Percutaneous ablation: current and future tools
Franco Brunello
Ecografia Digestiva – Gastro-Epatologia Az. Osp. S. Giovanni Battista di Torino
Ablative treatments:
Non-surgical techniques of in-site destruction of the neoplasia
Coagulative effect of ethanol
1986: PEI
PSIT PAI
MW Cryo
Proton beam HIFU
3D CRT
Electroporesis
Mono/Bi/multipolar RF Laser
2010: RF
History of ablation
Ablative treatments
• Abandoned – PSIT
– PAI
• Marginal-Local – Cryo
– Laser
– Proton beam – MCT (MW) – 3D CRT
– HIFU
– Bipolar RF – Multipolar RF
• Current
– Monopolar RF – PEI
• Under re-evaluation – MW
• Experimental
– Electroporesis
HCC stages and treatments
intermediate
very early early advanced terminal
Best
supportive care
TACE Sorafenib
Resection
Liver transplantation Ablative treatments
RE OLT Ablation TACE Sorafenib BSC
10 10 60 30 20 20
x 3 = 180-200
Incident HCC/year: 150
Gastro-Hepatology Dept.
S. Giovanni Battista Hospital, Turin
Ethanol injection
(today selected cases only)
• Chemical effect of a fluid (ethanol 95-98%)
• Multisession procedure
Radiofrequency (standard technique)
• Thermal effect of RF (450 kHz)
• Monosession procedure
Monopolar RF
• Most popular current technique
• different devices on the market
• Good safety
• Good technical effectiveness (lesion ≤ 30mm)
RF safety : deaths/major complications
• Mulier (Br J Surg 2002) 3670 0.5 8.9
• Livraghi (Radiology 2003) 2320 0.3 2.2
• Rhim (Radiographics 2003) 1139 0.09 2.4
• Kasugai (Oncology 2007) 2614 0.3 7.9
N D MC
Comparative RCT on PEI/RF
• 5 RCTs published
• 957 patients
• Survival advantage for the RF in the Far East studies
• Non evidence of survival advantage for the RF in the European studies
better local control in the RF arm, particularly in nodules >2cm
1. Lencioni et al, 2003 2. Lin et al, Gut 2005
3. Lin et al, Gastroenterology 2005 4. Sheena et al, Gastroenterology 2005
5. Brunello et al, Scand J gastroenterol 2008
Meta analytic studies
Cho et al Hepatology 2009
Orlando et al Am J Gastroenterol 2009
Local control
Overall survival
3yrs OS
Ablation treatments in our Dept.
(2001-2008 experience)
0 20 40 60 80 100 120 140 160 180 200
2001 2002 2003 2004 2005 2006 2007 2008
PEI RF MW Gastro-Hepatology Dept. S. Giovanni Battista Hospital, Turin - Italy
Limitations of RF: site
• Location
– Main bile
ducts/gallbladder – Hollow viscera
– Pericardium/pleura
• Superficial lesions
tumor seeding
• “Heat sink” effect
reduces the
temperature close to main blood vessels
Limitations of RF: size
2.5cm 2cm
>3cm
• 218 patients with single HCC<2cm
• Sustained complete response in 97.2%
• Perioperative mortality 0%
• Major complications 1.8%
• 5-years survival rate 68.5%
Hepatology 2007
35
Ø mediano=36 mm 70 esposizioni (media 2.0)
(1 cluster)
34
Ø mediano 36 mm 55 esposizioni (media 1.62)
(1 ago da 5.0cm)
34
Ø mediano 35 mm 50 esposizioni (media 1.47)
(14 volte esteso a 5cm)
70,58% risposta completa (dopo 1 anno: 47,05%)
78,78% risposta completa (dopo 1 anno: 58,06%)
63,63% risposta completa (dopo 1 anno 49.09%)
p= 0.3747 (χ square test)
HCC 31-50mm
Brunello et al ILCA Barcellona 2008
Microwaves
Microwaves
• Electromagnetic waves 900-2450 MHz
• Flip and rotation of water molecules
O H
H
MW: theoretical advantages over RF (1)
• Primarily active heating
• Broader zone of active heating
• Not related to electrical conductivity
• Not limited by tissue dessication/charring
MW: theoretical advantages over RF (2)
• Less affected by “heat sink“ effect
• Multiple antennas do not interfere (synergistic effect)
• No skin pads: no risk of burning
• No interference with US image
• Faster than RF
MW: asian experience (since 1999)
• Seki S et al Cancer 1999
• Lu MD et al Radiology 2001
• Shiina S et al Oncology 2002
• Dong B et al AJR 2003
• Morita T et al Gan to Cagacu Ryoho 2004
• Liang P et al Radiology 2005
• Seki S et al Endoscopy 2005
• Dong BW et al Zhonghua YiXue Za Zhi 2006
Eastern MW devices
• Microtaze (Heiwa
Electronics Industry, Inc, Tokio, Japan)
• FORSEA (Quighai Microwave
Electronic Institute,
Nanjing, China) 2450Mhz 1 antenna
Small volume of necrosis
Comparison RF
versusMW
• HCC <3cm
• No difference in
recurrence, survival and complications
• Lower recurrence rate for tumors > 3cm
treated by MW
Shibata, Radiology 2002 Lu, J Gastroenterol 2005
MW: western experience (since 2003)
• Wright AS et al Ann Surg Oncol 2003
• Simon CJ et al Radiographics 2005
• Simon CJ et al AJR 2006
• Iannitti DA et al HPB 2007
• Martin RCG et al J Surg Oncol 2007
• Hope WW et al J Gastrointest Surg 2008
• Boutros C et al Surgical Oncol 2009
USA MW devices
• Vivant (Vivant Medical Inc Mountain View, CA)
• MicroTherm X-100 (BSD Medical Corp, Salt Lake City, UT)
915MHz
Multiple antenna
European MW devices
• Acculis MTA TM (Microsulis Medical Ltd, Hampshire, UK)
• Amica (Hospital Service, Rome , Italy)
2450 MHz
Single/multiple antenna
Vivant ® (Vivant Medical Inc, USA)
915 MHz
Amica ® (Hospital Service, Rome , Italy)
2450 MHz
MW early experiences
• Large ablation may be obtained
• Tumors of 31-50mm could be more easily treated ?
MW: a pilot experience
• 10 patients with liver cirrhosis and HCC
• 11 lesions treated
• Diameter 31-80mm (2 with 55 and 80mm lesions)
• Percutaneous approach
• Amica ® (HS, Italy), 40-50W for 8-10 minutes
• US guidance
• Deep sedation (as for RF)
• Single session with 1 needle and 1-3 expositions
Results (1)
• Pt 1 40 PR OLT PR (85%)
• Pt 2 40 and 37 CR x2
• Pt 3 80 PR TACE
• Pt 4 38 CR
• Pt 5 39 CR CR follow up
• Pt 6 42 CR
• Pt 7 31 CR CR follow up
• Pt 8 50 CR
• Pt 9 32 CR
• Pt 10 55 PR OLT PR (85%)
Diameter Technical effectiveness Notes
Necrosis from MW (explanted liver)
Results (2)
• An early complete response was observed in 88% of the cases ≤50mm
• “Gain” of about 18% in comparison to our retrospective RF data
• No complication was observed
• Collateral effects similar to that of RF (2
patients with superficial lesions experienced prolonged pain)
