DOI: 10.1097/SLA.0b013e3182034862

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PMID: 21107101

Issn Print: 0003-4932

Publication Date: 2010/12/01


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Radiofrequency Ablation Leads to Excellent Local Tumor Control and Durable Longterm Survival in Specific Subsets of Early Stage HCC Patients Confirming to the Milan Criteria

Steven A. Curley

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Excerpt

In 2011 it will have been 10 years since the U.S. Food and Drug Administration approved radiofrequency ablation (RFA) as a treatment for unresectable primary or secondary liver malignancies. Since that time, hundreds of articles have been written about the use of RFA for treating not only liver malignancies, but cancers in the breast, thyroid, kidney, bones, lungs, and prostate. As experience with this tool to treat malignant liver tumors is gained around the world, the approaches, indications, and limitations of this thermal tumor destruction technique have become evident. It is clear from numerous reports that treating tumors in the liver more than 4 to 5 cm in diameter is associated with an increased incidence of incomplete treatment of the tumor. This is usually, in my opinion, reported erroneously as a local recurrence. It actually represents a failure to produce sufficiently high temperatures through all areas of the tumor treated when placing the needle electrodes multiple times and attempting to overlap zones of thermal ablation in large malignant tumors. There have also been reports, particularly with use of cooled-tip RF electrodes, of tumor seeding of the needle track. This led to a change in practice to include ablation of the needle track upon withdrawal of the needle electrode, both to secure hemostasis and to destroy any possible tumor cells expelled upward along the needle track during the thermal treatment process.
There is a great deal of interest in treatment of both primary and metastatic liver tumors with RFA. Most patients with metastatic liver tumors have relatively normal livers: specifically, they do not have a high incidence of cirrhosis or preexisting liver disease. Therefore, patients with resectable liver metastases are considered for multidisciplinary treatment programs that include resection and active systemic chemotherapy agents. Our group reported our experience with resection compared with RFA for colorectal cancer liver metastases.1 Although this was a prospective study, it was not randomized. Patients with resectable lesions underwent resection, whereas patients treated with RFA either had bilobar lesions and underwent a combination of resection and RFA or had lesions abutting major vascular structures (that precluded a margin-negative resection) and underwent RFA alone. This study demonstrated a 58%, 5-year survival rate for patients who underwent resection and received active systemic chemotherapy agents, versus 5-year survival rates of less than 30% for patients undergoing RFA alone or RFA plus resection. It is unlikely that there will be a randomized trial comparing resection versus thermal ablation for resectable colorectal cancer liver metastases given the improved surgical treatment approaches for these patients and the higher survival rates associated with complete resection.
Hepatocellular cancer (HCC) is a much different consideration. The majority of patients who develop HCC have preexisting liver disease caused by chronic hepatitis B or C virus infections, aflatoxin exposure, excessive ethanol ingestion, nonalcoholic steatohepatitis, or inherited disorders such as hemochromatosis. All hepatobiliary surgeons know that resection of a cirrhotic liver is associated with an increased risk for complications, including liver insufficiency or liver failure and death of the patient. Patients with Child class B or C cirr-hosis are generally not considered candidates for surgical resection other than a very small wedge or minor resection. Patients who would require a major hepatic resection are often excluded because of their poor functional hepatic reserve. Therefore, treatments such as RFA play an important role in the management of disease in patients with early stage HCC and concomitant cirrhosis.
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