Survival and intra-hepatic recurrences after laparoscopic radiofrequency of hepatocellular carcinoma in patients with liver cirrhosis. J Surg Oncol. 2005;89:218-225; discussion 225-226. [PMID: 15726623 DOI: 10.1002/jso.20204]

Patient Selection and Outcomes of Laparoscopic Microwave Ablation of Hepatocellular Carcinoma

Background: Laparoscopic microwave ablation (MWA) of hepatocellular carcinoma is underutilized and predictors of survival in this setting are not well characterized. Methods: The prognostic value of clinicopathologic variables was evaluated on progression-free survival (PFS) and overall survival (OS) by univariate and multivariate analyses. The aim of this study was to evaluate a preferred laparoscopic MWA approach in HCC patients that are not candidates for percutaneous ablation and further classify clinicopathologic factors that may predict survival outcomes following operative MWA in the setting of primary HCC. Results: 184 patients with HCC (median age 66, (33–86), 70% male) underwent laparoscopic MWA (N = 162, 88% laparoscopic) compared to 12% undergoing open MWA (N = 22). Median PFS was 29.3 months (0.2–170) and OS was 44.2 months (2.8–170). Ablation success was confirmed in 100% of patients. Ablation recurrence occurred in 3% (6/184), and local/hepatic recurrence occurred in 34%, at a median time of 19 months (9–18). Distant progression was noted in 8%. Median follow up was 34.1 months (6.4–170). Procedure-related complications were recorded in six (9%) patients with one 90-day mortality. Further, >1 lesion, AFP levels ≥ 80 ng/mL, and an “invader” on pre-operative radiology were associated with increased risk of progression (>1 lesion HR 2.92, 95% CI 1.06 –7.99, p = 0.04, AFP ≥ 80 ng/mL HR 4.16, 95% CI 1.71–10.15, p = 0.002, Invader HR 3.16, 95% CI 1.91–9.15, p = 0.002 ) and mortality (>1 lesion HR 3.62, 95% CI 1.21–10.81, p = 0.02], AFP ≥ 80 ng/mL HR 2.87, 95% CI 1.12–7.35, p = 0.01, Invader HR 3.32, 95% CI 1.21–9.81, p = 0.02). Conclusions: Preoperative lesion number, AFP ≥ 80 ng/mL, and an aggressive imaging characteristic (Invader) independently predict PFS and OS following laparoscopic operative MWA.

Early experience with laparoscopic treatment of liver tumors using a separable cluster electrode with a no-touch technique

Introduction

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Laparoscopic RFA has the benefit of direct visual control of the RFA procedure. Cluster electrodes (Octopus RF electrodes) can create a common ablation zone.

Aim

Using these two methods (laparoscopic approach and no touch technique), this present study evaluated the technical and clinical outcomes of early experience with laparoscopic RFA and a no-touch technique.

Material and methods

Between November 2015 and November 2018, 21 patients underwent laparoscopic RFA for hepatocellular carcinoma with a no-touch technique using cluster electrodes. Laparoscopic RFA is recommended for patients with a contraindication for surgical resection, patients wants and a relative contraindication for conventional percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct, or heart.

Results

In the 21 tumors, 2 were treated with a single electrode, 12 with 2 electrodes, and 7 tumors with 3 electrodes. The mean time of ablation per lesion was 20.43 ±8.77 min. There was no mortality, local tumor progression, delayed destructive biliary damage, or liver abscess at the follow-up computed tomography. No technical failures occurred.

Conclusions

Laparoscopic RFA can access lesions for which percutaneous RFA is contraindicated or risky. Cluster electrodes can create sufficient ablation zones without contact and can achieve a sufficient margin with a low complication rate and no tumor dissemination. Therefore, laparoscopic RFA with a no-touch technique might be a safe and feasible treatment for HCC tumor in selected patients.

Videolaparoscopic microwave ablation in patients with HCC at a European high-volume center: Results of 815 procedures

BACKGROUND

Videolaparoscopic (VL) microwave ablation (MWA) is not included in most of the international guidelines as a therapeutic option for hepatocellular carcinoma (HCC). Aim of this study was to assess the safety of VL MWA in patients with HCC for whom resection or percutaneous ablation is unsuitable.

METHODS

A retrospective analysis was performed on a prospective database of patients with HCC treated with VL MWA at our institution from 2009 to 2016. Patient demographics, operational characteristics, and complications were recorded. Statistical analysis was performed to identify safety profile, overall survival and recurrence rate.

RESULTS

A total of 815 VL MWA were performed in 674 patients with a mean age of 64 years. Patients had a mean Model for End-stage Liver Disease score of 10 (±3); 32.8% were Child B, 44.1% Barcelona Clinic Liver Cancer B-C. Perioperative mortality was 0.4%. Overall morbidity was 30.8%, with Dindo-Clavien complications ≥3 in 2%. The median length of stay was 2 days. In 43.1% VL MWA was the first-line therapy. Overall 1-, 3-, and 5-year survival rates were 81.9%, 54.9%, and 35.9%.

CONCLUSIONS

The present is the largest series of VL ablation and the bigger number of patients with HCC treated with MW reported nowadays. It confirms the safety of a minimally invasive procedure for patients with HCC when resection or percutaneous ablation is not feasible.

Laparoscopic Microwave Ablation of Hepatocellular Carcinoma at Liver Surface: Technique Effectiveness and Long-Term Outcomes

Background and Aims:

To evaluate long-term outcomes and prognostic factors of laparoscopic microwave ablation as a first-line treatment for hepatocellular carcinoma located at the liver surface not feasible for percutaneous ablation.

Methods:

51 consecutive patients receiving laparoscopic microwave ablation in our center between January 11, 2012, and July 31, 2014, were enrolled. Technique effectiveness (complete ablation or incomplete ablation) was evaluated 1 month postprocedure. Procedure-related complications were recorded. The influences of patients’ baseline characteristics on recurrence-free survival and overall survival were analyzed after a median follow-up of 34.0 (ranging 19.0-49.0) months.

Results:

Complete ablation was gained in 47 (92.2%) of the 51 patients. No patients died within 30 days of microwave ablation procedure. A total of 3 (5.9%) cases of complications were observed. Tumor progression/recurrence were observed in 40 patients (78.4%). The median recurrence-free survival and median overall survival of the total cohort was 11.0 months (95% confidence interval: 7.573-14.427) and 34.0 months (95% confidence interval: 27.244-40.756), respectively. Multivariate analysis identified alanine transaminase level and tumor number as independent significant prognosticators of recurrence-free survival whereas α-fetoprotein level as significant prognosticators of overall survival.

Conclusions:

As a first-line treatment, laparoscopic microwave ablation provides high technique effectiveness rate and is well tolerated in patients with hepatocellular carcinoma located at liver surface. Alanine transaminase and tumor number were significant predictors of recurrence-free survival, whereas α-fetoprotein level was significant predictor of overall survival. Laparoscopic microwave ablation might serve as a rational treatment option for patients with hepatocellular carcinoma with tumors at the liver surface, which merits validation in future perspective studies.

Needle track seeding after radiofrequency ablation for hepatocellular carcinoma: prevalence, impact, and management challenge

Neoplastic seeding may arise after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). A low risk of seeding after RFA (0–1.1%) has been reported, which may rise up to 2.5% if ablation followed diagnostic biopsy. Needle track seeding presents with one or multiple rounded nodules along the needle track located within the peritoneum, along the abdominal muscles, which were penetrated by the needle, pleural surface, or in the subcutaneous and cutaneous tissues. The most widely used method for the assessment of seeding nodules is ultrasound (US), which usually displays hypoechoic nodules with intralesional vascularization. Fine needle aspiration biopsy of the nodule suspicious for malignant implant is mandatory to confirm the diagnosis and plan therapy. Wide surgical excision is the treatment of choice for neoplastic seeding. Thanks to early diagnosis and prompt treatment, development of needle track seeding is not likely to affect the long-term survival of patients.

Comparison of Laparoscopic Microwave to Radiofrequency Ablation of Small Hepatocellular Carcinoma (≤3 cm)

BACKGROUND

Laparoscopic thermal ablation is a common alternative to surgical resection in treating hepatic tumors, particularly in those located in difficult-to-reach locations.

OBJECTIVE

The aim of this study was to compare the safety and long-term efficacy of laparoscopic radiofrequency ablation (RFA) and microwave ablation (MWA) in treating hepatocellular carcinoma (HCC).

METHOD

From February 2009 to May 2015, data from patients with HCC nodules who had undergone either laparoscopic MWA or laparoscopic RFA were examined. Complications, complete ablation rates, local tumor progression (LTP) rates, and disease-free and cumulative survival rates were compared between the two treatment groups.

RESULTS

A total of 154 patients with HCC (60 MWA and 94 RFA) were treated via the laparoscopic approach. Major complication rates were identified as 1 and 2 % in the RFA and MWA groups, respectively (p = 0.747). Complete ablation rates were 95 % for both treatment groups (p = 0.931), and LTP rates were 21.2 % for RFA and 8.3 % for MWA (p = 0.034). Disease-free survival rates at 5 years were 19 % in the RFA group and 12 % in the MWA group (p = 0.434), while cumulative survival rates at 5 years were 50 % in the RFA group and 37 % in the MWA group (p = 0.185).

CONCLUSION

Laparoscopic RFA and MWA appear to be safe in the treatment of early-stage HCC. The LTP rates were lower in the laparoscopic MWA group compared with the laparoscopic RFA group, but their respective overall and disease-free survival rates remained similar.

Laparoscopic ablation therapies or hepatic resection in cirrhotic patients with small hepatocellular carcinoma

BACKGROUND

The Barcelona Clinic Liver Cancer staging system recommends radiofrequency ablation as treatment of choice for patients with "small" (up to 2 cm in size) hepatocellular carcinoma.

AIMS

Aim of the study was to assess whether laparoscopic ablation therapies or hepatic resection could be proposed as alternative option if percutaneous approach is not feasible.

METHODS

Overall survival and tumour recurrence rate were compared in a retrospective cohort of 176 consecutive patients with small hepatocellular carcinoma on cirrhosis treated by laparoscopic ablation therapies or surgery. To balance the covariates between the two groups, a propensity case-matched analysis was developed to generate a matched sample, which included 76 patients in each arm.

RESULTS

Local tumour progression (p=0.005), intra-segmental recurrence (p=0.0001), and 5-year recurrence rates (80% vs. 60%; p=0.0014) were significantly higher in the ablation therapies group. The 5-year survival rate were 48% after ablation therapies and 69% after hepatic resection (p=0.0006). Multivariate analysis showed that MELD score, alpha-fetoprotein value, procedure category and intraoperative restaging were associated with survival, while the surgery was the only independent predictor of intra-hepatic recurrence.

CONCLUSIONS

The present study suggests that, if percutaneous ablation is not feasible, hepatic resection may be considered as a sound option in the treatment of small hepatocellular carcinoma.

Long-term outcome of laparoscopic ablation therapies for unresectable hepatocellular carcinoma: a single European center experience of 426 patients

BACKGROUND

Radiofrequency ablation (RFA) is widely used as a first-line option in patients with hepatocellular carcinoma (HCC). However, since percutaneous approach of RFA may be, in some cases, unfeasible by the tumor size and its location, laparoscopic ablation therapies (LATs) were used as an alternative. Objective of the present study was to assess the efficacy of laparoscopic ultrasound examination in addition to LATs in the treatment of HCC in patients not eligible for percutaneous RFA or surgical resection.

METHODS

Four hundred and twenty-six patients who underwent LATs were analyzed. Laparoscopic approach was offered to patients fulfilling at least one of the following criteria: (a) patients with a single nodule or up to three nodules smaller than 3 cm not suitable for liver transplantation or not eligible for HR because of severe portal hypertension, impaired liver function, or coexistent comorbidities; (b) patients not suitable for percutaneous RFA because of inconvenient tumor location; and (c) short-term recurrence of HCC (<3 months).

RESULTS

Technical success was achieved in one session in 396 patients (93 %). One-month mortality and morbidity rates were 0.23 % (1 patient) and 25 % (106 patients), respectively. During a median follow-up of 37.2 months (range 2-193) in the remaining 425 patients, 276 (65 %) developed intra-hepatic recurrence: It appeared as a local tumor progression in 65 cases (15 %). Patients median survival was 39 months (95 % CI 34.8-47.2), while overall survivals at 1, 3, and 5 years were 88, 55, and 34 %, respectively.

CONCLUSIONS

In the treatment of HCC, LATs proved to be a safe and effective technique, as they permit to treat with low-morbidity-rate lesions not manageable by percutaneous approach. Moreover, they allow achieving a more accurate staging of the disease in one-fifth of patients, thus better redefining the prognosis of such individuals.

Laparoscopic approach for down-staging in hepatocellular carcinoma patients who are candidates for liver transplantation

INTRODUCTION

The aim of this study was to assess the impact of laparoscopic thermoablation (LTA) and laparoscopic resection (LR) as neoadjuvant therapy before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC).

METHODS

From June 2005 to November 2010, 50 consecutive patients affected by HCC with liver cirrhosis were treated with LTA under ultrasound guidance or LR. Of them, 10 patients (mean age, 58.3 ± 5.59 years; male:female, 8:2) underwent OLT. They were mostly Child-Pugh class A (80%).

RESULTS

A LTA of 12 nodules was achieved in 7 patients and an LR of 3 HCC nodules in the other 3 subjects. The mean length of surgery was 163 minutes (range; 60-370). The mean hospital stay was 6.1 days. Transient mild postoperative liver failure was reported in 1 case. Complete tumor necrosis was observed in 10 thermoablated nodules (83.3%) via spiral computerized tomographic scan at 1 month after treatment; the resected patients showed absence of recurrence. All patients underwent OLT after a mean interval of 7 months. The histology of the native liver showed complete necrosis in 9/12 thermoablated nodules (75%); a recurrence at surgical site occurred in 1 patient in the resection group.

CONCLUSIONS

Laparoscopic ultrasound can be used in potential OLTs candidates to accurately stage HCC in advanced cirrhosis with minimal morbidity. LTA and LR proved to be safe and effective techniques for HCC patients, representing a valid "bridge" to OLT.

Laparoscopic-assisted ablation of hepatic tumors: a review

Thermal ablation of hepatic tumors has been an evolving field over the last two decades. It is used in the treatment of both primary and metastatic neoplasms, and with evolutions in the technology, there has been an increasing interest in treating lesions where hepatic resection is not an option. Laparoscopic or minimally invasive surgical procedures have also advanced during this same time period, and the interface of these tools has been associated with the genesis of a new approach for treating hepatic lesions which are located in difficult to reach locations or found immediately adjacent to other intra-abdominal organs. This review summarizes the published literature focusing on the treatment of primary and metastatic neoplasms located in the liver, including a review of outcomes.

Hepatocellular carcinoma: Clinical study of long-term survival and choice of treatment modalities

AIM: To analyze the prognostic factors of 5-year survival and 10-year survival in hepatocellular carcinoma (HCC) patients, and to explore the reasons for long-term survival and provide choice of treatment modalities for HCC patients.

METHODS: From January 1990 to October 2012, 8450 HCC patients were included in a prospective database compiled by the Information Center after hospital admission. Long-term surviving patients were included in a 10-year survival group (520 patients) and a 5-year survival group (1516 patients) for analysis.The long-term survival of HCC patients was defined as the survival of 5 years or longer. Clinical and biologic variables were assessed using univariate and multivariate analyses. The survival of patients was evaluated by follow-up data.

RESULTS: The long-term survival of HCC patients was associated with the number of lesions, liver cirrhosis and Child-Pugh classification. It was not found to be associated with tumor diameter, histological stage, and pretreatment level of serum α-fetoprotein. The differences in clinical factors between the 5-year survival and the 10-year survival were found to be the number of lesions, liver cirrhosis, Child-Pugh classification, and time elapsed until first recurrence or metastasis. The survival period of different treatment modalities in the patients who survived for 5 years and 10 years showed significant differences: (in order of significance) surgery alone > surgery-transcatheter arterial chemoembolization (TACE) > TACE-radiofrequency ablation (RFA) > TACE alone > surgery-TACE-RFA. The 10-year survival of HCC patients was not associated with the choice of treatment modality.

CONCLUSION: This retrospective study elucidated survival outcomes, prognostic factors affecting survival and treatment modalities in HCC patients.

Intraoperative ablation for small HCC not amenable for percutaneous radiofrequency ablation in Child A cirrhotic patients

BACKGROUND

Radiofrequency ablation (RFA) was initially started by radiologists as a percutaneous treatment, but surgeons started to use RFA by surgical approach for patients with tumors at locations difficult for the percutaneous procedure. The aim was to evaluate the results of intraoperative RFA for small hepatocellular carcinomas (HCCs) (<3 cm) in locations difficult for a percutaneous approach.

METHODS

Two hundred forty-seven patients with small solitary HCC (<3 cm) were treated; 196 via percutaneous RFA while 51 patients presented at sites not amenable for percutaneous route. Twenty-seven out of 51 patients underwent surgical resection, while 24/51 patients underwent intraoperative RFA.

RESULTS

The location and depth of the tumor from the liver capsule was the only significant factors in the choice of the surgeon between resection and RFA. RFA was successful in all tumors (complete ablation rate of 100 %). In the surgery group, all patients achieved R0 resection. Complication rate was comparable (p = 1.0). After a median follow-up of 37 months (range, 10-45 months), no tumors showed neither local progression nor local recurrence and no significant difference was observed between two groups as regards early recurrence and number of de novo lesions (p = 0.49). One-year and 3-year survival rates were 93 % and 81 %, respectively, in the resection group comparable to the corresponding rates of 92 % and 74 % in the RFA group (p = 0.9).

CONCLUSION

For small HCC in locations difficult for a percutaneous approach, intraoperative RFA can be an alternative option for deep-seated tumors necessitating more than one segmentectomy achieving similar tumor control, and overall and disease-free survival.

Novel non-trocar technique for laparoscopic radiofrequency ablation

We have developed a novel insertion method, a non-trocar technique (NTT), for laparoscopic radiofrequency ablation, whereby an ablation needle, guided by a 14.8-mm echo probe (PVM-787LA; Toshiba, Tokyo, Japan), accurately and easily punctures the target tumor in the liver. By existing methods, an ablation needle is inserted into the abdominal cavity through a puncture hole away from the echo probe because of the presence of a 15-mm trocar. Under such circumstances, fitting and sliding an ablation needle along the groove of the probe into the abdominal cavity is difficult because of the longitudinal dissociation between the needle and the probe. To avoid this dissociation, an echo probe is inserted directly through the small incision from which the 12-mm trocar is withdrawn and an ablation needle is introduced directly into the abdominal cavity through a puncture hole adjacent to and slid along the groove of the probe.

Recurrent hepatocellular carcinoma successfully treated with laparoscopic thermal ablation

BACKGROUND

Aggressive treatment of intrahepatic recurrence of hepatocellular carcinoma (HCC) increases patients' survival. This study aimed to evaluate laparoscopic thermal ablation (TA) in the treatment of intrahepatic HCC recurrences.

METHODS

A retrospective analysis was performed on 88 patients (REC group) who underwent laparoscopic TA after prior TA (66 patients.) or partial hepatic resection (HR) (22 patients) as initial local treatment. Another 170 patients with primary HCC tumors (PRIM group) were regarded as the control group.

RESULTS

The postoperative morbidity rates were similar for the patients with prior TA (18%) and those with prior HR (21%) (nonsignificant difference [NS]). The overall survival rates were not significantly different between the two groups (3-year survival rates of 59 and 78%, respectively; P = 0.1662). Moreover, the disease-free survival (DFS) rates did not differ significantly between the patients with prior TA and those with prior HR (3-year DFS of 21 and 8%, respectively; P = 0.1911). The incidences of morbidity in the whole REC (21%) and PRIM (20%) groups were similar (P = NS), and no mortality occurred in either group (0%). The cumulative 3-year survival rate was 63% in the REC group and 59% in the PRIM group (P = 0.5739), whereas the 3-year DFS rate was 17% in the REC group and 22% in the PRIM group (P = 0.5266).

CONCLUSION

Laparoscopic TA can be performed safely and may be effective for intrahepatic HCC recurrence after prior TA or HR. It leads to survival and DFS rates similar to those obtained using laparoscopic TA for primary HCC without increasing morbidity. Laparoscopic TA could be proposed as first-line treatment of intrahepatic HCC recurrence for selected patients.

Hepatic resection for "BCLC stage A" hepatocellular carcinoma. The prognostic role of alpha-fetoprotein

BACKGROUND

Our aim was to assess the capability of Barcelona Clinic Liver Cancer (BCLC) staging system in allocating stage A patients to hepatic resection (HR) and the effect on survival.

METHODS

We enrolled 132 patients with hepatocellular carcinoma (HCC) amenable to HR. All patients underwent ultrasound (US)-guided anatomical resection (≤2 segments) and then postoperative results were evaluated.

RESULTS

Results showed 95% of patients were Child A, 49% in BCLC A1, 21% in A2, 6% in A3, and 24% in A4. No 30-day mortality occurred. Overall survival got worse from A1 to A4 (P = 0.0271), while no differences were found in Childs A patients with or without portal hypertension (P = 0.1674). Multivariate analysis (Cox model) shows that only AFP (<20 ng/ml) was an independent predictor of survival: If the AFP is incorporated in BCLC staging system (all A1 and A2 patients with abnormal AFP levels were included in A3 subgroup), 5-year survival rate including normal AFP for A1 was 57% and for A2 was 65%, whereas the survival rates impaired in the worst candidates (5-year survival rate including AFP abnormal for A3 and A4 was 36%; P = 0.002). So, introducing AFP in BCLC classification it is possible to simplify the algorithm in only 2 classes, well-separated in survival curves (class 1 [AFP-]: 60%; class 2 [AFP+]: 37%; P = 0.0001).

CONCLUSION

Our experience stressed the high value of BCLC system in staging of patients with HCC, but underlined that in selected patients (normal AFP) even A2 group may benefit from HR with a good survival.

Intraoperative ultrasound score to predict recurrent hepatocellular carcinoma after radical treatments

Despite the high complete necrosis rate of radio-frequency ablation (RFA) or the complete removal following curative hepatic resection (HR), recurrent hepatocellular carcinoma (HCC) remains a significant problem. The aim of the study is to identify some intraoperative ultrasound (IOUS) patterns, predicting intrahepatic recurrences. From January 1997 to July 2009, 410 patients with HCC were treated (162 HR and 248 RFA through a surgical access). All patients were submitted to IOUS examination: 148 IOUS were performed during the laparotomic access while 262 IOUS were performed during the laparoscopic access. Primary HCC was classified according to diameter, HCC pattern (nodular or infiltrative), echogenicity (hyper- or hypo-echoic), echotexture (homogeneous or inhomogeneous), capsular invasion, mosaic pattern, nodule in nodule aspect and infiltration of portal vessels. Number of HCC nodules was also considered. Multivariate analysis (Cox model) was performed to determine features associated with recurrent HCC using IOUS patterns that independently predicted recurrent HCC, a IOUS score was developed. The patients were followed for 3-127 months, (median follow-up: 21.5 months). In 220 patients (54%), intrahepatic recurrences occurred. In 155 patients (38%), distant intrahepatic recurrences arose in different segments at the primary tumor site. In 65 HCC cases (16%), local recurrences were found. At multivariate analysis, multiple nodules, HCC diameter (>20 mm), HCC pattern (infiltrative), hyperechoic nodule and portal infiltration were statistically significant for risk factor of intrahepatic recurrences. Therefore, a IOUS scoring system was calculated on the basis of multivariate analysis and identified three risk categories of patients: in group 1 recurrences occurred in 37%, group 2 in 46% and group 3 in 66% (p = 0.0001). IOUS is an accurate staging tool during "surgical" procedures. This study showed an added value of IOUS: it permitted to identify ultrasound patterns, which can predict the risk of HCC recurrences. The calculated IOUS score permits to intraoperatively evaluate the actual surgical choice and to program the best treatment strategies during the follow-up period.

Long-term results of hepatic resection combined with intraoperative local ablation therapy for patients with multinodular hepatocellular carcinomas

BACKGROUND

Recently, local ablation therapy has been widely used for treatment of small hepatocellular carcinoma (HCC). The present study assessed the outcome of hepatic resection combined with intraoperative local ablation therapy in patients with multinodular HCCs.

METHODS

Forty-one patients with initial and multinodular HCCs underwent hepatic resection combined with intraoperative local ablation therapy. The mean maximum diameter of all tumors was 3.8 cm (range 2.1-16.0 cm), and the mean number of nodules was 3.2 (range 2-11). We evaluated the survival rates and assessed the prognostic factors associated with overall survival rates using Cox proportional hazard models.

RESULTS

Intraoperative local ablation therapy was completed in all patients with no evidence of residual viable tumor on the first postoperative computed tomography (CT) scan. The 3-, 5- and 7-year overall survival rates were 84.3%, 61.2%, and 61.2%, respectively. Patients with preoperative des-gamma carboxyprothrombin (DCP) level >300 mAU/ml showed significantly worse overall survival than those with DCP level <or=300 mAU/ml (P < 0.01).

CONCLUSIONS

Hepatic resection combined with intraoperative local ablation therapy is effective for multinodular HCCs. DCP >300 mAU/ml was a significant prognostic factor of long-term overall survival.

Surgical resection versus laparoscopic radiofrequency ablation in patients with hepatocellular carcinoma and Child-Pugh class a liver cirrhosis

BACKGROUND

This study compared two homogeneous groups of patients submitted to either surgical resection (HR) or laparoscopic radiofrequency ablation (LRFA) for the treatment of hepatocellular carcinoma (HCC). When compatible with the liver functional reserve, HR remains the treatment of choice for HCC, while LRFA seems to be a promising, less invasive alternative. We thus compared HR or LRFA for short- and long-term outcomes in patients with a single HCC nodule and Child-Pugh class A liver cirrhosis.

METHODS

We enrolled 152 cirrhotic patients out of 372 cases consecutively evaluated for HCC. Enrolled patients with similar baseline characteristics underwent HR (n = 78) or LRFA (n = 74), in both cases with intraoperative ultrasonography, and they were then followed for similar durations (mean +/- standard deviation, 36.2 +/- 23.5 months for HR vs. 38.2 +/- 28.4 for LRFA). Outcomes included short- and long-term morbidity, HCC recurrence, and overall survival.

RESULTS

Short-term morbidity was far higher in the HR group while, during follow-up, HCC recurrence (mainly local) was more frequent in patients treated with LRFA. More importantly, baseline alfa-fetoprotein levels and early HCC recurrence after treatment greatly influenced overall survival, while the use of HR or LRFA did not predict it. On the other hand, HCC recurrence was found to be determined by the surgical approach and ultrasound characteristics of the tumor.

CONCLUSIONS

Our data were obtained from a large number of HCC cases and support similar survival rates after HR or LRFA for single HCC nodules on Child-Pugh class A liver cirrhosis, despite a marked increase in HCC recurrence rates after LRFA.

Laparoscopic radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Although the percutaneous approach is less invasive and is considered the first choice, RFA with laparoscopic guidance is highly recommended for patients with a relative contraindication for percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct and heart. Recent advances in laparoscopic ultrasound have widened the indication for laparoscopic ablation. In the present paper, we review the indications, advantages, prognosis and safety of laparoscopic RFA for hepatocellular carcinoma.

Clinical application of laparoscopic ultrasonography in radiofrequency ablation for hepatic cancer

AIM: To evaluate 1aparoscopic ultrasonography in radiofrequency ablation (RFA) for hepatic cancer.

METHODS: A total of 15 patients with 20 hepatic cancer 2.5-7.3 cm in diameter with the mean size of 4.5 cm, were treated by laparoscopic radiofrequency ablation therapy under laparoscopic ultrasound guidance at our hospital form September 2007 to April 2008. One lesion was found in 12 patients, two lesions in 1 patient, and three lesions in 2 patients. Hepatitis B positive was diagnosed preoperatively in 10 patients, and hepatitis C positive in 1 patient. There were eleven patients with liver cirrhosis and nine patients with chronic calculous cholecystitis. All patients were followed up with helical computed tomographie (CT) scan and ultrasonography.

RESULTS: Laparoscopic RFA therapy was performed successfully in 12 patients. 8 of 15 patients were performed laparoscopie cholecystectomy at the same time. The mean RFA time per lesion was 40.2 ± 12.3 min, the mean total operation time was 98.7 ± 28.5 min, and the mean blood loss was 145.3 ± 82.8 mL. No specific complications developed during or after RFA therapy. During a mean follow-up period of 8 months, there were 4 patients with loca1 recurrence at the ablation site, 1 patient having a new malignant nodule, on whom percutaneous RFA therapy was performed successfully. When two of these patients took a third regular (check) reexamination, they were diagnosed with recurrent primary liver cancer and were recommended to undergo liver transplantation. The other 13 patients survived.

CONCLUSION: Laparoscopic ultrasonography has become a very useful means in laparoscopic radiofrequency ablation therapy for patients with hepatic cancer.

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection.

METHODS

A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound.

RESULTS

From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8).

CONCLUSION

Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

Intraoperative radiofrequency ablation for hepatocellular carcinoma: long-term results in a large series

BACKGROUND

Intraoperative radiofrequency (RF) ablation with or without surgical resection currently plays one of important roles in modern hepatocellular carcinoma (HCC) therapy. We evaluated long-term follow-up results including prognostic factors of intraoperative RF ablation for HCC that was difficult to treat percutaneously.

METHODS

A total of 133 patients (male, 22 female, mean age 55.8 years) underwent intraoperative RF ablations for 200 HCCs (follow-up period 3.0-79.7 months, median 22.3 months). Hepatic resection was also performed in 29 patients. Reasons for the intraoperative procedure included no safe electrode path (n = 59), excessive tumor burden (n = 41), nonvisualization of the HCC on ultrasonography (n = 20), and risk of collateral thermal damage to adjacent organs (n = 13). We evaluated the technique effectiveness rate at 1 month computed tomography (CT), cumulative local tumor progression rate, cumulative disease-free and overall survival rates, and complications. We also sought significant prognostic factors for overall survival.

RESULTS

The technique effectiveness at 1 month was 94.7% (126/133). The cumulative local tumor progression rates at 1 and 3 years were 4.9% and 8.8%, respectively. The cumulative disease-free and overall survival rates at 1, 3 and 5 years were 51.8%, 21.3%, and 16.0% and 92.3%, 72.6%, and 46.5%, respectively. Major complications occurred in nine patients (6.8%). Procedure-related mortality was 1.5% (2/133). The patients treated for recurrent HCC (P = 0.003) or with high serum alpha-fetoprotein levels (P = 0.009) had poor survival by multivariate analysis.

CONCLUSION

The results of this study showed that intraoperative radiofrequency ablation with or without hepatic resection is a safe and effective treatment for hepatocellular carcinoma in patients who are not candidates for the percutaneous approach.

Laparoscopic radiofrequency ablation of hepatocellular carcinoma: A critical review from the surgeon's perspective

BACKGROUND

The treatment of choice for hepatocellular carcinoma (HCC) is surgical resection but only a small percentage of patients are operative candidates. Percutaneous radiofrequency interstitial thermal ablation (RFA) has proved to be effective in the treatment of unresectable HCC. However, there is a sub-group of patients who may benefit from a laparoscopic rather than a percutaneous approach. Laparoscopic RFA offers the combined advantages of improved tumor staging based on the intracorporeal ultrasound examination and safer access to liver lesions that are difficult or impossible to treat with a percutaneous approach. The aim of our review was to evaluate the advantages and limitations of the laparoscopic approach, according to the criteria of evidence-based medicine.

CONCLUSIONS

Laparoscopic RFA of HCC proved to be a safe and effective technique, at least in terms of the short- and mid-term results. This technique may be indicated in selected cases of HCC when percutaneous RFA is very difficult or contraindicated.

Laparoscopic radiofrequency of hepatocellular carcinoma using ultrasound-guided selective intrahepatic vascular occlusion

BACKGROUND

The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are operative candidates. The authors aimed to assess a novel operative combination of laparoscopic radiofrequency (LRF) with a selective intrahepatic vascular occlusion (SIHVO) to obtain an increased rate of total necrosis and a reduced rate of local HCC recurrences.

METHODS

For this study, 37 patients with HCC in liver cirrhosis were submitted to LRF with SIHVO. An LRF was indicated for patients not amenable to liver resection who evidenced at least one of the following criteria: severe impairment of the coagulation tests, large tumors (but <5 cm) or multiple lesions requiring repeated punctures, superficial lesions adjacent to visceral structures, deep-sited lesions with a very difficult or impossible percutaneous approach, and short-term recurrence of HCC after percutaneous loco-regional therapies.

RESULTS

Laparoscopic ultrasound identified seven new malignant lesions (19%) undetected by preoperative imaging. There was no operative mortality. Of the 37 patients, 31 experienced no complications (84%). Computed tomography (CT) evaluation 1 month after treatment showed that a complete response with 100% necrosis had been achieved for all the patients (100%). During the follow-up period (mean, 11.8 +/- 8.2 months), new malignant nodules developed in 14 patients (42%), and 36% of these recurrences were located in the same treated segment of the HCC.

CONCLUSIONS

The combined LRF and SIHVO procedure proved to be a safe and effective technique at least in the short and mid term. In fact, it permitted the treatment of lesions not treatable using the percutaneous approach with a complete clearance, and it had a low morbidity rate.

Laparoscopic surface scanning and subsurface targeting: Implications for image-guided laparoscopic liver surgery

Segmental liver resection and locoregional ablative therapies are dependent upon accurate tumor localization to ensure safety as well as acceptable oncologic results. Because of the liver's limited external landmarks and complex internal anatomy, such tumor localization poses a technical challenge. Image guided therapies (IGT) address this problem by mapping the real-time, intraoperative position of surgical instruments onto preoperative tomographic imaging through a process called registration. Accuracy is critical to IGT and is a function of: 1) the registration technique, 2) the tissue characteristics, and 3) imaging techniques. The purpose of this study is to validate a novel method of registration using an endoscopic Laser Range Scanner (eLRS) and demonstrate its applicability to laparoscopic liver surgery. Six radiopaque targets were inserted into an ex-vivo bovine liver and a computed tomography (CT) scan was obtained. Using the eLRS, the liver surface was scanned and a surface-based registration was constructed to predict the position of the intraparenchymal targets. The target registration error (TRE) achieved using our surface-based registration was 2.4 +/- 1.0 mm. A comparable TRE using traditional fiducial-based registration was 2.6 +/- 1.7 mm. Compared to traditional fiducial-based registration, laparoscopic surface scanning is able to predict the location of intraparenchymal liver targets with similar accuracy and rate of data acquisition.

Thermo-ablation par radiofréquence des tumeurs hépatiques

The basic principle of radiofrequency ablation is that the deposit of electromagnetic energy in a tumor causes heat ("cooks the tumor") and thereby destroys it. In the liver, this ablation may be performed percutaneously (by needles) or surgically (laparotomy, laparoscopy). Guidance by an imaging technique is necessary: ultrasound, CT or magnetic resonance imaging. The principal hepatic indications are hepatocellular carcinoma and hepatic metastases smaller than <5 cm. There is no associated mortality and only slight morbidity, due principally to hemorrhage, infection or stenosis of the bile ducts. Results show a 5-year survival rate of 40% for hepatocellular carcinoma and 22% for metastases.

Morbidity and mortality of laparoscopic vs. open radiofrequency ablation for hepatic malignancies

AIMS

Surgical radiofrequency ablation (RFA) of hepatic malignancies is associated with superior oncological outcome as compared to percutaneous RFA. The aim of this prospective non-randomized cohort study was to compare morbidity and mortality of laparoscopic (LRFA) vs. open (ORFA) radiofrequency ablation of liver cancer.

METHODS

Between October 1999 and November 2006, RFA was performed in 154 consecutive patients (percutaneous 12, LRFA 93, ORFA 49) for a total of 291 hepatic tumours (HCC 81, colorectal metastases 157, other 53). Seventy-four patients simultaneously underwent additional surgery. Laparoscopic RFA was performed in 45/54 patients with HCC, and in 44/54 patients with cirrhosis. Laparotomy was performed in 14/22 patients who underwent simultaneous colorectal resection, and in 12/22 patients with hepatic resection.

RESULTS

Postoperative complications occurred in 25 patients with subsequent mortality in 2. As compared with LRFA, ORFA was associated with significantly (p<0.01) higher intra-operative blood loss (median 20 (range 0-1700) vs. 10 (0-900) ml), longer duration of surgery (180 (25-440) vs. 75 (30-390) min), more postoperative complications (17 vs. 8), and longer postoperative hospital stay (8 (1-127) vs. 4 (1-51) d). According to the therapy-oriented severity grading system (TOSGS) classification, postoperative complications in the ORFA-group were more severe than those in the LRFA-group (p<0.01). These findings were consistent in patients without simultaneous colorectal and/or hepatic resection and in patients with liver tumours measuring 3cm or less. In univariate analysis the following factors were significantly (p<0.01) related to the presence of postoperative complications: simultaneous colorectal resection, laparotomy, duration of surgery, tumour location in right liver, liver segment 7 (p=0.01), absence of cirrhosis (p=0.02), liver segment 8 (p=0.03), and metastatic liver cancer (p=0.04).

CONCLUSION

LRFA for hepatic malignancies seems preferable above ORFA, provided good patient selection, surgical expertise, and long-term oncological control.

Impact of intraoperative ultrasonography in laparoscopic liver surgery

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases.

METHODS

A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2-6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS).

RESULTS

From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29-79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 +/- 50 min (median, 150 min; range, 60-250 min), and the perioperative blood loss was 190 +/- 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 +/- 4.9 days (median, 6 days; range, 2-25 days) and 5.6 +/-1.4 days (median, 6 days; range, 2-8 days) for the 15 laparoscopic patients.

CONCLUSION

Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.

Management of hepatocellular cancer

The nearly ubiquitous association of hepatocellular cancer (HCC) with underlying liver dysfunction portends a dismal prognosis. At the time of presentation with HCC, many patients have advanced cirrhosis that precludes effective therapy. Important prognostic factors include characteristics of the tumor (size, location, involvement of major blood vessels) and the functional state of the liver (quantified by synthetic function and portal hypertension). Localized tumors in a noncirrhotic liver may be treated successfully with surgical resection. In the setting of mild to moderate cirrhosis, localized therapy such as radiofrequency ablation, percutaneous ethanol ablation, chemoembolization, or Yttrium 90 microsphere infusion may be options, depending on the liver reserve and resources available. In the setting of advanced cirrhosis, treatment of the tumor may exacerbate liver decompensation, resulting in a shortened survival. In all of these instances, regardless of the therapy pursued, the underlying field defect with malignant potential remains in place. Liver transplantation has been employed to resolve both life-threatening problems, but it is fraught with many barriers. Appropriate patient selection and the use of adjuvant therapies are being pursued to improve the outcome of transplantation for HCC. Patients may have limited therapy options if they have poor performance status, are not surgical candidates, have a tumor that extends into the main portal vein, or have metastases to distant lymph nodes or organs. Chemotherapy is of marginal efficacy. Emerging therapies exploiting molecular targets are being explored with some promise.