Intraoperative radiofrequency ablation (RFA) for irresectable liver malignancies

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Abstract

Aims. To evaluate the outcome of patients who received radiofrequency ablation (RFA) at open laparotomy in patients with irresectable liver malignancies.

Methods. Twenty-six consecutive patients who underwent explorative laparotomy and were found to be irresectable or who had been assessed not suitable for either resection or percutaneous RFA received intraoperative RFA. An expandable electrode (RITA Medical systems) was used. Follow-up comprised CT-scans in 6–12 week intervals.

Results. Patients' age ranged from 35 to 72 years (median 61). A variety of pathologies were treated. In 26 patients, 88 hepatic lesions were treated: 32 with resection and 56 with RFA. The mean diameter was 4.0±2.6 cm with a maximum of 10 cm. In 22 patients with hepatic metastases (18 colorectal, one leiomyosarcoma, one endometrium carcinoma, one renal cell carcinoma, one malignant phaeochromocytoma) 74 lesions (median 3.4 per patient) were treated (25 by resection, 49 by RFA). Eleven patients received simultaneous resection and RFA: resection of anatomical segments in six and atypical resection in seven patients. Procedure related complication rate was 19.2%. The mean follow-up was 14.6±9.2 months (2–36 months). Three patients developed recurrence at the site of previous RFA indicating incomplete ablation. The overall local control rate after one year was 92 and 90.9% for patients with colorectal liver metastases, respectively. Seventeen patients (65.4%) suffered from tumour progress. In 14 patients (53.9%) tumour occurred at new hepatic localisations and in five patients extrahepatic tumour relapse was diagnosed. Twelve patients have died so far (median survival 18 months, range 4–27). Nineteen patients had either completed a follow-up of at least 12 months or died within this period, resulting in an one year survival rate of 79% (80% for liver metastases).

Conclusion. Intraoperative RFA is a valuable tool in liver surgery which extends the surgical spectrum in cases of irresectable malignancies.

Introduction

Liver metastases of colorectal carcinoma are the most common secondary liver malignancies. Since the first resection of such tumours was performed in 19401 it has become generally accepted that resection offers the best therapeutic option. Five year survival rates of 35–45% after primary resection2., 3., 4. and of 21–57% after repeated resection5., 6., 7. have been reported. Completeness of tumour removal, number of lesions and tumour size have significant influence on survival.6., 7. The benefits of resection have been demonstrated also for patients with hepatic metastases of other origin.8., 9., 10., 11.

Due to extrahepatic disease or intrahepatic growth pattern only 10–25% of all patients with colorectal liver metastases are candidates for surgery.12., 13., 14. For all other patients treatment is palliative although a variety of cytostatic drugs have been studied and the role of novel agents is yet to be defined.15 Intratumoural ethanol injection, cryoablation, radiofrequency ablation (RFA), microwave ablation, laser induced thermo ablation (LITT) and high intensity focused ultrasound have been tested as therapeutic option to control disease in irresectable patients or as adjunct to liver surgery.16 RFA applied intraoperatively at open or laparoscopic surgery or percutaneously has been shown to be a relatively safe procedure by which effective local tumour control can be achieved.17., 18. It appears to bear less complications compared to cryoablation19 and is easier to apply intraoperatively than LITT. Nevertheless its precise role is still to be defined. We have used RFA during the past three years intraoperatively in patients assessed as irresectable. The aim of this study was to report the results for its use in open surgery.

Section snippets

Methods

In this study 26 patients (nine female, 17 male) from August 2000 to September 2003 with hepatic malignancies were included who either underwent explorative laparotomy and were found to be irresectable and received RFA or in whom resectability was already ruled out preoperatively and percutaneous RFA was not feasible. In some of the former cases (n=11) RFA was combined with simultaneous liver resection.

For RFA an expandable electrode with temperature control (RITA Medical Systems, USA) was

Patients and treatment

Patients age ranged from 24 to 72 years (median 61). Twenty-one patients had undergone operative therapy previously: 17 for colorectal cancer, one each for hepatocellular carcinoma, for adenocarcinoma of the endometrium, for leiomyosarcoma and for renal cell carcinoma. One patient each with liver metastasis (adenocarcinoma) of unknown primary (CUP-syndrome), with colorectal cancer and liver metastasis, with cholangiocarcinoma, with hepatocellular carcinoma and with metastasized

Discussion

Liver resection remains to be the best curative option for most hepatic malignancies, especially colorectal liver metastases. But due to size and distribution of tumour only a minority of these patients is resectable.12., 13., 14. Although imaging modalities have been improved tremendously throughout the past years the definitive identification of irresectable patients pre-operatively is often impossible.20 In these cases, an explorative laparotomy is performed. If it reveals irresectability

Conclusion

Intraoperative RFA alone or in combination with liver resection is a valuable new tool which extends the spectrum of liver surgery in cases where complete resection is not possible.

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