Opinioni a confronto: l’approccio percutaneo vs laparoscopico

MF Meloni Interventional Ultrasound

Institution of Care Igea – Milano

Clinical Adjunct Professor University of Pavia

University of Milano Bicocca

University of Wisconsin-School of Medicine and Public Health Madison (WI)

Background

•  Thermal ablation is a procedure in which a needle-device is inserted under imaging-guidance delivering energy directly in the surronding tissue

•  RF and MW ablation are the two most widely adopted •  Both RFA and MWA have been shown to provide a

survival benefit in HCC and metastases •  Recent advances in high-powered MWA have allowed

physicians to realize the theoretical heating advantages of MW energy compared to other modalities

Ablation: how to do it? •  Ablation therapies can be used

transcutaneously or intraoperative via laparotomy or laparoscopy

• Much of ablation treatments are performed percutaneously

•  Percutaneous approach carries a higher risk of local recurrence compared to open and laparoscopic (Mulier 2005)

Ablation therapies

Percutaneous approach Laparoscopic approach

Courtesy of dott Santambrogio

#clinical case Pre treatment evaluation:

CEUS TC-Arterial phase

MW-ablation: 1 ins 40watt-15’ MW ablation CEUS post

Post treatment evaluation #clinical case

CEUS 24h TC 24h

#clinical case Follow-up

CEUS 5 yrs Follow-Up 5yrs Follow-Up

Very early HCC

MW 5’ 65 watt

CEUS post – TC 24h

Difficult percutaneous approach •  Technical contraindications to

percutaneous approach

•  Severe impairment of coagulation test

•  Critical locations (GI tract, gallbladder, major hepatic vessels, liver surface, diaphragm, heart

•  Lesion undetectable at US

Difficult percutaneous approach •  Technical contraindications to

percutaneous approach

•  Severe impairment of coagulation test

•  Critical locations (GI tract, gallbladder, major hepatic vessels, liver surface, diaphragm, heart

•  Lesion undetectable at US

AJR Am J Roentgenol. 2015 Jan;204(1):197-203. doi: 10.2214/AJR.14.12879. Microwave ablation of hepatic tumors abutting the diaphragm is safe and effective. Smolock AR1, Lubner MG, Ziemlewicz TJ, Hinshaw JL, Kitchin DR, Brace CL, Lee FT Jr

J Vasc Interv Radiol. 2017 Apr;28(4):490-497. doi: 10.1016/j.jvir.2016.12.1216. Epub 2017 Feb 10. Safety and Efficacy of Percutaneous Microwave Hepatic Ablation Near the Heart. Carberry GA1, Smolock AR2, Cristescu M2, Wells SA2, Ziemlewicz TJ2, Lubner MG2, Hinshaw JL2, Brace CL3, Lee FT Jr3.

If percutaneous approach is not possible?

• TACE • LPS

• SBRT

Large HCC close to risk structures

HCC VI segment Post-TACE

Residual Viable tissue

CEUS TC post TACE

Large HCC close to risk structures

Percutaneous RF Post- RF

Large HCC close to risk structures 24h Post RF 1 year Follow-Up

Recurrence post ablation difficult approach

Recurrence post-MW TACE

Recurrence post MW ablation

Recurrence POST MWA LPS MW ABLATION

HCC close to risk structures

PRE treatment 5 yrs of Follow-Up

SBRT

•  J Hepatol. 2017 Feb 28. pii:

S0168-8278(17)30119-8. doi: 10.1016/j.jhep.2017.02.022. [Epub ahead of print]

•  Stereotactic body radiotherapy versus TACE or RFA as a bridge to transplant in patients with hepatocellular carcinoma. An intention-to-treat analysis.

•  Sapisochin G1, Barry A2, Doherty M3, Fischer S4, Goldaracena N5, Rosales R6, Russo M2, Beecroft R7, Ghanekar A5, Bhat M6, Brierley J2, Greig PD5, Knox JJ3, Dawson LA2, Grant DR5.

Microwave ablation in primary and secondary liver tumors: technical and clinical approaches

MF Meloni et al. International Journal of Hyperthermia 2016

Complications Liang P. et al Radiology 2013 2.6% Livraghi et al Cardiovasc Intervent Radiol 2.9%l

RESULTS

Limits of efficacy in ablation

•  Critical Tumor location

- surface of the liver -  Tumor close to risk structures -  Blood vessels

•  Size

Laparoscopic thermal ablation

Conclusions

• Multidisciplinary panel should provide a tailored approach for each patient

considering both guide-line indications and patient-specific characteristics