Percutaneous thermal ablation

It is our experience that the type of HCC seen at MDACC, and perhaps in the Western World, is different or at least more advanced from that more commonly treated by the interventional radiologist in Japan (Yamashita et al. 1993). Nodular HCC is seen in less than 25% of our patients, while it comprises 75% of the Japanese patient population. However, this is now changing due to the present influx of patients with positive hepatitis B and C. This type of tumor can be approached by surgery, by the direct injection of absolute ethanol, by direct percutaneous thermal ablation (radiofrequency or cryoablation), by chemoembolization, or the combination of these techniques (Figs. 9.4,9.5). 

Percutaneous thermal ablation therapies have been receiving increasing attention as a potential primary treatment for focal HCC and fiver metastases. Possible advantages of ablative therapies as compared to surgical resection include a lower morbidity and mortality... 

Minimally invasive interventional management of lung metastases can be categorized into percutaneous thermal ablation and the recently developed transarterial chemoembolization. All these methods are relatively new and almost all are widely regarded as experimental. 

Radiofrequency is the most widespread percutaneous thermal ablation technique used in liver tumors. In the few studies in vdiich it was used in lung tumors it achieved a morphological response of up to 100% with a mean survival of up to 19.7 months (Lee et al. 2004). 

The real-time nature of US makes it ideally suited for accurate and safe biopsy of focal lesions, as respiratory motion can be imaged directly during the needle passage and accounted for interactively. Also, US is commonly used for guidance of percutaneous thermal ablation of metastases. 

Xu HX, Xie XY, Lu MD, et al (2004) Ultrasound-guided percutaneous thermal ablation of hepatocellular carcinoma using microwave and radiofrequency ablation. Clin Radiol 59 53-61... 

Lencioni R, Cioni D, Bartolozzi C (2001) Percutaneous radio-frequency thermal ablation of liver malignancies techniques, indications, imaging findings, and clinical results. Abdom Imaging 26 345-360... 

Rossi S, Di Stasi M, Buscarini E, Cavanna L, Quaretti P, Squassante E et al (1995) Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular carcinoma. Cancer J Sci Am 1 73 Rossi S, Buscarini E, Garbagnati F, Di Stasi M, Quaretti P, Rago M et al (1998) Percutaneous treatment of small hepatic tumors by an expandable RF needle electrode. AJR Am J Roentgenol 170 1015-1022... 

In general, tumor ablation can be divided into two main categories. The first one is chemical ablation, the second one is thermal ablation. Additionally, other interventional oncological therapeutic approaches have to he defined, such as the percutaneous dehvery of radioactive seeds and the transcatheter delivery of chemotherapy and chemoemho-lization. 

Allgaier HP, Deibert P, Zuber I, Olschewski M, Blum HE (1999) Percutaneous radiofrequency interstitial thermal ablation of small hepatocellular carcinoma. Lancet 353 1676-1677... 

Lin SM, Lin CJ, Lin CC, Hsu CW, Chen YC (2005) Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3cm or less. Gut 54 1151-1156 Eivraghi T (1998) Percutaneous ethanol injection in the treatment of hepatocellular carcinoma in cirrhosis. Hepatogastroenterology 45 1248-1253 Eivraghi T, Giorgio A, Marin G, Salmi A, Sio I de, Bolondi... 

Rossi S, Garbagnati P, Lencioni R et al (2000) Percutaneous radio-frequency thermal ablation of nonresectable hepatocellular carcinoma after occlusion of tumor blood supply. Radiology 217 119-126 Seong J, Keum KC, Han KH, Lee DY, Lee JT, Chon CY, Moon YM, Suh CO, Kim GE (1999) Combined transcatheter arterial chemoembolization and local radiotherapy of unresectable hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 43 393-397... 

P, Crocetti L, Frings H, Laubenberger J, Zuber I, Blum HE (2003) Small hepatocellular carcinoma in cirrhosis randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology 228 235-240... 

Various percutaneous, locoregional therapeutic modalities have been developed and tested clinically over recent years for the treatment of HCC. These include intratumoral injection of ethanol or acetic acid and thermal ablation with RF, laser, micro-waves, or cryosurgery. Percutaneous ethanol injection (PEI), more frequently performed in the past, is considered to be effective for the treatment of relatively small-sized, encapsulated early-stage HCC and therefore may achieve 5-year survival rates of 32%-47% (Lencioni et al. 1995 Livr aghi et al. 1995). The... 

Pontana RJ, Hamidullah H, Nghiem H et al (2002) Percutaneous radiofrequency thermal ablation of hepatocellular carcinoma a safe and effective bridge to liver transplantation. Liver Transpl 8 1165-1174 Gadaleta C, Mattioli V, Coined G et al (2004) Radiofrequency ablation of 40 lung neoplasms preliminary results. AJR Am J Roentgenol 183 361-368... 

The introduction of minimally invasive thermal ablation techniques offers a safe and accurate alternative to open or laparoscopic surgery in the treatment of renal tumors. Experimental as well as clinical studies proved RF ablation to be a safe and effective treatment option for small RCCs. It is well tolerated in patients with percutaneously accessible lesions. However, the long-term outcome remains to be determined. Until then its use is limited to selected patients. Despite these limitations, published experience with renal RF ablation is continuously growing. As soon as its long-term effectiveness is proven, this technique holds the potential to replace surgery as first-line therapy in small RCCs. 

Rosenthal DI, Hornicek FJ, Torriani M et al (2003) Osteoid osteoma percutaneous treatment with radiofrequency energy. Radiology 229(1) 171-175 Schaefer O, Lohrmann C, Herling M et al (2002) Combined radiofrequency thermal ablation and percutaneous ce-mentoplasty treatment of a pathologic fracture. J Vase Interv Radiol 13(10) 1047-1050 Shankman S, Desai P, Beltran J (1997) Subperiosteal osteoid osteoma radiographic and pathologic manifestations. Skeletal Radiol 26(8) 457-462... 

Simon CJ, Dupuy DE (2006) Percutaneous minimally invasive therapies in the treatment of bone tumors thermal ablation. Semin Musculoskelet Radiol 10(2) 137-144 Toyota N, Naito A, Kakizawa H et al (2005) Radiofrequency ablation therapy combined with cementoplasty for painful bone metastases initial experience. Cardiovasc Interv Radiol 28(5) 578-583... 

These disappointing results coupled with the poor response of HCC to traditional chemotherapy have provided the impetus for the development of a variety of nonsurgical techniques for the treatment of hepatic neoplasms (Table 10.1). Such techniques are generally divided into transarterial interventions versus percutaneous ones. The latter group is further subdivided into thermal ablation techniques versus chemical ablation techniques. 

All of the percutaneous techniques are limited by the size and number of the lesions (up to three lesions each measuring up to 4 cm) as well as their location. Subdiaphragmatic lesions may be percutaneously inaccessible, and lesions close to large vascular structures respond poorly to thermal ablation techniques (RFA, MCT, Cryo, and LIPC). On the contrary, intra-arterial techniques are not limited by the number, size, or location of the lesions rather by the hepatic function reserve, as shown in Table 10.2. TACE, trans-arterial chemo-embolization TARE, trans-arterial radio-embolization MCT, microwave coagulation therapy RFA, radio frequency ablation LIPC, laser interstitial photocoagulation Cryo, cryo-ablation PEI, percutaneous ethanol injection PAAI, percutaneous acetic acid injection PCI, percutaneous chemotherapy injection... 

---