rfa experience in nicosia general hospital (clm) p. hadjicostas,,m.dietis, c. antreou / surgical...
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RFA Experience In Nicosia General Hospital (CLM)
P. Hadjicostas,,M.Dietis, C. Antreou / Surgical Department
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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
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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
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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
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“ 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
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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
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The Cool-Tip™RF
System
Slide 7Ε
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Useful Tips
2. Always place the end of the Cool Tip needle to the distant end of Lesion.
Slide 5Δ
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Cool-tip™Radio Frequency Ablation
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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
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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
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Indications RFA
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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)
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RFA
- percutaneously (65-75%)
-Open Surgery
-Laparoscopic
(Treatment approach individualized in any given patient)
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If not resectable is ablated.
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Post – RFA
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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%
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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
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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%
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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
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Ablation Vs Resection
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Tension: Resection VS Ablation
Open Resection Ablation
Long Term Risk of Recurrence
Short Term Risk of QOL impairment
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Score Sheet
Short term QOL
Safety Access / Anatomy
Prognostic Recurrence Survival
Ablation
Resection
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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
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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
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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.
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Technical Method
1. Patient re-evaluation.
2. Operation theatre.
3. Presence of anesthesiologist, radiologist.
4. US guidance.
5. Single probe, triple probe, overlapping technique.
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Follow up
1. Patient follow up evaluation from specialized team.
2. Ablation CT scan re-evaluation. (1-6 months)
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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
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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)
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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
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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
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93% / 12m
59% / 24m
42% / 36m
92% / 12m
55% / 24m
39% / 36m
Abdalla et al, Annals of Surgery 2004
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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
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68% / 36m
43% / 36m
52% / 36m
20% / 36m
Abdalla et al, Annals of Surgery 2004
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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
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Berber et al, Journal of Clinical Oncology 2005
50% / 36m
65% / 36m
≤3cm
3 – 5cm
<5cm
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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
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Marginal Recurrence S/P-Hepatic Resection
Not zero but 1.2- 10.4% ( Mulier 2008)
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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
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Conclusion
1. Minimally invasive method. Low complications.
2. Well tolerated.
3. Low cost effective.
4. Easily repeatable.
5. Local recurrence?