Radiofrequency Ablation for Hepatocellular Cancer
Abstract & Commentary
William B. Ershler, MD, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC, is Editor for Clinical Oncology Alert.
Synopsis: Radiofrequency ablation is a relatively new approach to the management of hepatocellular cancer. Tateishi and colleagues from the University of Tokyo describe their experience with this technique applied to 644 patients for a total of 1000 treatments. In their hands, RFA has proven safe and very effective, comparable in terms of 5-year overall survival to prior surgical series.
Source: Tateishi R, et al. Cancer. 2005;103(6):1201-1209.
Hepatocellular carcinoma (HCC) remains among the most common and most difficult-to-treat malignancies worldwide. Surgical resection is preferred, but when lesions are multicentric, or compromised liver function precludes surgery, alternative approaches are needed. Chemotherapy is of marginal value. Tateishi and colleagues from the University of Tokyo report their 4-year experience with percutaneous radiofrequency ablation (RFA). During the years 1999 to 2003 they performed 1000 treatments on a total of 664 patients using a cooled-tip electrode delivering radio frequency directly into tumor nodules. The electrode, connected to a 500-kHz RF generator, produces 200 W at 50 Ohms of impedance. The electrode tip was inserted directly into the lesion and from 40 to 140 W was delivered at a rate of 20 W/min for a duration of between 6 and 12 minutes.
The series included patients for whom the approach was taken because they were not surgical candidates (n = 419) and others (n = 245) who were surgical candidates but chose this approach after informed consent. Inclusion criteria for RFA were: total bilirubin concentration < 3 mg/dL, platelet count > 5 ´ 105/mm3, and prothrombin activity >50%. Patients with portal vein tumor thrombosis or extrahepatic metastases were excluded.
The median age of patients was 67 years and 69% were male. The mean tumor size was 2.6 cm (range, 0.8-9.7 cm). The majority of the patients (437) received only one treatment, but 227 patients received 2 or more and the total number of treatments was 1000.
A total of 40 major complications (4%) and 17 minor complications (1.7%) were observed over the 1000 treatments. There were no treatment-related deaths. Surgical intervention was required in one case each of bile peritonitis and duodenal perforation. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 94.7%, 86.1%, 77.7%, and 54.3% for those who were previously untreated and 91.8%, 75.6%, 62.4%, 53.7%, and 38.2% for previously treated patients, respectively. Tumor size was an important prognostic indicator, with patients with small tumors faring better than those with intermediate, who fared better than those with large tumor mass (> 5 cm). Similarly, patients with more advanced liver disease (Childs B/C) had significantly poorer survival when compared to those without (Childs A). In general, however, the survival in this series was comparable to published surgical outcomes for HCC.1
Comment by William B. Ershler, MD
Novel, non-surgical approaches for hepatocellular carcinoma are needed because of the frequent presentation of this disease at a stage where resection is impossible or underlying disease (particularly liver dysfunction) is prohibitive. Targeted therapies have included transcatheter arterial embolization (TAE),2 percutaneous ethanol injection (PEIT)3 and the recently developed radio frequency ablation as described in this report. TAE is widely performed, however complete lesion necrosis is rarely observed and local relapse rates are high. PEIT has proven effective, particularly for patients with small tumors, and 5-year survival is comparable to surgery.4 However, the efficacy of PEIT is dependent on tumor size, and a local tumor progression rate of >20% was reported for tumors > 3 cm.5
As apparent from the current series, RFA offers a relatively safe alternative method for providing an excellent chance for local control. The technique is gathering momentum worldwide but it is fair to say that the learning curve is steep and more general experience is needed before the technique should be endorsed, particularly as an alternative to surgery for those with resectable lesions, or in clinics where few patients with HCC are treated.
References
1. Ikeda K, et al. Cancer. 1993;71:19-25.
2. Higuchi T, et al. Cancer. 1994;73:2259-2267.
3. Livraghi T, et al. Radiology. 1995;197:101-108.
4. Shiina S, et al. AJR Am J Roentgenol. 1993;160:1023-1028.
5. Sato S, et al. J Hepatol. 2001;35:225-234.
Radiofrequency ablation is a relatively new approach to the management of hepatocellular cancer. Tateishi and colleagues from the University of Tokyo describe their experience with this technique applied to 644 patients for a total of 1000 treatments. In their hands, RFA has proven safe and very effective, comparable in terms of 5-year overall survival to prior surgical series.
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