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					         H.GHANAATI
Assistant professor of Tehran
University of Medical Sciences
  GHANAATI@YAHOO.COM
In untreated patients with colorectal hepatic
metastases the longest survival reported*
was 23% and 8% respectively at the 3 and 5
year follow-up



Wagner JS et al: Ann Surg 1984
       AUTHORS                3y   5y   10y
Jamison RL   Arch Surg 1997   46   27   20
  Fong Y     Ann Surg 1999    57   37   22
Minagawa M   Ann Surg 2000    51   38   26
In practice, historical evidence shows that
30-35% of patients presenting liver
metastases are candidates for resection, and
20-26% of these will be definitely cured, i.e.
6-7% of the total population
 Surgery is gold standard but it’s not possible in
  majority of cases
 Systemic chemotherapy is the first step
 In case of systemic chemotherapy failure
  oncointerventional techniques may have brillinat
  effects.
• Accurate selection of lesions and patients to be treated
•Choice of best method of treatment or combination
• Use of biopsy devices or dedicated transducers
•Visualization of the needle/electrode during insertion
• Real-time control of the entire procedure
• Choice of the best and safest approach, angulation &
path
• Techniques preventing from needle tract seeding
•Techniques to avoid post-treatment pain
   For many tumors , each imaging
    technique provides a piece of
    information which like a
   puzzle must be combined with
    findings from other imaging
    techniques as well as clinical
    information to achieve a diagnosis
Several phases of enhancement after IV
 administration of a bolus of contrast
 material :

 Hepatic arterial phase ( HAP )
 portal venous phase ( PVP )
 Equlibrium phase (obscuring lesions)
   Ethanol Ablation: (PEI)
   Acetic Acid Ablation
   Percutaneous Hot Saline Infusion Therapy
   Hepatic Art Infusion Chemotherapy: HAI
   Chemoembolization: HACE
   Radioembolization
   Cryoablation
   RF: Radio-frequency Ablation
   Microwave Ablation
   Laser Ablation or laser induced interstitial
    thermotherapy (LITT)
   High intensity focused ultrasound (HIFU)
º   The same patient (tumor) can be treated with
    different techniques

º   Thermoablation, PEI and sTACE are considered
    complementary

º   Treatment is tailored according to the lesion
    pattern and the response
   Easy
   Inexpensive
   Good results
PEI is preferable in lesion:
º At risk of RFA, i.e. adjacent to main biliary
  ducts or to intestinal loops.
º At risk of sink effect.
In exophytic HCCs : PEI into the peripheral zone + RF
in
the intrahepatic portion
In exophytic HCCs : PEI into the peripheral zone + RF
in
the intrahepatic portion
                    RF ABLATION


1.   Induces ionic agitation

2.   Frictional Heat Production in the tissue

3.   Causing local tissue destruction by coagulation
     necrosis
Applicators – Ablative Devices




  Different types of electrodes
   Ideal for: tumors less than 3 cm, 1 cm
    deep to capsule, and 2 cm away from
    large vessels
 Less toxic than chemoembolization
 Size of thermal injury is larger than laser
  ablation
 The main limitation: marginal tumor
 There are limitations: size, location, numbers
visualization
In colorectal metastases, presence of occult
(microscopic) invasion within 10 mm from the
edge of the tumor in 22% of lesion <4 cm,
and in 85% of lesions >4 cm



Shirabe et al, Brit J Surg 1997
Lack of capsule
Infiltrative growth                NO “oven effect”
Normal liver tissue around


Variable (unpredictable) size and shape of necrosis area
> Sink effect of blood vessels



  Need for large necrotic areas (thick “safety halo”)
  Overlapping of multiple volumes of necrosis
       (1 cm Ø      2 cm Ø = volume x 8)
   RFA-induced necrosis can be depicted
    within the spatial resolution of CT and MRI
    shortly after ablation

     Most accurate predictor of induced coagulation
      was the identification of previously enhancing
      regions of tumor that were subsequently lacking
      enhancement post-treatment
     CT and MRI are unable to detect small residual foci
      when the tumor size and ablation areas were
      identical on imaging

    Goldberg et al, Cancer, 88(11) June 2000.
 Possibility to treat non-surgical candidates and
   patients previously undergone resection
 Repeatability in case of partial necrosis, local
   recurrence and development of new lesions
 Low cost

* Moderate invasiveness :
    - no permanent impairment of liver function
    - no systemic toxicity
    - low rate of major complications
RISKS
 1 - MODALITY - DEPENDANT

 Treating completely and safely tumors in“difficult”
   anatomical situations (subcapsular , adjacent to
   bowel walls, GB, CBD, etc..) and/or in pts. in critical
   conditions

  2- OPERATOR - DEPENDANT
 Uncontrolled diffusion among users with poor
  experience in image -guided interventional
  procedures
   >>> severe risk of increasing complication rate
    COMPLICATIONS OF RFA
 IN COLORECTAL METASTASES

• 683 patients
• Mortality: 0,14%
• Major complications: 2,3%



Livraghi T. et al.: Radiology 2003
    Major complications

12 Peritoneal bleeding, requiring surgery 11 HCC, 1 M
   (3), transfusions (9), TAE (1)

12 Seeding                                                   8 HCC, 4 M

6     Hepatic abscesses, requiring surgery                   3 HCC, 3 M
      (1), drainage (4), antibiotics (1)

5     Gl perforation                                         1 HCC, 4 M

               Livraghi T, Solbiati L., et al - Radiology,
                                 2003)
Complications in RFA of HCC
             1620 pts with HCC (Italian RFA group)

    Deaths =         4 (0,25%)

    Major           =    24 (1.5 %)

     Peritoneal bleeding     12
       requiring surgery (3), transfusions (8), TAE (1)

     Seeding                  8
     Hepatic abscesses        3
       requiring surgery 1, drainage 1, antibiotics 1

     GI perforation                  1


                    (Livraghi T, Solbiati L., et al - Radiology, 2003)
      Local control and long-term survival of pts. with CRC mets post-RFA


 Author            # pts # mets      Size       Technique F/U                Local      Survival
                                     (cm)                                   control

Solbiati L, 2006   121     320    0.9 - 4.0     percutaneous     4 - 88     83.1%       3 yrs 47%
                                  mean 2.1                                              5 yrs 27%


Berber E, 2005      135   432     1.2 - 10.2    laparoscopic   12 - 52                  3 yrs : 28 %
                                                                                        median : 28.9

Gillams AR         167     354      1 - 12    percutaneous     0 - 89        125/167    5 yrs : 26 %
          2004                     mean : 3.9                   mean : 17

Veltri A, 2005      98     163     0.5 - 8.0  percutaneous     12 - 108       59%        3 yrs : 48%
                                   mean : 2.7 intraop (21)                               5 yrs : 30%

Jakobs TF 2006      68      183   0.5 - 5.0     percutaneous   8 - 38         82%       3 yrs : 68%
                                   mean : 2.2                  mean : 21


Tumor RFA          423     543    0.5 - 5..0   percutaneous  1 - 78          85.4%      3 yrs : 47%
Italian network                     mean : 2.7              mean : 19       R0: 88.2%   5 yrs : 24%
(Lencioni R)
           2005
   Portal vein embolization
   Hepatic artery infusion chemotherapy
   Chemoembolization
   Chemoembolization
   Mechanism:
    Arterial delivery
    increases the
    drug
    concentration in
    liver tumors 10-
    100 times
    compared with
    systemic infusion
   HCC derive 80-85% blood supply from
    hepatic art.
   Chemotherapeutic agents delivered
    angiographically
   Embolisation increases dwell time and tissue
    ischaemia
   Mechanism:Embolization prolongs the dwell
    time of the drug from hours to weeks.
   Embolization by gelfoam, polyvinyl alcohol
   Catheters: Cobra and a microcatheter
   Drug: doxurobicin, cisplatin, mitomycin-c
    adriamycin
   Effective in both primary and metastatic
    liver tumors
   Contraindications: Absence of hepatopedal
    portal flow, encephalopathy, biliary
    obstruction, Bil.>2mg/dl, elevated enzymes
   Response rate for metastatic tumors:60-80%
    for an average duration of one year
   1-3-5 year survival: 70-40-10%
   Major complications: 5%
   Researchers long ago recognized that the liver has the
    remarkable ability to regenerate, making hepatic
    resection possible for many patients with cancers such
    as hepatocellular carcinoma or hepatic metastases
    from primary cancers such as colorectal cancer.
   Extended hepatic resection in which 25% or less of the
    liver remains after surgery, however, was for many
    years not an option owing to the high risk of
    complications and even death associated with the
    surgery. Complications associated with resection of
    75% or more of the liver include fluid retention caused
    by the increased portal pressure, transient jaundice
    resulting from insufficient excretory function of the
    remaining liver, and abnormal coagulation—which
    may lead to bleeding—due to decreased synthesis of
    clotting factors in the liver .
 As portal vein embolization (PVE) allows physicians to
  preoperatively stimulate hypertrophy of the future
  liver remnant (FLR), the portion that remains after
  liver resection
 PVE induces growth of the contralateral liver [the side
  that is not embolized] by diverting blood flow and
  hepatotrophic factors such as insulin and glucagon to
  that side

				
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posted:4/11/2010
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