Interventionelle, laparoskopische und offen operative Radiofrequenztherapie maligner Leberläsionen

Zusammenfassung

Die wachsende klinische Bedeutung der Radiofrequenz induzierten Ablation an der Leber wird begleitet von einer schnell zunehmenden Zahl an Publikationen. Im experimentellen Bereich liegt ein besonderes Augenmerk darauf Faktoren zu definieren, die die Variabilität der Nekroseausdehnung reduzieren. Das Pringle-Manöver steht hier für den Chirurgen an erster Stelle. Die Lokalrezidivrate steigt in großen Einzelserien und einer Metaanalyse bei einem Tumordurchmesser > 3 cm drastisch an. Ein offen chirurgischer Zugang ist mit einer signifikant geringeren Lokalrezidivrate nach RFA verbunden. Gallenwegsschäden und intrahepatische Abszesse sind die häufigsten Komplikationen. Die intraduktale Gallenwegskühlung vermindert experimentell und klinisch die Häufigkeit dieser Komplikationen. Die Indikation zur RFA ist bei hepatozellulären Karzinomen durch 3 prospektive, randomisierte Studien gesichert. Für die Indikation bei kolorektalen Metastasen liegen Einzelserien bei Patienten mit multiplen Metastasen und einem 3-Jahres-Überleben > 35 % vor. In zukünftigen multimodalen Therapiekonzepten wird die RFA aufgrund der günstigen Kosten / Nutzen-Relation einen im Detail noch zu definierenden Platz einnehmen.

Abstract

The growing clinical impact of radiofrequency ablation of liver lesions is reflected by a rapidly increasing number of published papers. Experimental work focuses on factors that reduce the variability of the ablation zone. The Pringle-maneuver plays a key role in this question from a surgeon's perspective. Large single center studies and a meta-analysis show a sharp rise in the rate of local recurrences for tumors larger 3 cm. An open surgical approach is significantly correlated to a low local recurrence rate. Bile duct lesions and intrahepatic abscesses are the most frequent complications. Intraductal bile duct cooling can prevent these complications. Three prospective randomized trials support the use of RFA for small hepatocellular carcinoma. The use of RFA in patients with multiple colorectal metastases is supported by single center studies showing a 3 year survival of > 35 %. The favourable cost / benefit ratio will make RFA a part of future multimodal cancer therapy concepts.

Lebermetastase - Leberzellkarzinom - RFA - Zugang - Patientenüberleben

liver metastasis - primary liver cancer - RFA - approach - outcome

Literatur

• 1 Abdalla E K, Vauthey J N, Ellis L M, Ellis V, Pollock R, Broglio K R, Hess K, Curley S A. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection / ablation for colorectal liver metastases.  Ann Surg. 2004;  239 818-825
• 2 Ahmed M, Liu Z, Afzal K S, Weeks D, Lobo S M, Kruskal J B, Lenkinski R E, Goldberg S N. Radiofrequency ablation: effect of surrounding tissue composition on coagulation necrosis in a canine tumor model.  Radiology. 2004;  230 761-767
• 3 Bangard C, Gossmann A, Kasper H U, Hellmich M, Fischer J H, Holscher A H, Lackner K, Stippel D L. Experimental radiofrequency ablation near the portal and the hepatic veins in pigs: differences in efficacy of a monopolar ablation system.  J Surg Res. 2006;  (im Druck)
• 4 Berber E, Pelley R, Siperstein A E. Predictors of survival after radiofrequency thermal ablation of colorectal cancer metastases to the liver: a prospective study.  J Clin Oncol. 2005;  23 1358-1364
• 5 Cervone A, Sardi A, Conaway G L. Intraoperative ultrasound (IOUS) is essential in the management of metastatic colorectal liver lesions.  Am Surg. 2000;  66 611-615
• 6 Chang C K, Hendy M P, Smith J M, Recht M H, Welling R E. Radiofrequency ablation of the porcine liver with complete hepatic vascular occlusion.  Ann Surg Oncol. 2002;  9 594-598
• 7 Elias D, Baton O, Sideris L, Boige V, Malka D, Liberale G, Pocard M, Lasser P. Hepatectomy plus intraoperative radiofrequency ablation and chemotherapy to treat technically unresectable multiple colorectal liver metastases.  J Surg Oncol. 2005;  90 36-42
• 8 Elias D, Sideris L, Pocard M, de Baere T, Dromain C, Lassau N, Lasser P. Incidence of unsuspected and treatable metastatic disease associated with operable colorectal liver metastases discovered only at laparotomy (and not treated when performing percutaneous radiofrequency ablation).  Ann Surg Oncol. 2005;  12 298-302
• 9 Elias D, Sideris L, Pocard M, Dromain C, De Baere T. Intraductal cooling of the main bile ducts during radiofrequency ablation prevents biliary stenosis.  J Am Coll Surg. 2004;  198 717-721
• 10 Fong Y, Fortner J, Sun R L, Brennan M F, Blumgart L H. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases.  Ann Surg. 1999;  230 309-318
• 11 Germer C T, Buhr H J, Isbert C. Nonoperative ablation for liver metastases. Possibilities and limitations as a curative treatment.  Chirurg. 2005;  76 552-563
• 12 Gillams A R. The use of radiofrequency in cancer.  Br J Cancer. 2005;  92 1825-1829
• 13 Gillams A R, Lees W R. Radiofrequency ablation of colorectal liver metastases.  Abdom Imaging. 2005;  30 419-426
• 14 Goldberg S N. Science to practice: can we differenziate residual untreated tumor from tissue responses to heat following thermal tumor ablation?.  Radiology. 2005;  234 317-318
• 15 Goldberg S N, Gazelle G S, Dawson S L, Rittman W J, Mueller P R, Rosenthal D I. Tissue ablation with radiofrequency using multiprobe arrays.  Acad Radiol. 1995;  2 670-674
• 16 Goldberg S N, Gazelle G S, Dawson S L, Rittman W J, Mueller P R, Rosenthal D I. Tissue ablation with radiofrequency: effect of probe size, gauge, duration, and temperature on lesion volume.  Acad Radiol. 1995;  2 399-404
• 17 Goldberg S N, Gazelle G S, Halpern E F, Rittman W J, Mueller P R, Rosenthal D I. Radiofrequency tissue ablation: importance of local temperature along the electrode tip exposure in determining lesion shape and size.  Acad Radiol. 1996;  3 212-218
• 18 Goldberg S N, Grassi C J, Cardella J F, Charboneau J W, Dodd G D, Dupuy D E, Gervais D, Gillams A R, Kane R A, Lee F T, Livraghi T, McGahan J, Phillips D A, Rhim H, Silverman S G. Image-guided tumor ablation: standardization of terminology and reporting criteria.  Radiology. 2005;  235 728-739
• 19 Hansen P D, Rogers S, Corless C L, Swanstrom L L, Siperstien A E. Radiofrequency ablation lesions in a pig liver model.  J Surg Res. 1999;  87 114-121
• 20 Investigators C. Prospective validation of the CLIP score: a new prognostic system for patients with cirrhosis and hepatocellular carcinoma. The Cancer of the Liver Italian Program (CLIP) Investigators.  Hepatology. 2000;  31 840-845
• 21 Jansen M C, van Hillegersberg R, Chamuleau R A, van Delden O M, Gouma D J, van Gulik T M. Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review.  Eur J Surg Oncol. 2005;  31 331-347
• 22 Karmali S, Dixon E. Biliary stricture resulting from radiofrequency ablation.  Am J Surg. 2004;  188 76-77
• 23 Kim S H, Lim H K, Choi D, Lee W J, Kim M J, Lee S J, Lim J H. Changes in bile ducts after radiofrequency ablation of hepatocellular carcinoma: frequency and clinical significance.  AJR Am J Roentgenol. 2004;  183 1611-1617
• 24 Lencioni R A, Allgaier H P, Cioni D, Olschewski M, Deibert P, Crocetti L, Frings H, Laubenberger J, Zuber I, Blum H E, Bartolozzi C. Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection.  Radiology. 2003;  228 235-240
• 25 Lin S M, Lin C J, Lin C C, Hsu C W, Chen Y C. Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less.  Gut. 2005;  54 1151-1156
• 26 Lu D S, Yu N C, Raman S S, Limanond P, Lassman C, Murray K, Tong M J, Amado R G, Busuttil R W. Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver.  Radiology. 2005;  234 954-960
• 27 Marchal F, Elias D, Rauch P, Zarnegar R, Leroux A, Stines J, Verhaeghe J L, Guillemin F, Carteaux J P, Villemot J P. Prevention of biliary lesions that may occur during radiofrequency ablation of the liver: study on the pig.  Ann Surg. 2006;  243 82-88
• 28 Mazzaferro V, Battiston C, Perrone S, Pulvirenti A, Regalia E, Romito R, Sarli D, Schiavo M, Garbagnati F, Marchiano A, Spreafico C, Camerini T, Mariani L, Miceli R, Andreola S. Radiofrequency ablation of small hepatocellular carcinoma in cirrhotic patients awaiting liver transplantation: a prospective study.  Ann Surg. 2004;  240 900-909
• 29 Montgomery R S, Rahal A, Dodd G D, Leyendecker J R, Hubbard L G. Radiofrequency ablation of hepatic tumors: variability of lesion size using a single ablation device.  AJR Am J Roentgenol. 2004;  182 657-661
• 30 Mulier S, Mulier P, Ni Y, Miao Y, Dupas B, Marchal G, De Wever I, Michel L. Complications of radiofrequency coagulation of liver tumours.  Br J Surg. 2002;  89 1206-1222
• 31 Mulier S, Ni Y, Jamart J, Ruers T, Marchal G, Michel L. Local recurrence after hepatic radiofrequency coagulation: multivariate meta-analysis and review of contributing factors.  Ann Surg. 2005;  242 158-171
• 32 Mulier S, Ni Y, Miao Y, Rosiere A, Khoury A, Marchal G, Michel L. Size and geometry of hepatic radiofrequency lesions.  Eur J Surg Oncol. 2003;  29 867-878
• 33 Ng K K, Lam C M, Poon R T, Shek T W, Fan S T, Wong J. Delayed portal vein thrombosis after experimental radiofrequency ablation near the main portal vein.  Br J Surg. 2004;  91 632-639
• 34 Patterson E J, Scudamore C H, Owen D A, Nagy A G, Buczkowski A K. Radiofrequency ablation of porcine liver in vivo: effects of blood flow and treatment time on lesion size.  Ann Surg. 1998;  227 559-565
• 35 Pawlik T M, Izzo F, Cohen D S, Morris J S, Curley S A. Combined resection and radiofrequency ablation for advanced hepatic malignancies: results in 172 patients.  Ann Surg Oncol. 2003;  10 1059-1069
• 36 Pereira P L, Trubenbach J, Schenk M, Subke J, Kroeber S, Schaefer I, Remy C T, Schmidt D, Brieger J, Claussen C D. Radiofrequency ablation: in vivo comparison of four commercially available devices in pig livers.  Radiology. 2004;  232 482-490
• 37 Pompili M, Mirante V G, Rondinara G, Fassati L R, Piscaglia F, Agnes S, Covino M, Ravaioli M, Fagiuoli S, Gasbarrini G, Rapaccini G L. Percutaneous ablation procedures in cirrhotic patients with hepatocellular carcinoma submitted to liver transplantation: Assessment of efficacy at explant analysis and of safety for tumor recurrence.  Liver Transpl. 2005;  11 1117-1126
• 38 Poon R T, Ng K K, Lam C M, Ai V, Yuen J, Fan S T, Wong J. Learning curve for radiofrequency ablation of liver tumors: prospective analysis of initial 100 patients in a tertiary institution.  Ann Surg. 2004;  239 441-449
• 39 Rhim H. Complications of radiofrequency ablation in hepatocellular carcinoma.  Abdom Imaging. 2005;  30 409-418
• 40 Santambrogio R, Podda M, Zuin M, Bertolini E, Bruno S, Cornalba G P, Costa M, Montorsi M. Safety and efficacy of laparoscopic radiofrequency ablation of hepatocellular carcinoma in patients with liver cirrhosis.  Surg Endosc. 2003;  17 1826-1832
• 41 Shiina S, Teratani T, Obi S, Sato S, Tateishi R, Fujishima T, Ishikawa T, Koike Y, Yoshida H, Kawabe T, Omata M. A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma.  Gastroenterology. 2005;  129 122-130
• 42 Siperstein A, Garland A, Engle K, Rogers S, Berber E, String A, Foroutani A, Ryan T. Laparoscopic radiofrequency ablation of primary and metastatic liver tumors. Technical considerations.  Surg Endosc. 2000;  14 400-405
• 43 Solazzo S A, Liu Z, Lobo S M, Ahmed M, Hines-Peralta A U, Lenkinski R E, Goldberg S N. Radiofrequency ablation: importance of background tissue electrical conductivity - an agar phantom and computer modeling study.  Radiology. 2005;  236 495-502
• 44 Stippel D L, Bangard C, Kasper H U, Fischer J H, Holscher A H, Gossmann A. Experimental bile duct protection by intraductal cooling during radiofrequency ablation.  Br J Surg. 2005;  92 849-855
• 45 Stippel D L, Brochhagen H G, Arenja M, Hunkemoller J, Holscher A H, Beckurts K T. Variability of size and shape of necrosis induced by radiofrequency ablation in human livers: a volumetric evaluation.  Ann Surg Oncol. 2004;  11 420-425
• 46 Stippel D L, Tox U, Gossmann A, Beckurts K T, Holscher A H. Successful treatment of radiofrequency-induced biliary lesions by interventional endoscopic retrograde cholangiography (ERC).  Surg Endosc. 2003;  17 1965-1970
• 47 Wiersinga W J, Jansen M C, Straatsburg I H, Davids P H, Klaase J M, Gouma D J, Van Gulik T M. Lesion progression with time and the effect of vascular occlusion following radiofrequency ablation of the liver.  Br J Surg. 2003;  90 306-312