cause of cancer-related death. Surgical resection, liver transplantation and percutaneous ablation are generally considered the only curative treatment for early stage HCC. Besides the limitations of insufficient organ donors and a long waiting time for liver transplantation, however, resection is applied only to patients with good hepatic reserve and localized tumors, with a resectability of 30%. DATA SOURCES: Local ablation therapy, which is minimally invasive but contributes to the significant improvement of survival in patients with unresectable tumor, hasbeen widely used in treating small HCC. Among the techniques of local therapy, percutaneous ethanol injection (PEI) with a complete response in 80% of HCCs less than 3 cm has been accepted as an alternative to surgery in patients with small HCC. Moreover, percutaneous hepatic quantified ethanol injection (PHQEI) or PEI according to the standard criteria has been confirmed to benefit patients with HCC, especially when quantified ethanol is given at a short interval (QESI, the interval was 2-3 days). RESULT: Several limitations related to local percutaneous methods may result in incomplete therapeutic effect in case of larger HCC nodules (>3 cm). CONCLUSION: The combined use of different methods according to the clinical status of patients or tumors may be essential to the effective treatment of HCC.     

肝多房棘球蚴病的综合治疗现状和进展

多房棘球蚴病是一种危害严重的人兽共患寄生虫病。根治性手术切除是目前治疗肝多房棘球蚴病的首选方法，难以根治性切除的晚期肝多房棘球蚴病可行包括姑息性手术联合药物治疗、肝脏移植、单纯药物治疗、射频微波消融术等治疗手段。本文就肝多房棘球蚴病综合治疗现状和进展进行综述。     

肝多房棘球蚴病的综合治疗现状和进展

多房棘球蚴病是一种危害严重的人兽共患寄生虫病。根治性手术切除是目前治疗肝多房棘球蚴病的首选方法,难以根治性切除的晚期肝多房棘球蚴病可行包括姑息性手术联合药物治疗、肝脏移植、单纯药物治疗、射频微波消融术等治疗手段。本文就肝多房棘球蚴病综合治疗现状和进展进行综述。     

肿瘤残余在肝癌微波消融治疗后出现的原因及防治

目的:探讨微波消融术后肿瘤残余的原因及防治措施.方法:回顾性总结了中国医科大学附属第四医院2004-10/2010-06 465例(796个肿瘤结节)肝癌患者行微波消融治疗的临床资料,分析了48例患者微波消融术后肿瘤残余的原因.结果:436例患者(754个肿瘤结节)获得有效复查资料,其中48例(48/436,11.01...     

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma ≤4 cm

AIM: To determine which treatment modality -hepatectomy or percutaneous ablation - is more beneficial for patients with small hepatocellular carcinoma (HCC) (≤ 4 cm) in terms of long-term outcomes.METHODS: A retrospective analysis of 149 patients with HCC ≤4 cm was conducted. Eighty-five patients underwent partial hepatectomy (anatomic in 47 and nonanatomic in 38) and 64 underwent percutaneous ablation (percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6). The median follow-up period was 69 mo.RESULTS: Hepatectomy was associated with larger tumor size (P＜0.001), whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy (P＜ 0.0001). Survival was better following hepatectomy (median survival time:122 mo) than following percutaneous ablation (median survival time: 66 mo; P=0.0123). When tumor size was divided into ≤ 2 cm vs ＞ 2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors ＞2 cm (P= 0.0001). The Cox proportional hazards regression model revealed that hepatectomy (P= 0.006) and tumors ≤ 2 cm (P= 0.017) were independently associated with better survival.CONCLUSION: Hepatectomy provides both better local control and better long-term survival for patients with HCC ≤4 cm compared with percutaneous ablation. Of the patients with HCC ≤ 4 cm, those with tumors ＞ 2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.