RFA Experience In Nicosia General Hospital (CLM)

P. Hadjicostas,,M.Dietis, C. Antreou / Surgical Department

Liver Tumors (primary or metastatic)

Resection: is the gold standard of treatment.

BUT in only

9 – 27% in patients with HCC

& 20% inpatients with Liver CRM’s.

The 2nd cause of death

If untreated (6-18 months live)

70% recurence after Resection

50% recurence within the liver

The worsen development in a cancer patient

History:Thermal Cancer Therapy

Hot oil treatment of tumors described in 5000 y.o Egyptian papyrus

Tumor´´ cautery´´ used for numerous cancer types over past 400 years

Electrocautery destruction of superficial and endothelial malignancies over past 120 years

More recently, cryoablation, laser photocoagulation, radiofrequency ablation and microwave coagulation

Local Ablative therapy(unresectable Liver tumors)

A. Percutaneous injection 1. Chemicals - Alcohol (P.E.I.T) - Acetic acid 2. Radio active isotopes 3. Hyperthermic agents - Saline - Water

4. Chemotherapeutic agents - Chemoembolization

B. Percutaneous application of an energy source 1. Thermal ablation - Radiofrequency - Microwave (P.M.C.T)

- Interstitial laser photocagulation 2. Cryoablation

“ A good local ablative method should be locally effective to the cancer, non-toxic to nontumorous liver, and easy and safe to administer”.

“The endpoint of local ablation is complete tumor necrosis with a margin of tissue”

Lau et al 2002

RFA is a new promising treatment for Liver tumors.

“to heat and thereby kill tumor cells and normal surrounding parenchyma”

Strasberg et al 2003

“thermal tissue destruction” Curley et al 2000

“…… What is not cured by knife is cured by fire” Heppocrates

The Cool-Tip™RF

System

Slide 7Ε

Useful Tips

2. Always place the end of the Cool Tip needle to the distant end of Lesion.

Slide 5Δ

Cool-tip™Radio Frequency Ablation

Tissue response to Heat

100° C

50° CCollagen denatures

Thermal injury starts

60° C

70° C

80° C

90° C

RF Ablation Technology

Cool Tip Minimum Target Temp

RFA By Surgeon and in the OR Friendly environment Anesthesiologist is present Continuous monitoring (BP, Pulse, ECG, Sat

O2 ) Arrhythmia Hyperthermia/Sweating/ Discomfort More analgesia Maybe gen. anesthesia Higher safety

Indications RFA

RFA should be reserved for pts. Unresected metastases/ Downsizing Unable to tolerate lapatatomy for resection

BUT could challenged hepatectomy New hepatic metastasis following liver

resection( Elias 2002, Joosten 2007) Limited central

disease/hemihepatectomy( Evrard 2006,Abitabile 2007,Bremers 2007)

Small metastasis (Evrard 2007,Wagman 2007) Solidary metastasis ( Oshowo 2003)

RFA

- percutaneously (65-75%)

-Open Surgery

-Laparoscopic

(Treatment approach individualized in any given patient)

If not resectable is ablated.

Post – RFA

Early Studies: Local Recurrence

Mean (F/U) (months)

Tumor Type Local Recurrence

Rossi, 1996 22 HCC Perc 4.8%

Solbiati, 1997 18 Mets Perc 33%

Curley, 1999 15 HCC/Mets Perc/Open 1.8%

Siperstein, 2000 14 HCC/Mets Lap 12%

Da Baere, 2000 14 Mets Perc/Open 9%

Bowles, 2001 15 HCC/Mets Perc/Lap/Open 9%

Solbiati, 2001 28 Mets Perc 39%

Bleicher, 2003 13 Mets Perc/lap/Open 12%

Abdalla, 2004 21 Mets Open 9%

Berber, 2005 29 Mets Lap 46%

Cost-effectiveness of RFA vs Hepatic Resection

Treatment FU testing and

treatment (mo)

#Mets treated Cost/pt

RFA 12 6 24,800

Resection 12 6 61,000

Gazelle et al: radiology;2004:729

State Transition Decision Model – Disease Extent, Post Treatment Imaging

Morbitity of RFA Vs Resection

No Morbidity %

RFA Resection RFA Resection

Lu, 2006 51 54 8 11

Chen, 2006 71 90 4 55

Lupo, 2006 60 42 10 17

Guglielmi, 2008 109 91 10 36

Huang, 2010 115 115 4 28

Randomized Control Trials 7% 30%

Surgical Resection vs RFA (PCT)

180 Patients (HCC < 5cm)

Annals of Surgery:Chen MS 243:March, 2006

71 (RFA) 69 (Resection)

DFS OS DFS OS

1 year 86% 96% 86% 93%

2 year 69% 82% 77% 82%

3 year 64% 71% 69% 73%

4 year 46% 68% 51% 64%No Difference

Ablation Vs Resection

Tension: Resection VS Ablation

Open Resection Ablation

Long Term Risk of Recurrence

Short Term Risk of QOL impairment

Score Sheet

Short term QOL

Safety Access / Anatomy

Prognostic Recurrence Survival

Ablation

Resection

N.G.H. RFA Experience

FROM SEPTEMBER 2003 UNTIL TODAY

RFA

Number of Patients

74

HCC

Liver Metastasis Pelvic Tumor

Pancreas Ca

Liver Trauma

CLR Breast Ca

Gastric Ca

Sarc Renal Ca

Neuro endoc

10 36 2 4 2 1 1 2 15 1

Age (mean)

Gender Method

No Tumors

Tumor Size

Complication LR OSM F O P

68.1y 24 12 11 25 1 – 6 1– 9cm 5.6% 8.3% 32.2m median

N.G.H. RFA CLM Table

• RFA performed 36 patients

• Metastatic lesions 77

• Metastatic lesion / patient 1 – 5

•Metastatic lesion size 1 – 9cm

Patient pre-operative evaluation

1. Patient pre-operative evaluation from specialized team. (General surgeon, Oncologist, Pathologist, Radiologist)

2. Unresectional patients. Fits ablation criteria.

3. CT scan, occasional MRI.

4. Technical planning. (individualized)

5. Patient briefing, concept form.

Technical Method

1. Patient re-evaluation.

2. Operation theatre.

3. Presence of anesthesiologist, radiologist.

4. US guidance.

5. Single probe, triple probe, overlapping technique.

Follow up

1. Patient follow up evaluation from specialized team.

2. Ablation CT scan re-evaluation. (1-6 months)

Complication of RFA Patients

Hemorrhage

Abscess

Biliary Leakage / Stricture

Pleural Effusion

Damage to vascular Systems

Pneumothorax

Liver Failure

Ascites

Fever 2

Colon Perforation

Myocardial Infraction

TOTAL 2 ( 5.6%)

RFA Complications

Age (mean)

Gender Method

No Tumors

Tumor Size

Complication LR OSM F O P

68.1y 24 12 11 25 1 – 6 1– 9cm 5.6% 8.3% 32.2m median

N.G.H. RFA CLM Table

• Minor Complications 2 / 36 (5.6%)

•Local Recurrence 3 / 36 (8.3%)

•Survival (months) 1 – 72m (32m)

Age Gender Method No Tumors Tumor Size

≤ 68y > 68y M F O P =1 >1 ≤3cm >3cm

Patient 19 17 24 12 11 25 21 15 17 19

LR 1 2 2 1 0 3 2 1 1 2

OS

(Mean)

p=

35m 29.3m 33.4m 30.2m 35.1m 29m 37.6m 25m 38m 27m

0.281 0.561 0.279 0.01 0.05

N.G.H. RFA CLM Table

0

20

40

60

80

100

120

1 18 22 26 30 36 40 47 68

Time (Months)

Su

rviv

al %

92% / 12m

55% / 24m

39% / 36m

RFA

N.G.H. RFA Survival Chart

93% / 12m

59% / 24m

42% / 36m

92% / 12m

55% / 24m

39% / 36m

Abdalla et al, Annals of Surgery 2004

0

20

40

60

80

100

120

1 18 22 26 30 36 40 47 68

Time (Months)

Su

rviv

al %

N.G.H. RFA Survival Chart

Solitary tumor

>1 tumor

52% / 36m

20% / 36m

p=0.01

68% / 36m

43% / 36m

52% / 36m

20% / 36m

Abdalla et al, Annals of Surgery 2004

0

20

40

60

80

100

120

1 18 22 26 30 36 40 47 68

Time (Months)

Surv

ival

%

≤3cm

>3cm

65% / 36m

16% / 36m

N.G.H. RFA Survival Chart

p=0.05

Berber et al, Journal of Clinical Oncology 2005

50% / 36m

65% / 36m

≤3cm

3 – 5cm

<5cm

Article Year Method No Patients No Tumors

Tumor Size

LR OS

Jakobs 2006 P 68 2.7 2.3cm NR 3y, 68%

Chen 2005 P 96 NR 4.1cm 10.5% 3y, 25.1%

Gillams 2004 P 167 4.1 3.9cm 14% 3y, 40%

Oshowo 2003 P 25 NR 3cm NR 3y, 43%

Schindera 2006 P 14 NR 1.8cm 14.8% 3y, 60%

White 2004 P 30 1 3cm 16% 22m median

Basdanis 2004 O 18 NR 5.6cm 11% NR

Chow 2006 O,L,P 29 1 2.4cm 20.5% 6m median

Chhabra 2006 O,P 14 NR 3.1cm 7% 16m median

Marchi 2006 O,L,P 100 3.5 3cm 6.7% 3y, 42%

Abitabile 2007 O,L,P 47 3.1 2cm 1.6% 3y, 57%

Recurrence and Survival review table

Marginal Recurrence S/P-Hepatic Resection

Not zero but 1.2- 10.4% ( Mulier 2008)

Group Method No Patients No Tumors

Tumor Size

LR OS

MD Anderson Texas

O 57 1 2.5cm 9% 3y, 37%

John Wayne

O,L,P 74 3.3 3.6cm 31% >3cm

35.5%

Cleveland Clinic

L 135 3.2 3.8cm 46% 3y, 30%

Gustav Roussy

P,L 63 2 1.3cm 7.1% 3y, 46%

Italian Group

P 117 1.5 2.8cm 39% 3y, 46%

NGH O,P 36 1.9 4cm 8.3% 32m median

Recurrence and Survival review table

Conclusion

1. Minimally invasive method. Low complications.

2. Well tolerated.

3. Low cost effective.

4. Easily repeatable.

5. Local recurrence?