“How We Do it”—A Practical Approach to Hepatic Metastases Ablation Techniques

https://doi.org/10.1053/j.tvir.2013.08.005Get rights and content

Secondary liver malignancies are associated with significant mortality and morbidity if left untreated. Colorectal cancer is the most frequent origin of hepatic metastases. A multidisciplinary approach to the treatment of hepatic metastases includes medical, surgical, radiation and interventional oncology. The role of interventional oncology in the management of hepatic malignancies continues to evolve and applies to a large and continuous spectrum of metastatic disease, from the relatively small solitary metastasis to larger tumors and multifocal liver disease. Within the past 10 years, several publications of percutaneous image-guided ablation indicated the effectiveness and safety of this minimally invasive therapy for selected patients with limited number (arguably up to 4 metastases) of relatively small (less than 5 cm) hepatic metastases. Different image-guided procedures such radiofrequency, microwave, and laser cause thermal ablation and coagulation necrosis or cell death of the target tumor. Cryoablation, causing cell death via cellular freezing, has also been used. Recently, irreversible electroporation, a nonthermal modality, has also been used for liver tumor ablation. In the following section, we review the different liver ablation techniques, as well as indications for ablation, specific patient preparations, and different “tricks of the trade” that we use to achieve safe and effective liver tumor ablation. We also discuss appropriate imaging and clinical patient follow-up and potential complications of liver tumor ablation.

Section snippets

Patient Evaluation

Interventional oncologists have become important members of a multidisciplinary team managing a patient with cancer. As physicians treating cancer, interventional oncologists perform a thorough evaluation of the patient with cancer in dedicated clinic visits. A typical clinical evaluation should include the history of present illness, review of systems, medical and surgical history, assessment of performance status, family and social history, allergies, medications, physical examination,

Clinical Indications and Contraindications for Liver Tumor Ablation

The most common indications for image-guided ablation are the following:

  • 1.

    Patients with limited number (arguably less than 4) and small size (arguably less than 5 cm in largest diameter) of hepatic metastases that cannot undergo or refuse surgery.

  • 2.

    Lesions that are judged to be amenable to complete ablation with sufficient margin when using the appropriate ablation technique.Expanding from these criteria it should be noted that: The ideal tumor for percutaneous ablation is a solitary lesion with

Radiofrequency Ablation (RFA)

RFA involves the administration of energy with frequency of <900 kHz into tissue via needle electrodes. Ablation causes targeted tissue necrosis or cell death via ionic agitation of water molecules by elevating tissue temperature to lethal levels.

Highest success rates of ablation are achieved in patients with solitary colorectal liver metastases (CLM) or patients with small number of metastases <3 cm in the largest diameter.5

The principles and technical considerations of RFA are described

Irreversible Electroporation (IRE)

IRE technology (ie, Nanoknife System, AngioDynamics, Queensbury, NY) is a nonthermal ablation modality. Electroporation involves permeabilization of the cell membrane via application of electrical pulses across the cell, which creates permanent cell membrane pores (openings), causing lysis and cell death.7

IRE is presented in a separate review article in this issue.

Use of Anesthesia

A significant number of percutaneous ablation procedures can be done on an outpatient basis requiring short postprocedure observation before discharging the patient home, provided that patient is clinically stable and feeling well. As such, image-guided ablation is associated with significantly less morbidity and shorter length of hospital stay when compared with intraoperative interventions, such as laparoscopic resection, intraoperative ablation, or intraoperative resection.

Image-guided liver

Hemorrhage

Clinically significant bleeding is extremely rare especially after RF or MWA. Catastrophic bleeding was reported in early series of intraoperative cryoablation and was attributed to the thawing cycles causing liver fracture. Even in that scenario, the well-aware interventional radiologist, using current imaging modalities, would detect bleeding that could be managed with hepatic arterial embolization.12 The standard continuous electrophysiological monitoring of the patient during the procedure

Discussion and Outcomes of Ablation

A key concept when managing liver metastases with ablation is the “test-of-time’’ approach.24 Within this concept, patients who were candidates for liver resection underwent liver RFA instead. The patients in the trial were closely monitored with imaging to detect local, intrahepatic, or any other progression. This close observation allowed time for biology of the disease to express itself while the identified tumor was treated by ablation. During the follow-up period of this study, 98% of the

References (52)

  • A.I. Gomaa et al.

    Diagnosis of hepatocellular carcinoma

    World J Gastroenterol

    (2009)
  • B.B. Pua et al.

    Imaging to optimize liver tumor ablation

    Imaging Med

    (2010)
  • A.R. Gillams et al.

    Radio-frequency ablation of colorectal liver metastases in 167 patients

    Eur Radiol

    (2004)
  • F. Izzo

    Other thermal ablation techniques: Microwave and interstitial laser ablation of liver tumors

    Ann Surg Oncol

    (2003)
  • E.W. Lee et al.

    Advanced hepatic ablation technique for creating complete cell death: Irreversible electroporation

    Radiology

    (2010)
  • M.E. Allaf et al.

    Pain control requirements for percutaneous ablation of renal tumors: Cryoablation versus radiofrequency ablation—Initial observations

    Radiology

    (2005)
  • Ryan ER, Sofocleous CT, Schoder H, et al.: “Split-dose” technique for FDG PET-CT guided percutaneous ablation: A method...
  • J.L. Hinshaw et al.

    Radiofrequency ablation of peripheral liver tumors: Intraperitoneal 5% dextrose in water decreases postprocedural pain

    AJR Am J Roentgenol

    (2006)
  • T. de Baere et al.

    Percutaneous radiofrequency ablation of hepatic tumors during temporary venous occlusion

    AJR Am J Roentgenol

    (2002)
  • W.B. Ross et al.

    Cryotherapy of liver tumours—A practical guide

    HPB Surg

    (1995)
  • J.K. Seifert et al.

    Interleukin-6 and tumor necrosis factor-alpha levels following hepatic cryotherapy: Association with volume and duration of freezing

    World J Surg

    (1999)
  • A. Deodhar et al.

    Management of sepsis and recurrent abscess formation complicating radiofrequency ablation of pancreatic cancer liver metastasis and whipple resection

    J Intervent Oncol

    (2010)
  • I.S. Chang et al.

    Biloma formation after radiofrequency ablation of hepatocellular carcinoma: Incidence, imaging features, and clinical significance

    AJR Am J Roentgenol

    (2010)
  • J.P. Fox et al.

    Short-term outcomes of ablation therapy for hepatic tumors: Evidence from the 2006-2009 nationwide inpatient sample

    Ann Surg Oncol

    (2012)
  • T. Livraghi et al.

    Treatment of focal liver tumors with percutaneous radio-frequency ablation: Complications encountered in a multicenter study

    Radiology

    (2003)
  • H. Takaki et al.

    Frequency of and risk factors for complications after liver radiofrequency ablation under CT fluoroscopic guidance in 1500 sessions: Single-center experience

    AJR Am J Roentgenol

    (2013)

    • Cited by (0)

    View full text
    Copyright © 2013 Elsevier Inc. All rights reserved.