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Focal Treatment of Liver Metastasis
Bjørn SkjoldbyeThe Gastro Unit Herlev Hospital
Liver metastasis
CRC
Resectable ?
ChemotherapyOperable ?
Surgery
The
Classic
approach:
Potential cureable
disease
Liver metastasis
CRC
DiagnosisStaging
Management
(FUSION) IMAGING
Follow-up
Oncology
Surgery
MDT
Imaging
Image Fusion• Simultaneous display of two or more images
1.Different images (representing same geometry and site)2.Overlayed images
Treatment
of
liver metastasis
Approach
•
Systemic•
Regional
•
Local•
Focal
Methods
•
Systemic Chemo-therapy•
Genetic & Immuno-therapy
•
Hepatic arterial inf.(HAI)•
TACE
•
Surgical resection•
Ablation
The ideal ablation modality
•
Non invasive•
Effective tumor kill
•
Harmless to other tissue•
No complication
•
Controled treatment•
Easy, cheap and fast
Ablation
Methods•
Heat
•
Cold•
Toxic
•
Bio-genetical
Imaging Guidance •
US
•
CT•
MR
MIT Ablation
•
Ablation•
Laser
•
RF (400-450 KHz)
•
MW (915 MHz 2,4 GHz)
•
Cryo•
Injection (alcohol, etc)
•
HIFU•
Electro –
chemical
–
Electroporation/Nano-knife
(Why not) Cryo of Lmet
Semin. Surg. Oncol. 14:163-170, 1998•
136 patients (1-2) unresectable hepatic metastases
•
Recurrent disease: 78% -
82% in the liver. •
Complication rates comparable to liver resection. Operative mortality was 3.7%.
JK Seifert - World journal of surgery, 1999•
Following hepatic cryotherapy n=216, the phenomenon of cryoshock (DIC) was observed in 21 patients and was responsible for 6 of 33 perioperative deaths (18.2%).
T Sarantou, Jnal of Surgical Oncology, 1998
• incidence of operative hemorrhage by cryo ablation of liver tumor patients is approximately 14%
TACE with irinotecan beads
•
TACE: Transarterial chemoembolization, a procedure in which the blood supply to a tumor is blocked (embolized) and chemotherapy is administered directly into the tumor.
•
2-4 treatments, 4-6 weeks
Herlev; Local ablation of liver tumors
•
1989-1995: 10 pt (NdYAG Laser) •
1995-1998: 15 pt (Micro Wave -
PUMA)
•
1999-2002: Cool-Tip RF•
2002-2008: RITA & Cool-Tip RF
•
2008 : RITA & MW –
once again
In vitro MW
Percutaneous Approach Per-operative Approach
Percutan US-Guided MicroWave Ablation: PUMA (Skjoldbye et al, CIRSE 1995)
0
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2 12 24 36 48 60
PUMAResectionuden beh
3 HCC, 8 Lmet CRC, 4 Lmet other
3 pt lever > 10 år efter PUMA 1 CRC1 C.mam1 mal. schwanoma
Cool-Tip needle and temperature sensor
2 3 4 5 6 7
Multiple (9) expandable tines 5 temp. sensors
Percutaneous RFA
UL-vejledt MW behandling af levermetastase
Microwave (MW) generator
13 G MW needle
Whats
the
difference?
IRF Generator
RF-
Electrode
Dispersive
Electrode
Pad
MW Generator
MW-
Antenna
Radio Frequency 430 KHz. High conductivity in the body
Micro Waves 915 MHz
High speed oscillation/movements of water molecules generates friction heat
WHY ULTRASOUND?
•
2D imaging.•
Free choice of image plane.
•
Real Time Imaging.•
Availability
CT
Deployment of ablation devices
•
Percutaneous ablation–
US, CT, MR
•
Surgical assisted ablation–
IUS
–
LUS
Combined Resection and RFResecti
on
R F
RF
RF
Resection
CEIUS
Lmet
Haemangioma
Late phase CE-LUS identifies Lmet
Resection of liver metastasis from colorectal cancer
Operative mortality
5 %
Recurrence rate 50 %
5-year survival 30-35 %
Herlev Focal ablation of liver tumors
•
Inclusion criteria: ”The Rule of 5”
•
No. of Liver-mets ≤
5
•
Largest Ø
< 5
cm
•
Non-resectable•
No extra hepatic disease
Peroperativ ( “åben”) RF Ablation
Follow Up after RF treatment
•
5 weeks: CT + “tumor marker”
(tm)•
6 weeks: US + CEUS / biopsy (fnac)•
3 month: (CT) + US + (tm)
•
6 month: (CT) + US + ( tm) •
9,12,18,24,36,48 & 60 months: US + ( tm)
•
CT, PET & US-guided biopsy on indication.
Contrast enhanced US: CEUS
Evaluation of vascular activity before and after RF
Arterial phase before RF
RF ablation
Late phase
after RF
Simultaneously contrast-US and conventionelt US after RF
Conventionel US after RF
Multidisciplinary Approach Case illustration
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3000
CEA
febmaraprmayjunjulaugseptoktnovdecjanfeb
RF
5FU Leu
Reg 5FU Leu Oxilpl
Spl met
Herlev 1999-2008
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Lmet CRC Lmet andet HCC I alt
Antal behAntal Pt
Factors influencing success
•
Precise deployment•
Controled ablation
•
Feed-back•
Time & Cost
•
Size, number, shape, site•
Indication / Recruitment
RF 2000 - 2009
01020304050607080
Janu
arFe
brua
r
Mar
ts
April
Maj
Juni Juli
Augu
stSe
ptem
ber
Oktob
erNov
embe
rDec
embe
r
Måneder
Ant
al
Kumuleret 2000Kumuleret 2001Kumuleret 2002Kumuleret 2003Kumuleret 2004Kumuleret 2005Kumuleret 2006Kumuleret 2007Kumuleret 2008Kumuleret 2009
Herlev 1999-2008
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100
200
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Percutan "Åben" Alkoholinj
Lap/LUS
resect+RFAblations type
RF ablation Liver tumors 1999-2008
Mortality 0,16 %Rate of complications
5,5%
Mean survival * 2,7 yr (date = 1. RF)
5 year survival 20% (date = 1. RF)
•
minimal invasive, simple and effective •
relatively inexpensive, easy to access
•
percutaneous, laparoscopically or intraoperative approach –•
depending on the individual case.
•
short in-hospital time
1.0
0.8
0.6
0.4
0.2
00 1 2 3 4 5 6
Prob
abili
ty o
f sur
viva
l
Years from diagnosis
Resection Systemic chemotherapy Systemic chemotherapy No treatment
Survival in patients with colorectal liver metastases
RF ablation
Status•
New Technology –
New possibilities
•
Results depends on patient selection•
Randomized studies are difficult to justify
•
Liverresection has never been subject to randomized studies although it has been performed since 1923
•
Result interaction with other treatments•
New range of indications
•
Shift of Paradigme
•
Economy –
Time
Basics of focal treatment of livermetastasis
•
Imaging•
Intervention
•
Ablation modality•
Controled treatment
•
Follow up•
Other treatment possibilities
•
See•
Direct
•
Do•
Feed-back
•
Monitor
•
MDT
Systemic Chemotherapy Regional Chemotherapy
Surgical resection RF-ablation
Gentherapy Immunomodulation
Focal
treatment
of
livermetastasis. Demands
for optimal patient management.
•
Correct
Patient Selection–
Primary
cancer, precise
staging, concurrent
diseases
•
Multidiciplinary
Tumor-conference
(MDT)–
Individual
patient evaluation
–
Oncology, Surgery, Imaging, Intervention, Pathology
•
Availablility
of
Best
Possible
Treatment