ablazione versus chirurgia

Ablazione versus chirurgia

Paolo De Simone, MD PhD

Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy

1

Disclosures

• I have no disclosures relevant to the current presentation

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Dilemma

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Conundrum

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Background

• Although the best curative treatment for HCC is surgical resection, it is not always feasible because of the number and location of HCC, and the degree of underlying liver cirrhosis1,2

• In patients who are not eligible for surgical resection, RFA is widely performed for the treatment of HCC as a less invasive but curative form of locoregional therapy3

• Of various locoregional treatment modalities, RFA has shown • Of various locoregional treatment modalities, RFA has shown excellent treatment outcomes with an overall survival comparable to surgical resection in selected patients4,5

• Therefore, most guidelines recommend RFA as a curative treatment option for early-stage HCC6,7

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HCC, hepatocellular carcinoma; RFA, radiofrequency ablation

1. Zhou L, et al. World J Surg 2007;31:1782-7.

2. Shimozawa N, et al. J Am Coll Surg 2004;198:356-65.

3. Crocetti L, Lencioni R. Cancer Imaging 2008;8:19-26

4. Garrean S, et al. Am J Surg 2008;195:508-20.

5. Ng KK, et al. J Gastrointest Surg 2008;12:183-91.

6. Bruix J, et al. Hepatology 2011;53:1020-2.

7. European Association For The Study Of The Liver; European Organisation For Research And Treatment Of Cancer. J Hepatol

2012;56:908-43.

The BCLC algorithm

European Association For The Study Of The L, European Organisation For R, Treatment Of C. EASL-EORTC clinical

practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 56(4): 908-43.

An instance of perspective?

Natural History of T1N0M0Hepatocellular Carcinoma: Large-ScaleStudy in the United StatesHumaid O. Al-Shamsi a, k, l Reham Abdel-Wahab a, i Manal M. Hassan aAhmed S. Shalaby a Ibrahim Dahbour b Sahin Lacin a, j Armeen Mahvash cBruno C. Odisio c Ravi Murthy c Rony Avritscher c Mohamed E. Abdelsalam cAsif Rashid d Jean-Nicolas Vauthey e Thomas A. Aloia e Claudius Conrad e

Big data

8Al-Shamsi HO et al. Oncology 2017; 93:233-42.

Asif Rashid d Jean-Nicolas Vauthey e Thomas A. Aloia e Claudius Conrad eYun Shin Chun e Sunil Krishnan f Prajnan Das f Eugene J. Koay fHesham M. Amin g, h James C. Yao a Ahmed O. Kaseb aDepartments of a Gastrointestinal Medical Oncology, b Internal Medicine, c Intervention Radiology, d Patholgy,e Surgical Oncology, f Radiation Oncology, and g Hematopathology, The University of Texas MD Anderson CancerCenter, and h The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX , USA; i Department of Clinical Oncology, Assiut University, Assiut , Egypt; j Department of Medical Oncology, Hacettepe University, Medical Faculty, Ankara , Turkey; k Department of Medical Oncology, University Hospital Sharjah, Sharjah ,and l Department of Medical Oncology, Sheikh Khalifa Specialty Hospital, Ras al-Khaimah , United Arab Emirates

Oncology 2017;93:233–242

DOI: 10.1159/000455957

9Al-Shamsi HO et al. Oncology 2017; 93:233-42.

Global thinking

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Early complications after 1,843 RFAs on 1,211 patients

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Park JG et al. Clinical Radiology 2017; 72(8): 692.e9-692.e15 (August 2017) DOI: 10.1016/j.crad.2017.03.001

Early complications after 1,843 RFAs on 1,211 patients

Major complications 2%Liver abscess 0.8%

Intraperitoneal bleeding 0.4%

Liver failure 0.3%

Variceal bleeding 0.2%

Hemothorax 0.1%

Cholecystitis 0.1%

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Cholecystitis 0.1%

Bowel perforation 0.1%

Minor complications 4.8%Post-RFA syndrome 4.1%

Pleural effusion 0.4%

Skin wound infection 0.2%

Thermal injuries to the skin 0.2%

Outcomes of 1,843 RFAs on 1,211 patients*

Treatment outcomes of radiofrequency ablation for hepatocellular carcinoma.

Treatment outcomes

Complete ablation 1,802 (97.8%)

Incomplete ablation 31 (1.7%)

Mistargeting 10 (0.5%)

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*HCC within Milan criteria



Recurrence 955 (51.8%)

Local recurrence 205 (11.1%)

Intrahepatic distant recurrence 721 (39.1%)

Extrahepatic recurrence 29 (1.6%)

Outcomes of 1,843 RFAs on 1,211 patients*

Treatment outcomes of radiofrequency ablation for hepatocellular carcinoma.

Treatment outcomes

Complete ablation 1,802 (97.8%)

Incomplete ablation 31 (1.7%)


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*HCC within Milan criteria



Recurrence 955 (51.8%)

Local recurrence 205 (11.1%)

Intrahepatic distant recurrence 721 (39.1%)

Extrahepatic recurrence 29 (1.6%)

Why is RFA associated with higher rate of intrahepatic, distant recurrence?

• Historical bias

• Selection bias

– RFA series include more patients with cirrhosis than surgery

• Population bias

• Radiological staging

• Impact of etiology• Impact of etiology

– Preliminary, pilot experiences suggest that combination with DAA

reduces recurrence rate

• …...

• …...

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DAA, direct antiviral agents; RFA, radiofrequency ablation

1. Zhou L, et al. World J Surg 2007;31:1782-7.

2. Shimozawa N, et al. J Am Coll Surg 2004;198:356-65.

3. Crocetti L, Lencioni R. Cancer Imaging 2008;8:19-26

4. Garrean S, et al. Am J Surg 2008;195:508-20.

5. Ng KK, et al. J Gastrointest Surg 2008;12:183-91.

6. Park JG et al. Clinical Radiology 2017; 72(8): 692.e9-692.e15 (August 2017) DOI: 10.1016/j.crad.2017.03.001

1-year overall survival is numerically higher for hepatic resection versus RFA

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Duan C, et al. World J Surg Oncol 2013, 11:190

5-year overall survival is significantly higher for hepatic resection versus RFA

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5-year recurrence-free survival is significantly higher for hepatic resection versus RFA

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Surgery is associated with a significantly higher complication rate

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Surgery is associated with longer hospital stay

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Changyong E, et al. J Cancer Res Ther

2017;13(4):625-630. doi:

10.4103/jcrt.JCRT_406_17

Advancing the standards of surgical practice

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Minimally invasive surgical resection is associated with lower rate of local recurrence

• 45 patients MIS (laparoscopic or robotic) versus 60 RFA

• RFA patients showed worse liver synthetic function with lower albumin and higher bilirubin serum levels, and higher ASA scores

• Patients with HCC in segments 2-6 were more often treated by MIS

• The incidence of complications was similar between groups (RFA: 6/60, 10% vs. MIS: 5/45, 11%, p = 0.854)

• No measurable difference in the rate of procedure-related blood transfusions (RFA: 1/60, 1.7% vs. MIS: 3/45, 6.7%, p = 0.185)

• Local recurrence was only detected after RFA (11.7 %, p = 0.056, log-rank)

• Overall survival was higher in the MIS group (p = 0.042), with

median survivals of 100± 13.5 versus 68± 15.9 months

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MIS, minimally invasive surgery; RFA, radiofrequency ablation

1. Vitali GC, et al. Surg Endosc 2016;30(6):2301-7.

Advancing the standards of ablation procedures

ablazione versus chirurgia

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