Microwave ablation of liver metastases to overcome radiofrequency ablation limits

Transcription

1 Microwave ablation of liver metastases to overcome radiofrequency ablation limits Poster No.: C-2456 Congress: ECR 2012 Type: Scientific Exhibit Authors: G. Carrafiello 1, A. M. Ierardi 1, V. Molinelli 1, E. Duka 1, N. Lucchina 1, Keywords: DOI: F. Giorlando 1, F. Piacentino 2, C. Fugazzola 1 ; 1 Varese/IT, 2 varese/ IT Liver, Interventional non-vascular, Oncology, CT, Percutaneous, Ablation procedures, Metastases /ecr2012/C-2456 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Purpose It is estimated that only 10% of all liver metastases are resectable at the time of diagnosis. Over the years, various ablation techniques have been developed, including ethanol ablation, laser ablation, cryoablation and radiofrequency ablation. Among the above, radiofrequency ablation (RFA) has emerged, in recent years as a promising treatment option for liver metastases. However this technique has limits such as: serious complication that may require surgery and a considerable renewed local tumor growth at the RFA-treated site, with rates as high as 39%, as shown in recent studies with longer follow-up period. The purpose of our study was to evaluate the technical success, effectiveness and safety of microwave ablation (MWA) in patients with unresectable liver metastases, in those cases where RFA presents some limits. Methods and Materials From May 2008 to September 2011, 25 patients (17 male, 8 female), mean age of 65,96 (range 49-83) years, underwent percutaneous MWA of intra-parenchymal metastases, with a mean diameter of 3,7 cm. Inclusion criteria were: absence of extrahepatic disease or stable extrahepatic disease for at least 3 months; inoperable lesions; tumour size (greater than 3 cm); lesions located near vessels (with a diameter greater than 3 mm). Overall 31 lesions were treated: 21 colorectal cancer metastases and 10 not colorectal cancer metastases. The following pre-procedure work-up was performed on all patients: coagulation panel, complete blood count, serum bilirubin and liver enzyme levels. Pre-treatment imaging consisted of an abdomen multi-detector row contrast enhanced CT-scan. One week prior to the ablation treatment, patients with metachronous metastases underwent percutaneous biopsy performed with ultrasonography guidance, with histological confirmation of all lesions. Throughout the entire ablation session patients were monitored by an Anaesthesiologis. Page 2 of 10

3 A MWA system (Evident Microwave Ablation System, Covidien Ltd) consists of a generator capable of producing 45 W of power at a frequency of 915 MHz and coaxial cables to connect each generator with a straight (14.5 Gauge) microwave antenna. Antennas used for percutaneous procedures have the possibility to produce a radiating section length of 2 or 3.7 cm. Two or more antennas were used depending on the diameter of the lesion. Follow up was carried out by CT-scan after 1, 3, 6 and 12 months in combination with complete blood count and liver enzyme panel. Technical success was defined as the correct deployment of antennas into the lesions. Safety was defined as the frequency of complications. All complications were recorded and classified as minor and major, they were assessed according to CTCAE classification. Efficacy of the technique was defined on the basis of the recurrence rate. Local recurrence was defined as the presence of vital tissue around (<5 mm) and/or in the contest of treated lesion at CT-scan performed at least after 3 months. Images for this section: Page 3 of 10

4 Fig. 1: Colorectal metastases before(a) and after microwave ablation(b) Follow-up contrast enhanced CT-scan performed 3 months after the procedure documenting area of hypodensity at the site of the treated lesion reports complete ablation, in the absence of areas of enhancement attributable to residual disease. Page 4 of 10

5 Fig. 2: Metastases close to the inferior vena cava in A a CT-scan coronal view and in B axial view of the same lesion. Page 5 of 10

6 Fig. 3: This is a contrast enhanced CT-scan performed 1 month after the ablation procedure. It documents the presence of a crescent-shaped peripheral area of enhancment consistent with residual disease (A). Page 6 of 10

7 Results Technical success was 100%. In all cases, the antennas were correctly placed within the lesion. No major complications occurred in the intra-, peri- and post-procedural period. The complications encountered were classified into grade 1 according to the CTCAE criteria. Abdominal pain was noted in all patients after every session of treatment. The severity of pain was described as mild after all the sessions and no analgesic therapy was performed. All other laboratory tests were normal both before and after ablation. The mean follow-up duration was 12,04 months (3-36 months). In 4 of the 31 lesions treated (13%), a residual tumour was observed at CT scan performed after 1 month. Patients underwent additional ablation treatment at 3 months from initial treatment, producing complete necrosis of the residual lesion. In 3 of the 31 lesions treated (9,6%) a recurrence was observed during the follow-up period. In 6 of the 25 patients who underwent MWA (19,3%) was recorded the progression of disease during the follow-up period with the appearance of new lesions on CT-scans. Images for this section: Page 7 of 10

8 Fig. 4: Metastases close to the gallbladder before (A) and after (B) microwave ablation. Contrast enhanced CT-scan performed 3 months after the ablation procedure, which documentes a complete ablation at the site of the treated lesion,in the absence of enhancement of areas related to residual disease. Page 8 of 10

9 Conclusion The more relevant aspect that emerges from our small series is the possibility to perform MWA of metastases located in critical sites, where Literature data reveal that other ablative techniques, like RFA, may be neither radical nor completely safe. Furthermore it shows the possibility to treat large lesions simultaneously through the use of multiple antennas (the average diameter of lesions treated in our series is lower than that found in the Literature). MWA seems technically preferable in selected cases: Lesions with diameter > 3cm Lesions closer to large caliber vessels >3 mm Lesions closer to important structures such as gallbladder and the right flexure of the colon. In conclusion, further investigation of a greater number of patients with liver metastases is needed to confirm this encouraging findings and a randomized controlled trial is mandatory to compare RFA to MWA for liver metastases. References 1. Biasco G, Derenzini E, Grazi G et al.: Treatment of hepatic metastases from colorectal cancer: many doubts, some certainties. Cancer Treat Rev.2006;32(3):214-28; 2. Nuzzo G, Giuliante F, Giovannini I, et al (1997). Resection of hepatic metastases from colorectal cancer. Hepatogastroenterology 44:751-9; 3. Laganà D, Carrafiello G, Mangini M, et al (2008). Hepatic radiofrequency under CT fluoroscopy guidance. Radiol Med;113(1): Puls R, Langner S, Rosenberg C, et al (2009). Laser ablation of liver metastases from colorectal cancer with MR thermometry: 5-year survival. J Vasc Interv Radiol;20(2):225-34; 5. Solbiati L, Livraghi T, Goldeberg SN et al (2001) Percutaneous radiofrequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients.radiology221: ; 6. Xu KC, Niu LZ, He WB, et al (2008). Percutaneous cryosurgery for the treatment of hepatic colorectal metastases. World J Gastroenterol 14(9):1430-6; 7. Wright SA, Sampson LA, Warner TF et al (2005) Radiofrequency versus microwave ablation in a hepatic porcine model. Radiology 236: ; Page 9 of 10

10 8. Curley SA, Marra P, Beaty K, et al (2004). Early and late complications after radiofrequency ablation of malignant liver tumors in 608 patients. Ann Surg 239:450-8; 9. Van Duijnhoven FH, Jansen MC, Junggeburt JM, et al (2006). Factors influencing the local failure rate of radiofrequency ablation of colorectal liver metastases. Ann Surg Oncol 13 (5):651-8; 10. Gillams AR, Lees WR (2009). Five-year survival in 309 patients with colorectal liver metastases treated with radiofrequency ablation. Eur Radiol 19: ; 11. Wright SA, Lee FT, Mahvi DM (2003) Hepatic microwave ablation with multiple antennae results in synergistically larger zones of coagulation necrosis. Ann Surg Oncol 10: ; 12. Goldberg SN, Grassi CJ, Cardella JF, et al (2009). Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 20:S377-90; 13. Martin RCG, Scoggins CR, McMasters KM (2007). Microwave Hepatic Ablation: Initial Experience of Safety and Efficacy. J Surg Oncol 96: ; 14. Jones C, Badger SA, Ellis G (2011). The role of microwave ablation in the management of hepatic colorectal metastases. Surgeon 9(1):33-7; 15. Carrafiello G, Laganà, Mangini M et al: Microwave tumors ablation: principles, clinical application and review of preliminary experience. Int J Surg 2008;6:65-9; Personal Information Page 10 of 10