Feasibility, safety, and long-term efficacy of stereotactic radiofrequency ablation for tumors adjacent to the diaphragm in the hepatic dome: a case-control study

Successful diaphragm repair following radiofrequency ablation for renal cell carcinoma: A case report

INTRODUCTION AND IMPORTANCE

This study aimed to assess the effectiveness of surgical intervention in treating traumatic diaphragmatic rupture accompanied by pleural empyema resulting from radiofrequency ablation for renal cell carcinoma.

CASE PRESENTATION

A 72-year-old female patient underwent radiofrequency ablation at our institution's urology department to address a 4-cm tumor in the left upper kidney detected during routine health screening. Subsequently, the patient experienced persistent fever from the 5th day post- procedure. Chest radiography revealed increased opacity in the left lower lung, prompting further evaluation with contrast-enhanced chest computed tomography. Examination revealed multiple loculated effusions and discernible diaphragmatic defects. Consequently, the patient was referred to the department of thoracic surgery, where an emergency surgery was performed. The surgical procedure was performed under general anesthesia the following day, revealing a 4-centimeter defect in the diaphragm along with damaged surrounding tissue and multiple loculated empyema sacs within the thoracic cavity. The intervention included excision of the empyema sacs, extensive irrigation, and reconstruction of the diaphragm using a 2-mm Gore- Tex membrane. One week postoperatively, the patient was discharged without any complications related to the procedure.

CLINICAL DISCUSSION

Although radiofrequency ablation is considered a relatively safe procedure with low complication rates, vigilant post-procedural monitoring is essential for detecting potentially serious complications.

CONCLUSION

Surgical intervention remains the preferred approach for the repair of traumatic diaphragmatic ruptures and is typically performed via thoracotomy.

Stereotactic ablation: A game changer?

For both primary and metastatic liver cancer, thermal ablation represents an interesting alternative to surgery. However, except for a small fraction of patients, conventional ultrasound- and CT-guided single-probe approaches have not achieved oncologic outcomes comparable with surgery. In this overview, we describe our stereotactic ablation workflow and discuss the short- and long-term results of stereotactic radiofrequency ablation (SRFA) and stereotactic microwave ablation (SMWA) for the treatment of primary and secondary liver tumours. The advantages of this method are discussed together with a summary of the existing stereotactic techniques for thermal ablation and the clinical data that support them. Stereotactic ablation is based on an optical navigation system and a specialized aiming tool. The workflow includes advanced three-dimensional planning, precise needle/probe placements according to the plan and intraoperative image fusion to check the needle positions and the ablation margins. Stereotactic ablation offers all the advantages of a minimally invasive procedure while producing oncological results comparable with surgery. The number of locally treatable liver cancers may be significantly expanded with these cutting-edge instruments and methods. We firmly believe that it can become a cornerstone in the treatment of liver cancers.

Reliability of Stereotactic Radiofrequency Ablation (SRFA) for Malignant Liver Tumors: Novice versus Experienced Operators

PURPOSE

To compare the results of a novice with those of experienced interventional radiologists (IRs) for stereotactic radiofrequency ablation (SRFA) of malignant liver tumors in terms of safety, technical success, and local tumor control.

METHODS

A database, including all SRFA procedures performed in a single center between January 2011 and December 2018 was retrospectively analyzed. A total of 39 ablation sessions performed by a novice IR were compared to the results of three more experienced IRs. Comparative SRFA sessions were selected using propensity score matching considering tumor type, age, sex, tumor size, and tumor number as matching variables. Overall, 549 target tumors were treated in 273 sessions. Median tumor size was 2.2 cm (1.0-8.5 cm) for 178 hepatocellular carcinomas (HCCs) and 3.0 cm (0.5-13.0 cm) for 371 metastases. A median of 2 (1-11) tumors were treated per session.

RESULTS

No significant differences were observed when comparing the results of more experienced IRs with those of a novice IR regarding the rates of major complications (6.8% [16/234] vs. 5.1% [2/39]; p = 0.477), mortality (1.3% [2/234] vs. 0% [0/39]; p = 0.690), primary technical efficacy (98.5% [525/533] vs. 98.9% [94/95]; p = 0.735), and local recurrence (5.6% [30/533] vs. 5.3% [5/95]; p = 0.886). However, the median planning/placement time was significantly shorter for the experienced IRs (92 min vs. 119 min; p = 0.002).

CONCLUSIONS

SRFA is a safe, effective, and reliable treatment option for malignant liver tumors and favorable outcomes can be achieved even by inexperienced operators with minimal supervision.

Single medium-sized hepatocellular carcinoma treated with sequential conventional transarterial chemoembolization (cTACE) and microwave ablation at 4 weeks versus cTACE alone: a propensity score

Background

Microwave ablation (MWA) is a potentially curative treatment for unresectable patients with hepatocellular carcinoma (HCC) ≤ 3 cm, while its therapeutic efficacy decreases significantly for HCC > 3cm. Previous studies have demonstrated that conventional transarterial chemoembolization (cTACE) combined with MWA (cTACE-MWA) may improve local tumor control rate and reduce the recurrence rate for HCC > 3cm. However, there have been few study designs to analyze the clinical efficacy of cTACE-MWA for medium-sized HCC (3–5cm). Therefore, this study aims to compare the clinical efficacy and safety of cTACE-MWA with cTACE alone for a single medium-sized HCC of 3–5 cm in diameter.

Methods

We retrospectively investigate the data of 90 patients with a single medium-sized HCC who were referred to our hospital and underwent cTACE-MWA or cTACE alone from December 2017 to March 2020. Then, patients were identified with propensity score-matched (1:1). The local tumor response to treatment and time to progression (TTP) were compared using mRECIST criteria between the cTACE-MWA group and the cTACE group.

Results

A total of 42 patients were included after matching (cTACE-MWA: 21; cTACE: 21). Comparing with cTACE, cTACE-MWA demonstrate significantly better local tumor control (ORR: 95.2% vs 61.9%, p = 0.02; DCR: 95.2% vs 66.7%, p = 0.045) and TTP (median 19.8 months vs 6.8 months, p < 0.001). The 1- and 2-year cumulative probabilities of OS were 100% and 95% in the cTACE-MWA group, which were significantly higher than those in the cTACE group (95% and 76%) (p = 0.032). Multivariate Cox regression analysis illustrates that cTACE-MWA was associated with better TTP (hazard ratio, 0.28; 95% CI: 0.1, 0.76; p = 0.012), but tumor size was associated with worse TTP (hazard ratio, 1.71; 95% CI: 1.01, 2.89; p = 0.045).

Conclusions

cTACE followed by MWA improved TTP and OS in patients with a single medium-sized HCC, and no major complication was observed in this study.

Stereotactic and Robotic Minimally Invasive Thermal Ablation of Malignant Liver Tumors: A Systematic Review and Meta-Analysis

Background

Stereotactic navigation techniques aim to enhance treatment precision and safety in minimally invasive thermal ablation of liver tumors. We qualitatively reviewed and quantitatively summarized the available literature on procedural and clinical outcomes after stereotactic navigated ablation of malignant liver tumors.

Methods

A systematic literature search was performed on procedural and clinical outcomes when using stereotactic or robotic navigation for laparoscopic or percutaneous thermal ablation. The online databases Medline, Embase, and Cochrane Library were searched. Endpoints included targeting accuracy, procedural efficiency, and treatment efficacy outcomes. Meta-analysis including subgroup analyses was performed.

Results

Thirty-four studies (two randomized controlled trials, three prospective cohort studies, 29 case series) were qualitatively analyzed, and 22 studies were included for meta-analysis. Weighted average lateral targeting error was 3.7 mm (CI 3.2, 4.2), with all four comparative studies showing enhanced targeting accuracy compared to free-hand targeting. Weighted average overall complications, major complications, and mortality were 11.4% (6.7, 16.1), 3.4% (2.1, 5.1), and 0.8% (0.5, 1.3). Pooled estimates of primary technique efficacy were 94% (89, 97) if assessed at 1–6 weeks and 90% (87, 93) if assessed at 6–12 weeks post ablation, with remaining between-study heterogeneity. Primary technique efficacy was significantly enhanced in stereotactic vs. free-hand targeting, with odds ratio (OR) of 1.9 (1.2, 3.2) (n = 6 studies).

Conclusions

Advances in stereotactic navigation technologies allow highly precise and safe tumor targeting, leading to enhanced primary treatment efficacy. The use of varying definitions and terminology of safety and efficacy limits comparability among studies, highlighting the crucial need for further standardization of follow-up definitions.

Laparoscopic surgery for strangulated diaphragmatic hernia after radiofrequency ablation for hepatocellular carcinoma: a case report

BACKGROUND

Percutaneous radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma (HCC), but delayed thermal damage can cause diaphragmatic hernia (DH). Surgery is recommended for DH, and open surgery is widely accepted. This report presents a case of laparoscopic surgery for strangulated DH that occurred after RFA.

CASE PRESENTATION

An 80-year-old woman with a history of hepatitis C-induced liver cirrhosis and HCC was admitted to our institution owing to sudden-onset intense epigastric pain. Twenty-two months earlier, she received RFA treatment for HCC located in segment 6/7. Contrast-enhanced computed tomography revealed herniation of the small intestine into the thoracic cavity, with mesenteric fat haziness. Emergency laparoscopic surgery was performed, and the patient was diagnosed with strangulated DH associated with the prior RFA. The defect was closed using absorbable sutures, and the ischaemic small intestine was resected via mini-laparotomy. The patient was discharged on the 10th postoperative day without complications, and no evidence of DH recurrence 15 months after surgery was noted.

CONCLUSIONS

Laparoscopic surgery seems useful and feasible for strangulated DH.

Diagnostic evaluation and ablation treatments assessment in hepatocellular carcinoma

This article provides an overview of diagnostic evaluation and ablation treatment assessment in Hepatocellular Carcinoma (HCC). Only studies, in the English language from January 2010 to January 202, evaluating the diagnostic tools and assessment of ablative therapies in HCC patients were included. We found 173 clinical studies that satisfied the inclusion criteria.HCC may be noninvasively diagnosed by imaging findings. Multiphase contrast-enhanced imaging is necessary to assess HCC. Intravenous extracellular contrast agents are used for CT, while the agents used for MRI may be extracellular or hepatobiliary. Both gadoxetate disodium and gadobenate dimeglumine may be used in hepatobiliary phase imaging. For treatment-naive patients undergoing CT, unenhanced imaging is optional; however, it is required in the post treatment setting for CT and all MRI studies. Late arterial phase is strongly preferred over early arterial phase. The choice of modality (CT, US/CEUS or MRI) and MRI contrast agent (extracelllar or hepatobiliary) depends on patient, institutional, and regional factors. MRI allows to link morfological and functional data in the HCC evaluation. Also, Radiomics is an emerging field in the assessment of HCC patients.Postablation imaging is necessary to assess the treatment results, to monitor evolution of the ablated tissue over time, and to evaluate for complications. Post- thermal treatments, imaging should be performed at regularly scheduled intervals to assess treatment response and to evaluate for new lesions and potential complications.

Stereotactic Thermal Ablation of Liver Tumors: 3D Planning, Multiple Needle Approach, and Intraprocedural Image Fusion Are the Key to Success-A Narrative Review

Thermal ablation is an emerging, potentially curative approach in treating primary and metastatic liver cancer. Different technologies are available, with radiofrequency ablation (RFA) and microwave ablation (MWA) being the most widely used. Regardless of the technique, destruction of the entire tumor, including an adequate safety margin, is key. In conventional single-probe US- or CT-guided thermal ablation, the creation of such large necrosis zones is often hampered by technical limitations, especially for large tumors (i.e., >2-3 cm). These limitations have been overcome by stereotactic RFA (SRFA): a multiple needle approach with 3D treatment planning and precise stereotactic needle placement combined with intraprocedural image fusion of pre- and post-interventional CT scans for verification of treatment success. With these sophisticated tools and advanced techniques, the spectrum of locally curable liver malignancies can be dramatically increased. Thus, we strongly believe that stereotactic thermal ablation can become a cornerstone in the treatment of liver malignancies, as it offers all the benefits of a minimally invasive method while providing oncological outcomes comparable to surgery. This article provides an overview of current stereotactic techniques for thermal ablation, summarizes the available clinical evidence for this approach, and discusses its advantages.

Primary efficacy of percutaneous microwave ablation of malignant liver tumors: comparison of stereotactic and conventional manual guidance

In this study, we compare the primary efficacy of computed tomography-navigated stereotactic guidance to that of manual guidance for percutaneous microwave ablation of liver malignancies. In total, 221 patients (140, 17, and 64 with hepatocellular carcinoma, cholangiocellular carcinoma, and liver metastases, respectively) with 423 treated liver lesions underwent microwave ablation (MWA). Manual guidance (M) and stereotactic guidance (S) were used for 136 and 287 lesions, respectively. The primary endpoint was the primary efficacy and the secondary endpoint was the radiation dose. A generalised estimating equation was applied to analyse the correlation between the primary efficacy (lesion basis) and the type of guidance, size and location of lesion. The primary efficacy rate was significantly higher in the S-group (84.3%) than in the M-group (75.0%, p = 0.03). Lesion size > 30 mm was negatively correlated with the efficacy rate (odds ratio 0.38; 95% confidence interval 0.20–0.74). Stereotactic guidance was associated with a significantly lower dose length product (p < 0.01). In this retrospective study, percutaneous microwave ablation under stereotactic guidance exhibited significantly greater primary efficacy than conventional manual guidance.

Adjunctive hydrodissection of the bare area of liver during percutaneous thermal ablation of sub-cardiac hepatic tumours

OBJECTIVE

To report the technique of hydrodissection of the sub-diaphragmatic bare area of the liver, in order to protect the diaphragm/heart during percutaneous thermal ablation (PTA) of sub-cardiac hepatic tumours.

MATERIALS AND METHODS

Between January 2016 and December 2018, five patients (four female, one male; mean age 56.2 years) with five sub-cardiac liver tumours (two hepatocellular carcinoma, three metastases; mean size 39 mm) abutting the bare area (segments II/IVA) with expected ablation zones ≤ 5 mm from the myocardium were treated with PTA and adjunctive hydrodissection. Time to perform hydrodissection, distance between superior hepatic and diaphragmatic/pericardial surfaces before and after hydrodissection, ablation efficacy, complications, and local tumour progression (LTP) at last imaging follow-up were recorded.

RESULTS

Technical feasibility was 100%, with mean hydrodissection-volume of 126 ml (range 80-200 ml) and median hydrodissection-time of 9 min (range 8-45 min). Liver-diaphragmatic and liver-pericardial distance increased, respectively, from 2.4 mm (range 0-8 mm) to 10.8 mm (range 6-19 mm) and from 4 mm (range 1-10 mm) to 12.6 mm (range 8-20 mm) post-hydrodissection. All procedures were performed at full-power with complete tumour ablation and without complications (including peri-procedural haemodynamic/electrocardiographic disturbances, pericardial effusion and diaphragmatic hernia) or evidence of LTP at mean 12.2-month (range 1-26 month) follow-up.

CONCLUSION

Hydrodissection of the sub-diaphragmatic bare area of the liver is technically feasible and may potentially optimize safety PTA of sub-cardiac hepatic tumours.

"Primum Non Nocere" in Interventional Oncology for Liver Cancer: How to Reduce the Risk for Complications?

Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments.

Stereotactic Image-Guided Microwave Ablation for Malignant Liver Tumors-A Multivariable Accuracy and Efficacy Analysis

Background: Therapeutic success of thermal ablation for liver tumors depends on precise placement of ablation probes and complete tumor destruction with a safety margin. We investigated factors influencing targeting accuracy and treatment efficacy of percutaneous stereotactic image-guided microwave ablation (SMWA) for malignant liver neoplasms. Materials and methods: All consecutive patients treated with SMWA for malignant liver tumors over a 3-year period were analyzed. A computed tomography-based navigation system was used for ablation probe trajectory planning, stereotactic probe positioning, and validation of probe positions and ablation zones. Factors potentially influencing targeting accuracy [target positioning error (TPE)] and treatment efficacy within 6 months [ablation site recurrence (ASR)] were analyzed in a multivariable regression model, including challenging lesion locations (liver segments I, VII, and VIII; subphrenic location). Results: Three hundred one lesions (174 hepatocellular carcinomas, 87 colorectal liver metastases, 17 neuroendocrine tumors, and 23 others) were targeted in 191 interventions in 153 patients. The median TPE per ablation probe was 2.9 ± 2.3 mm (n = 384). Correction of ablation probe positions by repositioning was necessary in 4 out of 301 lesions (1%). Factors significantly influencing targeting accuracy were cirrhosis (R 0.67, CI 0.22-1.12) and targeting trajectory length (R 0.21, CI 0.12-0.29). Factors significantly influencing early ASR were lesion size >30 mm (OR 5.22, CI 2.44-11.19) and TPE >5 mm (OR 2.48, CI 1.06-5.78). Challenging lesion locations had no significant influence on targeting accuracy or early ASR. Conclusions: SMWA allows precise and effective treatment of malignant liver tumors even for lesions in challenging locations, with treatment efficacy depending on targeting accuracy in our model. Allowing for many tumors to be safely reached, SMWA has the potential to broaden treatment eligibility for patients with otherwise difficult to target tumors.

Simultaneous Stereotactic Radiofrequency Ablation of Multiple (≥ 4) Liver Tumors: Feasibility, Safety, and Efficacy

PURPOSE

To assess feasibility, safety, and clinical outcome of simultaneous stereotactic radiofrequency (RF) ablation of multiple (≥ 4) primary and metastatic liver tumors.

MATERIALS AND METHODS

This retrospective observational study included 92 patients (29 women, 62 men), 35 with ≥ 4 hepatocellular carcinomas (HCCs) and 57 with ≥ 4 metastatic liver tumors at initial stereotactic RF ablation between 2005 and 2018. The median size of 178 HCCs and 371 metastases was 2.2 cm (range, 1.0-8.5 cm) and 3.0 cm (range, 0.5-13 cm), respectively. At initial stereotactic RF ablation, 17 (48.6%) patients with HCC and 19 (33.3%) with metastases had 4 liver tumors, 11 (31.4%) and 19 (33.3%) had 5 tumors, and 7 (20%) and 19 (33.3%) had ≥ 6 tumors.

RESULTS

Major complications occurred in 2 of 35 ablations (5.4%) in patients with HCCs and in 7 of 63 (10%) with metastases. The primary technical efficacy rate (ie, successful initial ablation) was 100% (178/178) in HCCs and 98.8% (363/371) in metastases. Local recurrence was observed in 4 of 178 (2.2%) HCCs and in 17 of 371 (4.6%) metastases. Overall survival (OS) rates at 1, 3, and 5 years from the date of the first stereotactic RF ablation were 88.0%, 54.0%, and 30.4% for patients with HCCs with a median OS of 38.2 months and 86.1%, 53.1%, and 37.3% for patients with metastases with a median OS of 37.4 months.

CONCLUSIONS

Stereotactic RF ablation is a feasible, safe, and efficacious option in simultaneous management of multiple primary and metastatic liver tumors.

Updated 10-year outcomes of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm: emphasis on association of local tumor progression and overall survival

OBJECTIVES

The purpose of this study was to evaluate the 10-year overall survival and local tumor progression (LTP) of percutaneous radiofrequency ablation (RFA) for single nodular hepatocellular carcinoma (HCC) < 3 cm using a large longitudinal hospital registry and clinical factors associated with overall survival and LTP.

METHODS

A total of 467 newly diagnosed patients with single nodular HCC < 3 cm who underwent RFA as first-line therapy between January 2008 to December 2016 were analyzed. Overall survival and LTP were estimated using the Kaplan-Meier method. Cox regression and competing risks Cox regression analysis were performed to identify prognostic factors for overall survival and LTP, respectively.

RESULTS

The 5- and 10-year overall survival rates after RFA were 83.7% and 74.2%, respectively. LTP (hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.19-3.47) was one of the important factors for overall survival after RFA. The 5- and 10-year LTP rates after RFA were 20.4% and 25.1%, respectively. Periportal location (subdistribution HR, 2.29; 95% CI, 1.25-4.21), subphrenic location (2.25, 1.34-3.86), size ≥ 1.5-< 2.0 cm (1.88, 1.05-3.39), and size ≥ 2.0 cm (2.10, 1.14-3.86) were independent factors for LTP.

CONCLUSION

Ten-year therapeutic outcomes of percutaneous RFA as first-line therapy were excellent for single HCC < 3 cm. LTP was an important prognostic factor for overall survival after RFA. Periportal and subphrenic location of HCCs and tumor size were predictors for the development of LTP after RFA.

KEY POINTS

• Updated 10-year survival outcome of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm was higher than previously reported. • Local tumor progression was an important prognostic factor for overall survival after percutaneous radiofrequency ablation. • Periportal and subphrenic location of hepatocellular carcinomas and tumor size were predictors for the development of local tumor progression after percutaneous radiofrequency ablation.