The safety of radiofrequency thermal ablation in the treatment of liver malignancies

https://doi.org/10.1016/j.ejso.2007.05.003Get rights and content

Abstract

Introduction

Radiofrequency ablation (RFA) has become widely accepted as an important adjunct, and sometimes a viable alternative, to liver surgery. The aims of this study are to assess the risks associated with percutaneous RFA and to discuss the indications and contraindications to its use.

Patients and methods

This is a review of 130 consecutive patients who were treated for primary (n = 92) and metastatic (n = 38) liver tumours. Only complications after percutaneous RFA (83 patients) were evaluated. Interesting case studies are included to highlight potential complications following RFA and their management.

Results

One patient died of perforation of the colon and five others had major complications. There were 15 minor complications. Local recurrence rates reached 30% overall, and a further 25 patients developed a new hepatic lesion, different from the one treated by RFA. Median disease-free survival was 13 months. Overall survival rates at 1, 2 and 5 years were 85.3%, 71.3% and 57.6%, respectively.

Conclusion

Percutaneous RFA is a safe and efficient technique but not free of complications and with potential fatal outcome. It is also associated with significant local recurrence rates. The procedure should only be performed following adequate training and the indication should always be discussed in multidisciplinary meetings. Patient's liver function and general health as well as tumour size and position must be considered. Intraoperative or video laparoscopic RFA is useful for superficial tumours in order to avoid damage to viscera surrounding the liver surface.

Introduction

Hepatocellular carcinoma (HCC) is one of the most frequently occurring tumours worldwide and usually occurs in cirrhotic livers.1 Orthotopic liver transplantation (OLT) can increase 5 year survival up to 75–92%.2, 3, 4 However, the small donor pool and the current guidance under the Milan criteria,4 make OLT an option to only a small number of patients. Surgical resection is rarely feasible due to multifocality of the tumour, the grade of cirrhosis or poor synthetic liver reserve.2, 3 Furthermore, recurrence rate following resection is high5, 6 and recurrences are often difficult to resect.

Similar issues are also found in cases of hepatic metastases from colorectal cancer (CRC), where current evidence suggests that surgery, when feasible, can significantly improve prognosis.7 However, even when using new adjuvant drugs such as Oxaliplatin and Irinotecan, the percentage of resectable patients is still only around 25–30%.8, 9 Furthermore, in metastatic CRC as in HCC, the rate of recurrence following surgical resection remains high5, 6, 10 and recurrences are often difficult to resect.

Therefore, alternative approaches such as parenchymal sparing surgeries or complementary techniques such as radiofrequency thermal ablation (RFA) have evolved for the management of patients with primary and secondary liver tumours, which are deemed unsuitable for surgical treatment. This may be because of comorbidity, tumour location, inadequate parenchymal reserve or when there is recurrence following previous liver resection.

The use of RFA has increased in the past decade, supported by satisfactory results11 and its superior efficacy when compared to other local therapies.12, 13 The use of RFA has extended to the treatment of other liver lesions,14 and it has been shown to have an important role, alone or in combination with surgery, in the treatment of patients with metastases from neuroendocrine tumours (NEM).15

Published data indicate low mortality and complication rates associated with RFA.16 However, fatal complications have been reported.17, 18 This procedure, therefore, should only be performed following guidance and adequate training, and the indications for treatment should always be discussed within the multidisciplinary team.

In this study we report our results, assess the risks associated with percutaneous RFA, and investigate the indications and contraindications to its use. We also report on four interesting cases encountered in our study, to highlight potential complications following RFA, and their management.

Section snippets

Patients and methods

Between May 1998 and January 2002, 130 consecutive patients (81 male and 49 female, mean age 65.5 years (SD 10.7; range 33–85 years)) were treated by RFA at our institution. Median follow-up was 24 months. We only analysed complications that occurred in the percutaneous RFA cases, as it is difficult, in laparoscopic and laparotomic RFA, to distinguish complications of RFA from general complications of surgery. All patients were informed about the rationale behind the choice of their treatment and

Epidemiology and clinical procedures

In our cohort of patients, there were 81 males and 49 females; mean age was 65.5 years (SD 10.7 years). Ninety-two patients were treated for HCC, 25 for colorectal metastases (M-CRC) and 13 for metastases of other tumours (M-O). One hundred and forty-eight RFA sessions were performed (107 for 92 patients with HCC; 28 for 25 patients with M-CRC and 13 for 13 patients with M-O). The mean number of passes required per patient was 1.49 (total number 260 passages). Of the 148 sessions performed, 98

Discussion

RFA is an effective technique for the treatment of selected hepatic tumours.11, 12, 13, 15 Mortality rates and the incidence of major and minor complications are low.16

In a multicentre Italian study of 2320 patients, approximately two-thirds HCC and one-third M-CRC, there was a mortality rate of 0.25% (6/2320) and the incidence of major complications was only 2.1%.16 These results demonstrate the safety of RFA, bearing in mind the often complicated nature of the patient group and the currently

Conclusion

In our experience percutaneous RFA was associated with acceptable morbidity and mortality rates. RFA is not free from risks or complications, which may have a major significance and are more dangerous in cirrhotic patients because of their general health and poor liver function. To reduce the risk of complications, caution should be taken when treating lesions near the proximal bile ducts, large vessels, diaphragm and gut. Tumour diameter and position, liver function and general health of the

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