Robert M. Eisele

Ziele: Zur Behandlung hepatozellulärer Karzinomrezidive nach initialer chirurgischer Therapie ist bislang kein Standardverfahren etabliert. Die Radiofrequenzablation (RFA) oder die wiederholte Resektion repräsentieren therapeutische Alternativen. In der vorliegenden Arbeit werden beide Methoden retrospektiv verglichen. Methode: Aus zwei prospektiven Datenbanken einer einzelnen Institution wurden 54 Patienten identifiziert, die entweder eine RFA (n=27, Gruppe 1) oder eine Resektion (n=27, Gruppe 2) bei der Diagnose eines de novo-HCC-Rezidivs erhielten. Die initiale Behandlung umfasste 15 Erstresektionen und 12 RFAs in Gruppe 1 sowie 25 Erstresektionen und 2 RFAs in Gruppe 2. Beide Methoden wurden hinsichtlich Überleben, tumorfreiem Überleben, demografischen und tumorbiologischen Daten verglichen. Ergebnis: Das Überleben unterschied sich nicht nach RFA (median 40 Monate) oder Resektion (48 Monate, p=0.641, logRank-Test). Im tumorfreien Überleben zeigt sich ein deutlicher, statistisch aber nicht signifikanter Vorteil für die Resektion (29 vs. 15 Monate, p=0.07, logRank-Test). Beide Gruppen unterschieden sich zum Teil signifikant voneinander: RFA wurde bei den früheren Rezidiven (21 vs. 39 Monate, pSchlussfolgerung: RFA und Resektion sind gleichermaßen geeignet zur Therapie von HCC-Rezidiven nach initialer chirurgischer Therapie. Die RFA wird eher beim Frührezidiv, beim zirrhotischen Patienten und beim kleineren Tumor bevorzugt. Im rezidivfreien Überleben scheint die resezierende Therapie überlegen zu sein. Keywords: Hepatozelluläres Karzinom, Rezidiv, Radiofrequenzablation, Leberteilresektion, Re-Resektion Korrespondierender Autor: Eisele RM Charité Campus Virchow-Klinikum, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Augustenburger Pl.1, 13353 Berlin E-Mail: robert_m.eisele@charite.de

Radiofrequency ablation (RFA) in the liver is contraindicated in the presence of bilioenteric anastomoses, because it predisposes to occasionally devastating infectious complications. The purpose of this single-center experience is to demonstrate the technical feasibility of such procedures. Patients with bilioenteric anastomoses were offered ultrasound-guided RFA, if an interdisciplinary tumor board endorsed this decision, or an intraoperative opportunity to achieve a tumor-free situation emerged. All procedures were carried out under general anesthesia in a surgical operation theatre. RFA was performed percutaneously (n=3) and open surgically (n=3) with two different types of monopolar devices. All patients received antibiotic prophylaxis with various different agents. Six patients with seven tumor nodules were treated. The average age of the patients was 59 +/- 7 years. Mean size of the tumors was 20 +/- 7 mm. Median follow up was 15 months. No infectious complication including intrahepatic abscess occurred. No local recurrence was detected. The presented data indicates the feasibility of RFA in patients with bilioenteric anastomoses, and infectious problems, namely intrahepatic abscess formation, do not inevitably occur. The role of antimicrobial prophylaxis remains unclear. The importance of ensuring an unobstructed and uninhibited biliary flow distally in the bilioenteric track is stressed.

Purpose: This study was designed to determine the best approach to radiofrequency ablation (RFA) in the liver.Methods: From a total of 41 procedures, 37 patients with 47 tumors were treated with RFA for metastatic disease. Indications included colorectal cancer (n = 28, 68%), neuroendocrine tumors (n = 2, 5%), gynecological primaries (n = 4, 10%), pancreatic/duodenal cancer (n = 2, 5%), and miscellaneous entities (n = 5, 12%). Mean follow‐up period was 18 (median, 18) months. All ways of approach to RFA were applied: percutaneous was chosen in 17 (41.5%), laparoscopic and hand‐assisted laparoscopic in 5 (12.2%), and open surgical in 19 cases (46.3%), and in 10 cases, RFA was combined with hepatic resection. The average maximum tumor size was 2.3 (range, 0.8–6) cm, and the mean number of nodules treated per patient in a single session was 1.3 (range, 1–3).Results: Overall survival was 59.5% at 2 years, recurrence‐free 2‐year survival was 12.6%, local tumor recurrence rate was 34%, and overall recurrence was 75.6%. Local tumor recurrence and disease‐free survival were significantly improved in the open surgically treated patients compared with the percutaneous treatment group (15.8% [n = 3] vs. 58.8% [n = 10] and 11.5 vs. 7.9 months, p < 0.01 [χ² test] and p < 0.05 [log‐rank test], respectively).Conclusions: Open surgical approach is superior to percutaneous access for RFA in metastatic hepatic disease.

Radiofrequency ablation (RFA) is now an established tool for treating unresectable liver tumors. Monopolar RFA is currently the accepted standard. However, the variability of the ablation shape and size impedes their further advancement. For this study, we were interested in the evaluation of a new bipolar device for technical feasibility. We have treated 6 patients [5 with hepatocellular carcinoma (HCC) one with metastatic disease] with a total of 7 tumors (6 HCCs, a solitary metastasis), using a new bipolar RFA device consisting of two separate needles, each with deployable electrodes. The treatment approaches included two percutaneous, three laparoscopic, and one open surgical. Average tumor size was 2.5 cm. Follow-up examinations were performed at intervals of 3 months and included computed tomography, (18)fluorodeoxyglucose positron emission tomography, magnetic resonance imaging and B-mode ultrasound. All tumors could be ablated successfully. Electrode placement was accurate and visualization in transabdominal, laparoscopic, or intraoperative ultrasound was excellent. Because of the requirement of positioning two needles simultaneously, particularly in the laparoscopic RFA, the procedures were more time-consuming (average, 104 minutes) than placing a single needle. Local tumor control after a follow-up of 6 months was 100%. No major complication occurred. Successful ablation of liver tumors, using the new bipolar device, is feasible and without complications. The procedure is technically demanding; however, local tumor control seems to be superior, as compared to other RFA devices. The long-term success of the procedure has yet to be evaluated.

Radiofrequency ablation (RFA) is an established treatment for hepatocellular carcinoma (HCC) in patients awaiting liver transplantation, due to its comparably low rate of complication and high effectiveness. Complications are thought to be rare and mostly self-limiting. By contrast, we report on a life-threatening complication and discuss it in the context of other complications. Out of a total of 149 RFA procedures, the incidence of major complications was 4% on a per-procedure basis. Mortality was 0.67%. Major complications included intractable pain, intrahepatic hematoma, skinburn at the site of patch electrode, and sectorial bile duct stricture. All complications occurred after percutaneous RFA. Highlighted is a young patient listed for liver transplantation because of HCC recurrence following hepatic resection, who was treated by percutaneous RFA as a bridging therapy until a suitable graft became available. Post-operatively, gastric perforation occurred due to heat injury of the gastric wall. The percutaneous RFA approach can occasionally lead to detrimental complications, particularly in patients with intra-abdominal adhesions, due to previous surgery if new intrahepatic malignant lesions accrue near the resection margin. Even widespread HCC disease can be treated effectively with orthotopic liver transplantation if the tumor growth is limited to the liver.