Intraoperative Radiofrequency Ablation Research Articles

Analysis of pre and postoperative inflammatory scores in curative resections for colorectal cancer liver metastasis

Background: Inflammatory scores (neutrophil lymphocyte ratio NLR, platelet lymphocyte ratio PLR, Glasgow prognostic score GPS, prognostic nutritional index PNI, lymphocyte monocyte ratio LMR) predict oncologic survival after colorectal cancer liver metastasis (CRCLm). However, there are few studies analyzing their association with postoperative morbidity. Patients & Methods: Retrospective analysis of our CRCLm database from January 2014 to June 2018 at Valladolid University Clinic Hospital (Spain). Endpoints: morbidity according to Clavien-Dindo (CD) Classification, infectious complications, transfusion, length of stay (LOS). Study variables: aforementioned inflammatory scores (preoperative and postoperative day 1) and patient´s comorbidities. Results: 49 patients (males: 69.4%, age: 65.4±11.03years). Median number of resected CRCLm: 2 (IQR=1-3). Total tumor diameter (Σ): 34.8±19.6mm. Liver resection: segmentectomy (32.7%), metastasectomy (24.5%), left hepatectomy (18.4%), right hepatectomy (14.3%), left lateral sectionectomy (6.1%), right and left extended hepatectomy (2%), laparoscopic procedures: 2 cases (4.1%, no conversion). Additional intraoperative radiofrequency ablation: 6.1%. Neoadjuvant chemotherapy: 51%. Median LOS: 8(IQR= 6.5-11.5days). Comorbidities: arterial hypertension (12.2%), dyslipidemia (28.6%), smoking (18.4%), cardiovascular diseases (14.3%), diabetes mellitus (12.2%), alcohol consumption (8.2%), chronic obstructive pulmonary disease (4.1%). Postoperative complications: global (53.1%), infectious (24.5%), CD≥III (16.3%). 6.1% of patients required reoperation. No association between age, comorbidities, ASA and postoperative complications. Patients with pGPS=0 and pGPS=1 presented a median LOS of 9.2±6.4days and 22±8.2days respectively (p=0.001). Overall morbidity, CD≥III and reoperation rate was higher among patients with preoperative GPS(pGPS)=1 vs. pGPS=0(100% vs. 48.9%, p=0.05, 50% vs. 13.3%, p=0.05, and 50% vs 2.2%, p=0.015, respectively). 59% of patients with postoperative GPS(poGPS)=2 presented complications vs. 30% of patients with poGPS=1(p=0.1). Patients suffering overall complications had lower postoperative mean albumin values(2.93±0.46 vs. 3.39±0.42g/dL, p=0.001) and lower postoperative PNI(29.32±4.6 vs. 33.93±4.25, p=0.001). Conclusions: The pGPS could be a good predictor of complications following resection of CRCLm. Patients with complications had lower postoperative albumin and PNI values.

Radiofrequency ablation in pancreatic cancer.

Clinical study evaluating the impact of intraoperative radiofrequency ablation in pancreatic cancer. Patients with histologically proved pancreatic cancer were included. Two groups were defined. In the RFA group (n=24) intraoperative RFA of the pancreatic tumour was performed. In the control group (n=24) only the bypass procedure was indicated (gastroenteric and hepaticojejunal anastomosis). No patient received neoadjuvant chemotherapy. Three-month morbidity and mortality, overall survival, quality of life, pain relief and radiological response were studied. Overall three-month morbidity and mortality were 41.7% and 8.3%, respectively. RFA related morbidity and mortality reached 16.6% and 8.3%, respectively. The overall median survival time was 9.9 and 8.3 months in the RFA group and in the control group, respectively. The survival difference was not of statistical significance (p=0.758). QoL improvement after RFA was not proved. There was no statistically significant analgesic effect of RFA. Postoperative CT scan assessed as per RECIST criteria displayed progressive disease, stable disease, partial response and complete response in 41.6%, 45.8%, 8.3% and 0% cases, respectively. Intraoperative RFA of locally advanced and metastatic pancreatic cancer is afeasible palliative method. Asurvival benefit of this method remains doubtful, even though some positive results have been achieved in patients with localized, well-differentiated tumours. Although RFA was not associated with any impairment of the quality of life, no convincing evidence of apositive impact thereof on QoL was shown, either, during the three-month postoperative period. Pain relief was not achieved during the first 3 months after RFA.

117P - Short-term and long-term outcomes of hepatectomy combined with intraoperative radiofrequency ablation for multiple colorectal liver metastases: A propensity score matching study

BackgroundRadiofrequency ablation (RFA) helps to achieve R0 resection and may provide an alternative treatment for patients with unresectable colorectal liver metastases (CRLM) in combination with surgical resection. However, researches on efficacy and complication risks of hepatectomy combined with intraoperative RFA for multiple colorectal liver metastases (mCRLM) are limited. MethodsFrom January 2013 and March 2017, patients who underwent hepatectomy alone (HA cohort) or hepatectomy combined with intraoperative RFA (HIR cohort) for mCRLM were retrospectively identified from Zhongshan Hospital affiliated to Fudan University. The mCRLM patients that were given ‘hepatectomy combined with intraoperative RFA’ were matched with those treated with hepatectomy alone via 1:1 propensity score (PS) matching. Recurrence-free survival (RFS) and overall survival (OS) after the initial hepatectomy were compared. ResultsAfter PSM, 252 patients were included (126 in each group). The HIR cohort had more grade I complications while no difference in higher grade complications (p = 0.231) and postoperative morbidity(p = 0.534) was detected. Total recurrence which includes intrahepatic and extrahepatic recurrence was no significantly difference in HIR cohort compared to HA cohort (p = 0.320). The median total RFS for HIG and HA was 10.47months and 10.7 months respectively (HR = 1.086 95% CI 0.766-1.540). The median OS for HIG and HA was 43.9 months and 46.1 months respectively (HR = 0.986 95% CI 0.648-1.307). ConclusionsHepatectomy combined with intraoperative RFA can be safely performed in mCRLM patients without an increased severe risk in the procedure and is representing a beneficial treatment to otherwise inoperable patients. The outcome of hepatectomy combined with intraoperative RFA is even comparable to hepatectomy alone after propensity score matching. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Evaluation of Contrast-Enhanced Intraoperative Ultrasound in the Detection and Management of Liver Lesions in Patients with Hepatocellular Carcinoma.

Aim To evaluate the role of contrast-enhanced intraoperative ultrasound (CE-IOUS) during liver surgery in the detection and management of liver lesions in patients with hepatocellular carcinoma (HCC). Materials and Methods From December 2016 to December 2017, 50 patients with HCC, who were candidates for liver resection, were evaluated with intraoperative ultrasound (IOUS). For all patients, MRI and/or CT were performed before surgery. During surgery, IOUS was performed after liver mobilization, and when nodules that had not been detected in the preoperative MRI and/or CT were observed, CE-IOUS scans were carried out with the dual purpose of better characterizing the unknown lesion and discovering new lesions. Results In 12 patients, IOUS showed 14 nodules not detected by preoperative MRI and/or CT, before surgery. Out of the 12 lesions, five presented vascular features compatible with those of malignant HCC to the evaluation with CE-IOUS and four of these were simultaneously treated with intraoperative radiofrequency ablation (RFA). The fifth lesion was resected by the surgeon. The remaining nine lesions recognized by IOUS were evaluated as benign at CE-IOUS and considered regenerative nodules. The last diagnosis was confirmed during follow-up obtained by means of CT and/or MRI after 1, 3, 6, or 12 months. Conclusion In our experience, CE-IOUS is a useful diagnostic tool in both benign pathologies, such as regenerative nodules, and malignant liver lesions. The advantage of this approach is the possibility of intraoperatively characterizing, based on vascularization patterns, lesions that could not be diagnosed by preoperative imaging, resulting in modification of the surgical therapy decision and expansion of the resection or intraoperative ablation.

Results after simultaneous surgery and RFA liver ablation for patients with colorectal carcinoma and synchronous liver metastases

BackgroundApproximately 20% of patients with colorectal cancer present with synchronous liver metastases (sCRLM). These patients can be treated with a “one-step procedure” or staged resection, with or without radiofrequency ablation (RFA). Colorectal surgery in combination with intraoperative RFA leads to concerns regarding postoperative complications and survival. The purpose was to evaluate the one-step procedure with or without RFA in patients with sCRLM. Materials and methodsBetween January 2000 and September 2018, patients with sCRLM were selected in two tertiary referral centers and retrospectively analyzed. Postoperative morbidity and survival were analyzed. ResultsFrom a total of 410 patients presenting with sCRLM, 329 patients underwent a staged resection and 81 a one-step procedure. The 3-year overall survival (OS) was respectively 66% and 69% for one-step procedure and staged resection (P = 0.24). A total of 18 patients underwent RFA during the one step procedure. No significant differences were shown in postoperative complications whether intraoperative RFA was used in patients with sCRLM. In the one-step procedure, the 3-year OS was respectively 43% and 72% wheter patients did or did not receive RFA (P = 0.19). ConclusionOS for patients with sCRLM was similar for both one-step procedure and staged resection. Intraoperative RFA for sCRLM is technically safe.

Prognostic factors of radiofrequency ablation therapy for liver metastases from colorectal cancer

AbstractWe evaluated the prognostic factors in patients with colorectal liver metastases undergoing radiofrequency ablation (RFA). Between 2008 and 2013, 52 patients (males 34, mean age: 63 years) with colorectal liver metastases treated with either percutaneous RFA (n = 33) or intraoperative RFA plus resection (n = 19) were enrolled. Cumulative incidence of new recurrence was estimated using the Kaplan‐Meier method. The prognostic relevance of clinical variables and recurrence or survival were evaluated using the log‐rank test and multivariate Cox's regression analysis, respectively. Primary technical success was achieved in 45 (87%) of the cases. There were no procedure‐related deaths. Multinodularity (>3) (P = 0.001) predicted higher incidence of developing new recurrence after RFA. Overall 1‐, 2‐, and 3‐year survival from RFA was 87%, 61%, and 46%, respectively. Factors associated with overall mortality were age younger than 60 years (P = 0.036), extrahepatic metastasis (P = 0.003), and carcinoembryonic antigen (CEA) level ≥10 ng/mL before RFA (P = 0.011). Multivariate Cox's regression analysis showed that young age (<60 years) and high CEA level (≥10 ng/mL) were independent factors associated with overall survival. RFA for colorectal liver metastases is an effective treatment option. Young age and high CEA level predicted poorer outcomes after RFA.

Intraoperative radiofrequency ablation and distilled water peritoneal lavage for spontaneously ruptured hepatocellular carcinoma.

PurposeSpontaneously ruptured hepatocellular carcinoma (srHCC) is known to be a life-threatening complication with poor prognosis. Although there are various treatment modalities, there is no definite treatment guideline. The purpose of this study was to review the surgical outcome and prognosis of srHCC treated with intraoperative radiofrequency ablation (RFA) and distilled water peritoneal lavage (DWPL).MethodsFrom March 2012 to October 2018, 9 patients with srHCC who underwent emergent surgery were reviewed. After hematoma removal, intraoperative RFA and DWPL were applied to all patients. Hepatectomy was performed if necessary. Patients with multiple tumors, distant metastasis, and vascular tumor involvement in radiologic imaging were excluded.ResultsSix of 9 patients with diameters less than 7 cm were able to obtain hemostasis using RFA alone (RFA group). However, 3 patients with a tumor size of more than 10 cm underwent liver resection because they could not obtain hemostasis with RFA (hepatectomy only group). The RFA group had shorter operation time (148.3 ± 31.7 minutes vs. 251.7 ± 20.2 minutes, P < 0.05) and less red blood cell transfusion (5.8 ± 2.5 packs vs. 24.0 ± 11.5 packs, P < 0.05) than the hepatectomy only group. There was no peritoneal metastasis at long-term follow-up in the RFA group. Five-year recurrence-free survival rate was 0% in both groups. However, 5-year overall survival rate was better in the RFA group (83.3% vs. 0%, P < 0.05).ConclusionIntraoperative RFA and DWPL are easy to perform and theoretically the best methods for managing relatively small srHCC.

Pattern of hepatocellular carcinoma recurrence following living donor liver transplantation

Background: The aim of the present study was to identify the pattern of HCC recurrence after LDLT for early detection and management Methods: From April 2003 to October 2014, the record of 60 patients who underwent LDLT for HCC at the National Liver Institute, Menoufia University, Egypt, were retrospectively reviewed. Results: Seven patients (11.7 per cent) had HCC recurrence after LDLT. Pretransplant α-fetoprotein (AFP) > 1000 ng/mL, tumour grade and microvascular invasion were the incriminated risk factors for recurrence. Three patients (42.8 per cent) had intrahepatic and extrahepatic recurrence (lung and bone), two patients (28.6 per cent) had only extrahepatic recurrence in bones and two patients (28.6 per cent) had only intrahepatic recurrence. Management was as follows: two patients (28.6 per cent) had surgical excision of intrahepatic recurrence and extrahepatic metastasis, two patients (28.6 per cent) underwent radiotherapy for bone metastasis, one patient (14.2 per cent) underwent intraoperative radiofrequency ablation for liver recurrence and two patients (28.6 per cent) received sorafenib as medical treatment. The mean time of recurrence was 19.7 months, and mean survival was 29 months. Conclusion: The majority of HCC recurrences after LDLT are extrahepatic and occur mainly in the first 2 years; strict follow up is required during this period. A high level of pretransplant serum AFP and microvascular invasion are risk factors for tumour recurrence and should be taken into account when selecting candidates for LDLT.

Intraoperative radiofrequency ablation of functioning insulinoma: a case report and literature review

Introduction: Insulinomas are rare neoplasm with a reported incidence of 1-4 cases per million patient- year. Insulinoma is the most common form of the pancreas islet cells producing excessive amounts of insulin. It can be seen at every age but mostly seen between 30 and 60 yr of age, with women accounting for 59%. Case report: A 38-years-old young man was seen in the outpatient room of Hepato-Pancreato-Biliary department of our institution with the anxiety, dizziness, lightheadedness, personality changes and unusual behavior, which were relieved with eating something or taking glucose water orally. He had many times of unconscious situations in last 10 years. He thus had Whipple triad. Methods: Midline incision was created with scalpel and electrocautery. The duodenum and pancreatic head were mobilized. 18g semi-automatic biopsy-needle in tumor target central placement than take a one of filar tissue by under ultrasound guided. Intraoperative RFA was performed under direct vision of the duodenum to avoid burn damage. Simultaneously infusion/perfusion with cold normal saline of the areas around the tumors was done during ablation. Ultrasound guided biopsy was performed before RFA. The surgery was successfully finished without a perioperative complication but needed to reoperate 2 weeks later to drain pancreatic leakage and it was successfully managed. Results: Histology shows a solid pseudo-encapsulated insulinoma of the pancreas but needed to perform immunohistochemical assay to confirm the diagnosis. Conclusions: Intra-operative RFA is safe and feasible in patients with quotidian life difficulties in order to avoid surgerical approaches.

Percutaneous Laser Thermal Ablation in a Patient with 22 Liver Metastases from Pancreatic Neuroendocrine Tumours: A Case Report

The relatively indolent nature of well-differentiated neuroendocrine tumours (NET) and their proclivity to be hormonally active warrants aggressive multimodal treatment, even for advanced stage disease. Good results have been reported in well-selected patients with a median of 23 liver metastases (LM) from NET treated with surgical resection combined with intraoperative radiofrequency ablation. We report the case of a patient who underwent percutaneous laser thermal ablation (LTA) of 22 small LM from NET, treated over three consecutive sessions. After 2 years, five new LM were detected and treated with LTA. At present, 82 months after the first LTA session, the patient is still alive and disease-free. Due to enabling the use of one to four optical fibres at once to tailor the thermal lesion size to the nodule size, LTA could represent the ablation technique of choice in the presence of multiple, small, and variably sized LM.

Technique, safety, and feasibility of EUS-guided radiofrequency ablation in unresectable pancreatic cancer.

Radiofrequency ablation (RFA) is a well-recognized local ablative technique applied in the treatment of different solid tumors. Intraoperative RFA has been used for non-metastatic unresectable pancreatic ductal adenocarcinoma (PDAC), showing increased overall survival in retrospective studies. A novel RFA probe has recently been developed, allowing RFA under endoscopic ultrasound (EUS) guidance. Aim of the present study was to assess the feasibility and safety of EUS-guided RFA for unresectable PDACs. Patients with unresectable non-metastatic PDAC were included in the study following neoadjuvant chemotherapy. EUS-guided RFA was performed using a novel monopolar 18-gauge electrode with a sharp conical 1cm tip for energy delivery. Pre- and post-procedural clinical and radiological data were prospectively collected. Ten consecutive patients with unresectable PDAC were enrolled. The procedure was successful in all cases and no major adverse events were observed. A delineated hypodense ablated area within the tumor was observed at the 30-day CT scan in all cases. EUS-guided RFA is a feasible and safe minimally invasive procedure for patients with unresectable PDAC. Further studies are warranted to demonstrate the impact of EUS-guided RFA on disease progression and overall survival.

Evaluation of Effects of Radiofrequency Ablation of Ex vivo Liver Using the 1-Fr Wire Electrode.

Percutaneous and intraoperative radiofrequency ablation (RFA) has become a valued tool in the management of primary and secondary hepatic lesions. A recent FDA-approved endoscopic ultrasound (EUS)-guided RFA probe now offers promise to help manage such lesions. However, there are no data to determine the ideal power setting and duration of ablation needed to effectively treat hepatic masses. The aim of the study was to evaluate the macroscopic zone of hepatic injury for EUS-RFA using a variety of settings within a fresh porcine hepatic specimen. RFA was performed using the Habib EUS-RFA needle (EMcision Ltd, London, UK) which is a 1-Fr wire (0.33 mm, 0.013 inch) with a working length of 190 cm. A step by step approach to deliver radiofrequency energy at 5, 10, 15, 20, and 50 W of power and 10, 30, 60, 90, 120, and 300 seconds, respectively, was followed. Macroscopic and microscopic findings of the ablation zone were evaluated at each setting. The maximal zone (diameter, 8.2±0.14 mm; length, 20.85±0.21 mm) of coagulative necrosis was achieved using an ablation power of 10 W for duration of 90 seconds. Notably, increased power settings resulted in an unexpected and diminished effect on tissue destruction. Our findings support the use of 10 W power for 90 seconds for maximum ablation in the liver. Our data also provide initial guidance and alternate settings to be considered when performing EUS-RFA to adjust the ablation power and duration to match the lesion size, shape, and risk of injury to adjacent structures.

Ultrasound-Guided Intraoperative Radiofrequency Ablation and Surgical Resection for Liver Metastasis from Malignant Gastrointestinal Stromal Tumors.

ObjectiveTo evaluate the effectiveness, safety, and feasibility of intraoperative radiofrequency ablation (IORFA) under ultrasound guidance for the treatment of liver metastases from gastrointestinal stromal tumors (GISTs).Materials and MethodsFrom August 2009 to February 2017, 24 patients with liver metastases of GISTs underwent IORFA, 14 underwent concurrent IORFA and primary GIST resection, and 10 underwent IORFA to treat hepatic recurrence after previous primary GIST resection. Seventy-six hepatic metastases were treated, of which 47 were surgically resected and 29 underwent IORFA. All included patients received imatinib therapy as standard treatment before and after IORFA or surgical resection. A retrospective medical record review was conducted, and follow-up data were collected. Technical success and effectiveness, overall and GIST-specific survival, and complications were assessed.ResultsThe mean follow-up duration was 50.7 ± 34.7 months. The technical success rate of IORFA was 100%. New metastases developed in three of the 24 patients (12.5%) following a complete response 16, 51, and 95 months after IORFA, respectively. The cumulative one-, three-, and five-year overall survival rates were 100, 94.4, and 87.7%, respectively. The one-, three-, and five-year GIST-related survival rates were 100, 94.4, and 94.4%, respectively. Two major complications (biliary stricture and hepatic abscess) were observed.ConclusionIORFA appears to be a feasible and safe treatment option for liver metastasis in patients with primary GISTs. In addition, IORFA and surgical resection may be complementary, helping to obtain complete response in cases of otherwise inoperable liver metastases secondary to GISTs.

Ten-year outcome of intraoperative treatment of atrial fibrillation using radiofrequency ablation.

BackgroundIntraoperative radiofrequency ablation (RFA) has been advocated to treat atrial fibrillation (AF). This report examines the long-term effects of intraoperative RFA in the prevention of recurrence of AF when used as an adjunctive treatment in patients undergoing cardiac procedures for primary indications unrelated to their arrhythmia.MethodsThe study reviewed the records of patients from a tertiary medical center which had 2 cardiac surgeons performing an intraoperative adjunctive RFA procedure. A total of 20 patients undergoing RFA between April 11, 2003 and May 10, 2005 were included and followed for up to 10 years. The primary effectiveness outcome of the study was the recurrence of AF during the follow-up period. Data were collected from office or hospital medical records.ResultsA total of 20 patients were included (mean age 69.4 years, males 40%). Eight patients were followed for 10 years and 2 patients for 9 years; 7 patients died during the 10-year follow-up period and 3 patients were lost to follow-up. As their primary procedures, the patients underwent valve surgery (65%), bypass surgery (15%), or both (20%). Intraoperative RFA failed to restore sinus rhythm in 2 patients. In the remaining 18 patients, AF recurred in 10 patients within 2 months of surgery, in 1 patient at 5 months, in 1 patient at 7 months, and in 6 patients after 1 year.ConclusionAF had recurred in 100% of patients by the end of the long-term follow-up period. The adjunctive intraoperative RFA and postoperative interventions employed in this early study failed to maintain sinus rhythm.

Efficiency of contrast enhanced ultrasound for immediate assessment of ablation status after intraoperative radiofrequency ablation of hepatic malignancies.

To evaluate the efficiency of intraoperative contrast enhanced ultrasound (Io-CEUS) for assessment of radiofrequency ablation (RFA) during liver tumor surgery. Retrospective analysis was performed on a total number of 18 patients out of over 500 patients who underwent combined liver tumor surgery and RFA of 27 hepatic tumors between 02/2011 and 12/2016. Io-CEUS was performed by bolus injections of up to 10 ml sulphur hexaflourid microbubbles for diagnostic purposes. To guide the RFA up to 20 ml microbubbles were applied to monitor the procedure and assess the ablation status finally. A fully avascular area or absence of any residual vascularization intratumorally was considered technical success. These findings were correlated to findings of follow-up imaging results (CEUS, MRI, CT) at least 1 up to 40 months (mean 11 months) after surgery. 13 male and 5 female patients aged between 45-77 years (mean 59.2±17.1 years) with 26 malignant and one most probable benign hepatic lesion were treated with intraoperative RFA. Io-CEUS detected 23 preoperatively unknown liver lesions leading to a change in therapy in 13/18 cases (72,2%). All 27 treated lesions showed an avascular area immediately after RFA. According to follow-up imaging results (1 month - 3 years after surgery, mean follow-up time 11 months), 2/18 patients had local recurrences, 8 patients had distant intrahepatic recurrences or extrahepatic recurrence, 8 patients remained tumor-free. Thereby, a success rate of CEUS guided RFA of 89% could be obtained concerning the targeted liver lesions. Modern intraoperative ultrasound using B-mode and Io-CEUS is a valuable tool for optimization of diagnostic and therapeutic intraoperative liver procedures and ablative therapies.

Prognostic analysis of colorectal liver metastases treated by surgery combined with intraoperative radiofrequency ablation

Objective: To investigate the clinical value of intraoperative radiofrequency ablation (RFA) in the treatment of colorectal liver metastasis (CLM). Methods: A retrospectively analysis of 187 patients with CLM who underwent liver resection with or without RFA from January 2009 to August 2016 in Department of Hepatobiliary Surgery, Cancer Hospital, Chinese Academy of Medical Sciences was performed. According to whether RFA was used intraoperatively, patients were divided into resection only group and combined treatment group. The clinical and pathological characteristics of the two groups were compared to explore factors influencing survival and recurrence. Imbalance of background characteristics between the two groups was further overcome by propensity score matching method (PSM). Results: The number of liver metastases (267), simultaneous liver metastases (100%), bilobar involvement (73.3%) and preoperative chemotherapy (93.3%) rates were significantly higher in the combined treatment group than those in the resection only group(471, 74.7%, 42.0% and 63.1%)(all P<0.05). In the combined treatment group, median overall survival (OS) was 25.7 months; and 3-year and 5-year OS were 47.9% and 28.8%, respectively. In the resection only group, the median survival time was 46.9 months; and 3-year and 5-year OS rate was 59.1% and 42.4%, respectively (χ(2)=4.579, P=0.034). Median disease-free survival (DFS) was 5.4 months in the combined treatment group, and 10.1 months in the resection only group (χ(2)=5.399, P=0.023). In multivariate analysis, intraoperative RFA was not an independent prognostic factor for OS and DFS (HR=0.98, 95%CI: 0.47-2.08, P=0.965; HR=1.21, 95%CI: 0.71-2.07, P=0.465). After PSM, the median OS of the resection only and the combined treatment groups were 30.2 and 25.7 months (χ(2)=0.876, P=0.350). The median DFS in the two groups was 5.3 and 4.2 months, respectively (χ(2)=0.199, P=0.650). Conclusion: In patients with similar tumor burden, liver resection combined with intraoperative RFA for unresectable CLM can achieve long-term outcomes similar to hepatectomy alone for resectable CLM.

Combined resection and radiofrequency ablation versus transarterial embolization for intermediate-stage hepatocellular carcinoma: A propensity score matching study.

This study aimed to compare the outcomes of combined hepatic resection (HR) plus intraoperative radiofrequency ablation (RFA) and transarterial embolization (TAE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score. A total of 179 patients with multifocal HCC treated with HR plus RFA (n=26) or TAE(n=153) were retrospectively studied. All patients were classified as BCLC stage B and Child-Pugh class A. Analyses were performed over all participants as well as for propensity score-matched (1:3) patients to adjust for baseline differences. Cumulative overall survival (OS) and time to progression (TTP) were compared between the two groups using the Kaplan-Meier method, and independent predictors were identified by multivariate Cox regression analysis. Patients treated with HR plus RFA had better OS and longer TTP than those with TAE (p=0.011 and p<0.001, respectively). Multivariate Cox regression analysis showed that combined therapy (hazard ratio 0.31; 95% confidence interval (CI), 0.12-0.78; p=0.013), BCLC substage B2 (hazard ratio 1.82; 95% CI, 1.13-2.92; p=0.013) and alpha-fetoprotein≥400ng/ml (hazard ratio 1.85; 95% CI, 1.12-3.05; p=0.016) were independent factors associated with OS. After propensity score matching, combined therapy was the significant factor associated with OS and TTP by univariate and multivariate analyses. Combined HR plus RFA may provide survival advantage compared to TAE in patients with BCLC stage B HCC.

Clinical effect and prognostic factors analysis of intraoperative radiofrequency ablation in treatment of hepatocellular carcinoma with severe cirrhosis

Objective To investigate the clinical effect and prognostic factors of intraoperative radiofrequency ablation (RFA) in treatment of hepatocellular carcinoma (HCC) with severe cirrhosis. Methods The retrospective case-control study was conducted. The clinicopathological data of 188 HCC patients with severe cirrhosis who were admitted to the Zhongshan Hospital of Fudan University between January 2009 and December 2013 were collected. According to intraoperative exploration, tumor condition and liver cirrhosis situations, partial hepatectomy combined with intraoperative RFA or single RFA was selected. Observation indicators: (1) operation situations: operation time, volume of intraoperative blood loss, blood transfusion, hepatic inflow occlusion, number of tumors of surgical resection and number of tumors removed by RFA; (2) postoperative recovery situations: postoperative complications and duration of postoperative hospital stay; (3) follow-up; (4) factors analysis affecting tumor-free survival. Follow-up using outpatient examination and telephone interview was performed to detect tumor damage and survival of patients up to March 2016. Measurement data with normal distribution were represented as ±s. The survival rate was calculated by the Kaplan-Meier method. The univariate analysis was done by the the Log-rank test, and multivariate analysis was done using the COX regression model. Results (1) Operation situations: all the 188 HCC patients underwent successful operations, including 74 undergoing partial hepatectomy with intraoperative RFA and 114 undergoing single RFA. Of 188 patients, 11 were combined with cholecystectomy, 6 with right adrenalectomy and 1 with subtotal gastrectomy, without perioperative death. Operation time and volume of intraoperative blood loss in 188 patients were (2.3±1.4)hours and (64±4)mL, without blood transfusion and hepatic inflow occlusion. Numbers of patients with 1 tumor of surgical resection and with 2 tumors of surgical resection and total number of tumors of surgical resection were 61, 13, 87 in 74 patients undergoing partial hepatectomy with intraoperative RFA. Numbers of patients with 1, 2, 3 and 4 tumors removed by RFA and total number of tumors of RFA were 123, 58, 6, 1 and 261 in 114 patients undergoing single RFA. (2) Postoperative recovery situations: of 188 patients, 19 with severe complications were improved by symptomatic treatments, including 7 with massive pleural effusion, 5 with massive intra-abdominal effusion, 3 with intra-abdominal bleeding, 3 with severe local infection and 1 with massive pleural and intra-abdominal effusion. Duration of postoperative hospital stay was (7.61±0.20)days. (3) Follow-up: 182 of 188 patients were followed up for 21-85 months, with a median time of 41 months. Patients received enhanced rescans of magnetic resonance imaging (MRI) at 1 month postoperatively, 174 had complete tumor damage, with a tumor damage rate of 92.55%(174/188). During the follow-up, 46 patients died. The overall median survival time, 1-, 2-, 3-year overall survival rates, median tumor-free survival time and 1-, 2-, 3-year tumor-free survival rates were 38 months, 99%, 96%, 86%, 31 months, 92%, 77% and 41%, respectively. (4) Factors analysis affecting tumor-free survival: results of univariate analysis showed that preoperative alpha-fetoprotein (AFP), number of tumors and surgical procedures were relative factors affecting tumor-free survival of HCC patients with severe cirrhosis (χ2=5.623, 4.744, 7.293, P 20 μg/L and partial hepatectomy with intraoperative RFA were independent risk factors affecting tumor-free survival of HCC patients with severe cirrhosis after open RFA (RR=1.523, 1.615, 95% confidence interval: 1.056-2.198, 1.006-2.594, P<0.05). Conclusions Intraoperative RFA is safe and feasible in treatment of HCC with severe cirrhosis, with advantages of less postoperative complications and rapid recovery, and it can provide better long-term survival for patients. Preoperative AFP>20 μg/L and partial hepatectomy with intraoperative RFA are independent risk factors affecting tumor-free survival of HCC patients with severe cirrhosis after open RFA. Key words: Carcinoma, hepatocellular; Liver cirrhosis; Radiofrequency ablation; Hepatectomy; Prognosis

Laparoscopy-Guided Transthoracic Transdiaphragmatic Radiofrequency Ablation for Hepatic Tumors Located Beneath the Diaphragm.

It is often difficult to perform percutaneous radiofrequency ablation (RFA) for hepatic tumors beneath the diaphragm. Diaphragmatic thermal damage is one of the fatal late complications of percutaneous transdiaphragmatic RFA. Our experience with laparoscopic transthoracic transdiaphragmatic intraoperative RFA (LTTI-RFA) for hepatic tumors beneath the diaphragm is reported. Ten patients who underwent LTTI-RFA from 2009 to 2012 were evaluated. Two cases had concomitant partial hepatectomy, and one underwent RFA for two tumors at the same time. The diagnosis was hepatocellular carcinoma in eight cases and metastatic hepatic tumors in two cases. Nine of eleven tumors were located at segments 7 and 8. Nine tumors were less than 20 mm in diameter. The patients were placed in the half left lateral decubitus position with single-lumen tube intubation. After placement of four abdominal ports, a 12-mm port was inserted in the fourth or fifth intercostal space into the diaphragm. The tumor was ablated by an RFA needle through the port. The routine follow-up consisted of laboratory tests and abdominal imaging every 3-6 months. The median operation time for only one tumor was 137 minutes (range, 105-187 minutes). The median number of times for ablation was three. Severe postoperative complications (>Clavien-Dindo IIIa) were observed in one case (right upper limb paralysis). The median follow-up period was 35 months (range, 11-43 months). There was no local tumor progression. Recurrent hepatic tumor appearance occurred in other parts of the liver in 6 of the 11 patients. Laparoscopic transthoracic transdiaphragmatic RFA is an acceptable procedure with a low rate of local recurrence.

Short term and long term results of patients with colorectal liver metastases undergoing surgery with or without radiofrequency ablation

PurposeThe combination of resection and radiofrequency ablation (RFA) may provide an alternative treatment for patients with unresectable colorectal liver metastases (CRLM). Although the results in literature look promising, uncertainty exists with regard to complication risks and survival for this therapy. MethodsFrom January 2000 to May 2013, patients were included in a prospective multicenter database when treated for CRLM. Exclusion criteria were: two-staged treatment, synchronous resection of liver metastases and primary tumor, loss to follow-up or extrahepatic metastases. Patients were divided in a resection-only group (ROG) and combination group (CG). Outcome variables were retrospectively analyzed. ResultsIn CG, 98 patients were included versus 534 patients in ROG. There were no differences in general patient characteristics. Patients in CG had a higher Fong clinical risk score (CRS; P = 0.001), better ASA classification (P = 0.04) and received more neoadjuvant chemotherapy (P = 0.001). There was no difference in postoperative morbidity or 90-day mortality. The 5-year disease-free survival (DFS) for CG and ROG was 25% and 36.1% (P = 0.03), respectively. For the 5-year overall survival (OS) this was respectively 42% and 62.2% (P = 0.001). On multivariate analysis, Fong CRS was a significant predictor for DFS. For OS, Fong CRS, ASA class IV and the combination therapy were significant predictors. ConclusionThe combination of hepatic resection and intraoperative RFA is a safe procedure, without increase in postoperative morbidity or mortality. Combining RFA and resection in one session is a valid treatment option for patients who would otherwise be inoperable.