射频消融技术在肝癌综合治疗中合理应用

近年来,射频消融（RFA）因其出色的局部肿瘤控制能力和显著的微创特点,使其在肝癌（HCC）治疗领域扮演着越来越重要的角色,并成为继肝切除、 肝移植后又一小肝癌根治性治疗手段。由于HCC的特殊性,其治疗策略也应该个体化。因此,应合理运用RFA的特点,使其在HCC的各种治疗策略中灵活运用,并与肝移植及肝切除术的优点互相补充,从而使更多的HCC病人受益。     

射频消融在复发性肝癌治疗中的应用

肝癌在手术切除或肝移植后复发率仍有50%以上,术后复发是制约其疗效的主要因素。手术切除仍是复发性肝癌的首选治疗方法,可获得与初治相近的远期生存。但由于多数患者肝储备功能差及     

射频消融治疗肝癌应用进展

目前,肝癌治疗模式已由单一外科切除转变为以手术切除为主的多方法、多学科综合治疗模式[1].近年来,射频消融(radiofrequence ablation,RFA)以其微创、安全、有效的特点已成为小肝癌的一线治疗方法,也是目前研究最多、应用最广泛同时疗效最好的局部消融手段[2].其通过温度监控和阻抗调控控制整个消融过程...     

肝癌射频消融治疗合理选择与临床评价

肝癌射频消融(radiofrequency ablation,RFA)治疗最早始于20世纪90年代,随着射频消融技术的发展及临床疗效的不断提高,RFA已经成为肝癌综合治疗中重要的治疗手段之一。近年来,肝癌RFA的研究方兴未艾,从最开始的治疗晚期肝癌到现在应用于早期小肝癌的治愈性治疗,RFA在肝癌治疗中     

射频消融治疗中晚期肝癌

自上世纪90年代中期以来,射频消融（radiofrequency ablation,RFA）以其微创、可靠、安全、价廉的技术优势已在国内外广泛开展,用于治疗原发性和继发性肝癌。由于技术本身的限制,RFA尤其适用于早期肝癌的治疗。有报道RFA治疗小肝癌的疗效已可与手术切除效果相当;对于较大的、或多发的中晚期肝癌,RFA也取得了较好的佳绩。下面结合国内外文献及本所1000多例RFA治疗的经验对此问题作个讨论,并谈一下个人的观点。     

氩氦刀冷冻消融与射频消融在肝癌治疗中的临床应用

目的探讨氩氦刀冷冻消融与冷循环射频消融(cool-tip radiofrequency ablation,RFA)在恶性肝肿瘤治疗中的临床应用价值。方法超声引导下氩氦刀冷冻消融治疗肝癌38例共42个病灶;经超声引导下RFA治疗肝癌40例共44个病灶,治疗前后经超声造影、增强CT或增强MRI检查明确诊断及评价疗效。结果 42个病灶经一次冷冻消融治疗后32个达完全消融,10例经再次冷冻消融后达到完全消融;44个病灶经一次RFA治疗后完全消融33个,11例经再次RFA后达到完全消融。两者一次完全消融率分别为76.2%(冷冻消融)和75%(RFA),差异无统计学意义。结论氩氦刀冷冻消融和冷循环RFA均能有效地原位灭活肝癌细胞,是有效的非手术治疗恶性肝肿瘤的方法之一。     

射频消融在肝癌外科治疗中的应用

原发性肝细胞癌(hepatocellular carcinoma,HCC)是我国常见的恶性肿瘤之一。以肝癌手术切除为代表的外科治疗仍是目前肝癌治疗的首选[1]。但由于我国肝癌90%以上有HBV感染背景,多数合并肝硬化[2],患者就诊时晚期癌多、肝功能差,仅有20%～37%能获得手术根治性切     

手术切除联合射频消融治疗多发性肝癌合并肝硬化

目的探讨手术切除联合射频消融(radiofrequencyablation,RFA)治疗多发性肝癌合并肝硬化的可行性及疗效。方法2003年8月~2006年1月我院收治多发性肝癌合并肝硬化18例,术前经超声、螺旋CT或MRI共发现瘤体46个,其中2个病灶10例,3个病灶6例,4个病灶2例,全麻下距瘤体2cm做包括瘤体的不规则肝段切除、次病灶RFA治疗。结果18例均顺利完成手术切除及RFA治疗。同时行胆囊切除术2例,脾切除及食管胃底周围血管离断术1例。手术切除时间(37.4±8.8)min;单个病灶RFA时间(25.6±8.9)min,总RFA时间(39.8±14.7)min;总手术时间(152.6±30.8)min;总术中出血量(465.6±171.0)ml。未出现腹腔出血、胃肠道损伤、膈肌损伤及肝功能衰竭等严重并发症。术后1个月螺旋CT增强扫描证实,18例手术切除边缘未见残余肿瘤组织,RFA治疗病灶均完全坏死。随访6~31个月,5例发现肝内新病灶,采用经皮RFA进行治疗,其中1例术后15个月死于肝内再复发及肺转移;2例分别于术后7、16个月死于肝功能衰竭。结论手术切除联合RFA治疗多发性肝癌合并肝硬化安全可行,近期治疗效果肯定,最大程度保存受损的肝功能,但应根据病灶的位置及肝功能的状况选择合适的病人进行治疗。     

经皮微波和射频消融治疗肝细胞性肝癌的临床比较研究

目的探讨经皮微波和射频消融治疗肝癌临床效果的差异。方法以相同的纳入标准,回顾性比较了肝细胞性肝癌经超声引导经皮微波消融49例98个结节和射频消融53例72结节的局部疗效、并发症和远期生存率。结果微波组与射频组比较,肿瘤完全消融率分别为94.9%(93/98)和93.1%(67/72)(P=0.75),局部复发率为11.8%(11/93)和20.9%(14/67)(P=0.12)。主要并发症发生率分别为8.2%(4/49)和5.7%(3/53)(P=0.71)。1、2、3年无瘤生存率微波组分别为45.9%、26.9%和26.9%,射频组为37.2%、20.7%和15.5%(P=0.53)。1、2、3、4年累积生存率微波组分别为81.6%、61.2%、50.5%和36.8%,射频组为71.7%、47.2%、37.6%和24.2%(P= 0.12)。结论经皮微波和射频消融治疗肝癌的局部疗效、并发症和远期生存率无显著差别,均为安全有效的肝癌治疗手段。     

Intraoperative Radiofrequency Ablation for Hepatocellular Carcinoma: Long-Term Results in a Large Series

Background  Intraoperative radiofrequency (RF) ablation with or without surgical resection currently plays one of important roles in modern hepatocellular carcinoma (HCC) therapy. We evaluated long-term follow-up results including prognostic factors of intraoperative RF ablation for HCC that was difficult to treat percutaneously. Methods  A total of 133 patients (male, 22 female, mean age 55.8 years) underwent intraoperative RF ablations for 200 HCCs (follow-up period 3.0–79.7 months, median 22.3 months). Hepatic resection was also performed in 29 patients. Reasons for the intraoperative procedure included no safe electrode path (n = 59), excessive tumor burden (n = 41), nonvisualization of the HCC on ultrasonography (n = 20), and risk of collateral thermal damage to adjacent organs (n = 13). We evaluated the technique effectiveness rate at 1 month computed tomography (CT), cumulative local tumor progression rate, cumulative disease-free and overall survival rates, and complications. We also sought significant prognostic factors for overall survival. Results  The technique effectiveness at 1 month was 94.7% (126/133). The cumulative local tumor progression rates at 1 and 3 years were 4.9% and 8.8%, respectively. The cumulative disease-free and overall survival rates at 1, 3 and 5 years were 51.8%, 21.3%, and 16.0% and 92.3%, 72.6%, and 46.5%, respectively. Major complications occurred in nine patients (6.8%). Procedure-related mortality was 1.5% (2/133). The patients treated for recurrent HCC (P = 0.003) or with high serum alpha-fetoprotein levels (P = 0.009) had poor survival by multivariate analysis. Conclusion  The results of this study showed that intraoperative radiofrequency ablation with or without hepatic resection is a safe and effective treatment for hepatocellular carcinoma in patients who are not candidates for the percutaneous approach.     

Radiofrequency Ablation for Subcapsular Hepatocellular Carcinoma

Background: Limited data from recent studies suggested an increased risk of bleeding complications, needle-track seeding, and local recurrence after radiofrequency ablation (RFA) of subcapsular hepatocellular carcinoma (HCC).Methods: Between May 2001 and October 2002, 80 patients underwent RFA of 104 HCC nodules. Forty-eight patients had subcapsular HCC (group I), whereas the other 32 patients did not have subcapsular HCC (group II). RFA was performed via celiotomy, laparoscopy, or a percutaneous approach. Subcapsular HCCs were ablated by indirect puncture through nontumorous liver, and the needle track was thermocoagulated.Results: There were no significant differences between groups in treatment morbidity (14.6% vs. 15.6%; P = .898), mortality (2.1% vs. 0%; P = 1.000), complete ablation rate after a single session (89.4% vs. 96.9%; P = .392), local recurrence rate (4.3% vs. 12.5%; P = .216), recurrence-free survival (1 year: 60.9% vs. 49.2%; P = .258), or overall survival (1 year: 88.3% vs. 79.4%; P = .441). After a median follow-up of 13 months, no needle-track seeding or intraperitoneal metastasis was observed.Conclusions: This study shows that the results of RFA for subcapsular HCCs are comparable to those of RFA for nonsubcapsular HCCs. Subcapsular HCC should not be considered a contraindication for RFA treatment.     

Radiofrequency Ablation Versus Surgical Resection for the Treatment of Hepatocellular Carcinoma in Cirrhosis

Background and Aims Percutaneous radiofrequency ablation (RFA) demonstrated good results for the treatment of hepatocellular carcinoma (HCC) in cirrhotic patients; it is still not clear whether the overall survival and disease-free survival after RFA are comparable with surgical resection. The aims of this study are to compare the overall survival and disease-free survival in two groups of cirrhotic patients with HCC submitted to surgery or RFA. Methods Two hundred cirrhotic patients with HCCs smaller than 6 cm were included in this retrospective study: 109 underwent RFA and 91 underwent surgical resection at a single Division of Surgery of University of Verona. Results Median follow-up time was 27 months. Overall survival was significantly longer in the resection group in comparison with the RFA group with a median survival of 57 and 28 months, respectively (P = 0.01). In Child–Pugh class B patients and in patients with multiple HCC, survival was not significantly different between the two groups. In patients with HCC smaller than 3 cm, the overall survival and disease-free survival for RFA and resection were not significantly different in univariate and multivariate analysis. Whereas in patients with HCC greater than 3 cm, surgery showed improvement in outcome in both univariate and multivariate analysis. Conclusions Surgical resection significantly improves the overall survival and disease-free survival in comparison with RFA. In a selected group of patients (Child–Pugh class B, multiple HCC, or in HCC ≤3 cm), the results between the two treatments did not show significant differences.     

Incomplete Ablation After Radiofrequency Ablation of Hepatocellular Carcinoma: Analysis of Risk Factors and Prognostic Factors

Background Complete ablation rates after a single session of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) vary from 48% to 97%. Limited data are available regarding risk factors and prognostic significance of incomplete ablation. Methods Between April 2001 and March 2006, 298 patients underwent RFA of 393 HCC nodules with an intent of complete ablation after a single session. Risk factors for incomplete ablation and its effect on overall survival were analyzed. Results Two hundred seventy-three (91.6%) underwent complete tumor ablation, whereas the other 25 (8.4%) underwent incomplete tumor ablation after a single session of RFA. By multivariate analysis, tumor size >3 cm (P = .049) was found to be the only independent risk factor for incomplete ablation. There was no statistically significant difference in overall survival between patients with complete and incomplete ablation. By univariate analysis, no previous transarterial chemoembolization (TACE), preoperative serum alfa-fetoprotein ≤100 μg/mL, and complete response after further treatment of incomplete ablation were associated with better overall survival in patients with incomplete ablation. Conclusions This study demonstrated that incomplete ablation after RFA of HCC was associated with tumor size >3 cm. Our data also suggest that aggressive further treatment of tumors with incomplete ablation aiming at complete tumor response improves overall survival.     

Percutaneous Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma After Hepatectomy: Long-term Results and Prognostic Factors

Background We evaluated the long-term survival results and safety of percutaneous radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) after hepatectomy, and assessed the prognostic factors that can influence its long-term therapeutic results. Methods One hundred and two patients, who had 119 recurrent HCC in their livers, underwent ultrasound-guided percutaneous RFA. All the patients had a history of hepatic resection as a first-line treatment modality for HCC. The mean diameter of the recurrent tumors was 2.0 cm (range, 0.8–5.0 cm). We evaluated the effectiveness rates, local tumor progression rates, survival rates, and complications. We also assessed the prognostic factors of the survival rates by using Cox proportional hazard models. Results The primary effectiveness rate was 93.3% (111 of 119). The cumulative rates of local tumor progression at 1, 3, and 5 years were 6.0, 8.6, and 11.9%, respectively. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 93.9, 83.7, 65.7, 56.6, and 51.6%, respectively. Patients with a lower serum α-fetoprotein (AFP) level (≤100 μg/L) before RFA or with small resected tumors (≤5 cm) demonstrated better survival results (P < .05). There was only one major complication (liver abscess, 1.0% per treatment) during the follow-up period. There were no procedure-related deaths. Conclusions Percutaneous RFA is an effective and safe treatment modality for intrahepatic recurrent HCC after hepatectomy. Serum AFP level before RFA and resected tumor size were significant prognostic predictors of long-term survival.     

小肝癌射频消融治疗后患者生存及肝内肿瘤复发的有关因素分析

目的探讨射频消融(radiofrequency ablation,RFA)对≤5cm肝细胞癌(hepatocellular carcinoma,HCC)的疗效。方法2001年6月~2008年4月,对94例≤5cm的HCC进行了135次冷循环射频消融治疗,治疗途径包括超声引导下经皮穿刺(n=102),开腹(n=22),人工胸水辅助超声引导(n=11)。术后随访资料采用Kaplan-Meier模型分析患者的生存情况、肿瘤复发情况及其影响因素。结果射频消融术后1、2、3年的累计生存率分别为88.8%、72.2%、68.4%。45例术后1.5~36个月出现肝内复发,患者1、2、3年的无瘤生存率分别为58.8%、41.3%、28.1%。单因素分析显示:生存时间与肝功能Child-Pugh分级和血清甲胎蛋白水平有关(χ2=6.37,P=0.012;χ2=5.76,P=0.016);肝硬化、肝内多发病灶和高血清甲胎蛋白水平可能是术后肝内复发的危险因素(χ2=3.87,P=0.049;χ2=4.50,P=0.034;χ2=4.28,P=0.039)。结论对≤5cm的HCC,RFA是一种有效治疗方法。     

原发性肝癌术后复发的射频和无水酒精治疗

目的 比较原发性肝癌术后复发患者的射频（RF）治疗和无水酒精注射（PEI）治疗，探讨RF治疗的疗效。方法 回顾性分析我院诊断为原发性肝癌并行根治性手术治疗后肝内复发但没有肝外转移的患者137例，共161个病灶，除外肝功能为ChildC级的患者。分别行RF治疗74例，共86个病灶；行PEI治疗63例，共75个病灶。RF组中有9个病灶直径大于3cm（最大的肿瘤直径为4cm），平均为2．05cm；而PEI组所有病灶直径均小于3cm，平均为2．03cm。监测2组病例治疗前后血常规、肝功能、AFP、彩色多谱勒超声等变化，并统计患者的1、2及3年生存率。结果 RF组和PEI组均未出现严重并发症，RF组和PEI组的肿瘤完全坏死率分别为93．0％（80／86）及81．3％（61／75），前者明显高于后者（P〈0．05）；在RF组中，直径〈3cm和3～4cm的病灶的完全坏死率分别为96．1％（74／77）和66．7％（6／9），前者明显高于后者（P〈0．05）；RF组和PEI组的1、2和3年生存率分别为74．3％（55／74）、62．2％（46／74）及54．8％（17／31）和68．3％（43／63）、57．1％（36／63）及45．0％（9／20），差异均无统计学意义（P〉0．05）；RF组的病灶完全坏死平均治疗次数为1．3次，明显低于PEI组的2．5次（P=0．000）。结论 RF是原发性肝癌术后复发的有效治疗方法之一。     

Surgical Resection Versus Radiofrequency Ablation in the Treatment of Small Unifocal Hepatocellular Carcinoma

Background  Hepatocellular carcinoma (HCC) has a high worldwide prevalence and mortality. While surgical resection and transplantation offers curative potential, donor availability and patient liver status and comorbidities may disallow either. Interventional radiological techniques such as radiofrequency ablation (RFA) may offer acceptable overall and disease-free survival rates. Materials and Methods  Sixty-eight cirrhotic patients matched for age, sex, tumor size, and Child–Pugh grade with small (1–5 cm) unifocal HCC were studied retrospectively to find determinants of overall and disease-free survival in those treated with surgical resection and RFA between 1991 and 2003. Results  Multivariate analysis using Cox proportional regression modeling showed that overall survival was related to tumor recurrence (p = 0.010), tumor diameter (p = 0.002), and treatment modality (p = 0.014); overall p = 0.008. Recurrence was independently related to the use of RFA over surgery (p = 0.023) on multivariate analysis; overall p = 0.034. Conclusion  Surgical resection offers longer disease-free survival and potentially longer overall survival than RFA in patients with small unifocal HCC.     

Significant Long-Term Survival After Radiofrequency Ablation of Unresectable Hepatocellular Carcinoma in Patients with Cirrhosis

Background Radiofrequency ablation (RFA) offers an alternative treatment in some unresectable hepatocellular carcinoma (HCC) patients with disease confined to the liver. We prospectively evaluated survival rates in patients with early-stage, unresectable HCC treated with RFA.Methods All patients with HCC treated with RFA between September 1, 1997, and July 31, 2002, were prospectively evaluated. Patients were treated with RFA by using a percutaneous or open intraoperative approach with ultrasound guidance and were evaluated at regular intervals to determine disease recurrence and survival.Results A total of 194 patients (153 men [79%] and 41 women [21%]) with a median age of 66 years (range, 39–86 years) underwent RFA of 289 sonographically detectable HCC tumors. All patients were followed up for at least 12 months (median follow-up, 34.8 months). Percutaneous and open intraoperative RFA was performed in 140 (72%) and 54 (28%) patients, respectively. The median diameter of tumors treated with RFA was 3.3 cm. Disease recurred in 103 (53%) of 194 patients, including 69 (49%) of 140 patients treated percutaneously and 34 (63%) of 54 treated with open RFA (not significant). Local recurrence developed in nine patients (4.6%). Most recurrence was intrahepatic. The overall complication rate was 12%. Overall survival rates at 1, 3, and 5 years for all 194 patients were 84.5%, 68.1%, and 55.4%, respectively.Conclusions Treatment with RFA can produce significant long-term survival rates for cirrhotic patients with early-stage, unresectable HCC. RFA can be performed in these patients with relatively low complication rates. Confirmation of these results in randomized trials should be considered.Presented at the 57th Annual Cancer Symposium of the Society of Surgical Oncology, New York, New York, March 18–21, 2004.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

原发性肝癌三种根治性方法疗效的多中心对比研究

目的 探讨肝切除、原位肝移植及射频消融三种疗法对原发性肝癌的治疗效果,以便为原发性肝癌的治疗选择恰当的方法.方法 广州市三家医院近5年来采用射频消融、肝切除及原位肝移植治疗原发性肝癌患者1198例.接受上述三种不同治疗方案的患者分别分为三组,Ⅰ组为小肝癌组,Ⅱ组为大肝癌无血管侵犯组,Ⅲ组为大肝癌并血管侵犯组.分别比较三组间1、2、3年治疗后生存率,3年肿瘤复发率;并对接受上述三种疗法各组患者肝功能Child-Pugh分级进行比较.结果 符合米兰标准的小肝癌患者行肝移植较肝切除3年生存率高(P<0.05),复发率低(P<0.05);射频消融者3年生存率及复发率均比肝切除好(P<0.05);射频消融的疗效及复发率与肝移植差异无统计学意义(P>0.05);但接受射频消融及肝切除者肝功能绝大部分为Child A级,而肝移植者大部分为B及C级(P<0.01).超出米兰标准的大肝癌进行肝移植、肝切除或射频消融效果差异无统计学意义(P>0.05),但肝移植的3年复发率偏低(P<0.05).结论 对于符合米兰标准的小肝癌患者,肝移植的中远期疗效优于肝切除;射频消融(3 cm以下肿瘤)疗效比肝切除好;射频消融的疗效及复发率与肝移植相当;但接受射频消融及肝切除者肝功能绝大部分为Child A级,而肝移植者大部分为B及C级.因而小肝癌合并肝功能不全者或衰竭者肝移植应为首选.超出米兰标准的大肝癌进行肝移植、肝切除或射频消融效果差别不大,但肝移植三年复发率偏低,在供肝短缺的情况下不主张首选肝移植.

Abstract：

Objective Partial hepatectomy, liver transplantation, and radio frequency ablation for hepatocellular carcinoma (HCC) were compared to select the most suitable method for HCC. Methods 1198 patients with HCC in 3 hospitals in Guangzhou were divided into 3 groups: group Ⅰ , small HCC; group Ⅱ > HCC without vascular invasions and group Ⅲ , HCC with vascular invasion. The patients either received partial hepatectomy, transplantation or ablation. The 1-, 2- or 3-year survival rates, the 3-year recurrent rates and Child-Pugh grades in the 3 groups were compared. Results For small HCC, there was a significant increase in the 3-year survival rate (P<0. 05) and a significant decease in the recurrent rate (P<0. 05) in patients who received transplantation, compared with those who received hepatic resection. Patients who received ablation had a higher 3-year survival rate and a lower recurrence (P<0. 05) in comparison with those who received hepatectomy. There was no significant difference(P<0. 05) between transplantation and ablation, but there were more Child A patients who received hepatectomy and ablation, and more Child B and C patients who received transplantation. For advanced HCC, there was no significant different in the 3-year survival rates for the 3 therapies, but the 3-year recurrence was lower (P<0. 05) in the transplantation group. Conclusions For small HCC, superiority of transplantation versus resection was obvious. Ablation (diameter <3 cm) was also superior to resection, whereas ablation was as effective as transplantation. There were more Child B and C patients in the transplantation group than the ablation and resection groups. Therefore, small HCC with hepatic decompensation should receive liver transplantation. Transplantation was advantageous in having less tumor recurrent but there was no difference in the 3 therapies for advanced HCC.