Clin J Gastroenterol (2014) 7:510–515 DOI 10.1007/s12328-014-0531-1
CASE REPORT
A case of small hepatocellular carcinoma treated with laparoscopic multipolar radiofrequency ablation with a no-touch ablation procedure Naoki Morimoto • Norio Isoda • Shunji Watanabe • Toshiya Otake • Takuya Hirosawa • Mamiko Tsukui • Natsumi Miyata • Kozue Murayama Chihiro Iwashita • Yoshinari Takaoka • Hironori Yamamoto
•
Received: 16 July 2014 / Accepted: 28 September 2014 / Published online: 9 October 2014 Ó Springer Japan 2014
Abstract A 77-year-old man with hepatocellular carcinoma was admitted to our institution. Computed tomography revealed two nodules, one at the surface and one within the liver, B3 cm in diameter. We performed laparoscopic radiofrequency ablation using a bipolar system with a ‘‘no-touch ablation’’ procedure using multiple applicators for insertion, not into the tumor directly, but to the perimeter of the tumor. A sufficient ablated area was obtained regardless of tumor location. No operative complications were encountered and adequate therapeutic effect was achieved safely. Laparoscopic multipolar radiofrequency ablation is a feasible procedure for treating hepatocellular carcinoma. Keywords Laparoscopic radiofrequency ablation Multipolar Bipolar Hepatocellular carcinoma No-touch ablation Abbreviations HCC Hepatocellular carcinoma RFA Radiofrequency ablation LRA Laparoscopic radiofrequency ablation CT Computed tomography
Introduction The therapeutic options for patients with hepatocellular carcinoma (HCC) must be selected with attention to the concomitant underlying liver disease. Surgical resection is a curative therapy for HCC and is considered the first-choice treatment, but is only suitable for a minority of patients because of impaired liver function due to underlying cirrhosis. Radiofrequency ablation (RFA) is a minimally invasive method that can obtain radical localized therapeutic effects and has played a key role worldwide in the management of small HCCs B3 cm in diameter [1]. The safety and therapeutic efficacy of RFA have been confirmed in systematic reviews and meta-analyses [2, 3]. Osaki et al. [4] confirmed that a percutaneous approach using a bipolar RFA system (CelonPOWER System; Olympus Medical Systems, Tokyo, Japan) offered effective and safe RFA for treating HCC, and this system was approved in 2012 for use in Japan. We have employed laparoscopic RFA (LRA) to minimize complications and local recurrence since 1999, and report herein a case of HCCs treated with LRA using a bipolar RFA system.
Case report
N. Morimoto (&) N. Isoda S. Watanabe T. Otake T. Hirosawa M. Tsukui N. Miyata K. Murayama C. Iwashita Y. Takaoka H. Yamamoto Division of Gastroenterology and Hepatology, Department of Internal Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi 329-0498, Japan e-mail: [email protected]
123
The patient was a 77-year-old man, without drinking history, who had been diagnosed with chronic hepatitis C in 1994 and achieved sustained viral response with interferon therapy. In 2009, LRA was performed for HCCs in bilateral lobes of the liver. Although he suffered from diffuse largecell lymphoma, he underwent chemotherapy and achieved complete response in 2013. No recurrence of HCC was noted for 5 years, but computed tomography (CT) and
Clin J Gastroenterol (2014) 7:510–515
511
magnetic resonance imaging in 2014 revealed new HCCs located in segments 3 and 8 with diameters of 1.3 and 2.5 cm, respectively (Fig. 1). Since the recurrences of HCC occurred in bilateral lobes and he had been recently receiving chemotherapy for malignant lymphoma, it was thought that the burden of a hepatic resection was heavy for him and he was hospitalized to undergo LRA. At the time of admission, hepatitis C virus was not detected and liver function was Child–Pugh class A with 5 points (Table 1).
LRA was performed under general anesthesia, following the technique described previously [5, 6]. Laparoscopic examination revealed a nodule projecting from the hepatic surface of segment 3, adjacent to the stomach. After detailed observation of the tumors and the vicinity under laparoscopic ultrasonography with a linear probe (PEF704LA; Toshiba Medical, Tokyo, Japan), we employed three internally cooled bipolar electrode applicators for multipolar LRA in a ‘‘no-touch ablation’’ procedure that
Fig. 1 Abdominal enhanced CT before treatment. a, b CT shows HCC in segment 8 in early phase (a) and late phase (b) (arrow). c, d CT shows HCC in the hepatic surface of segment 3 in early phase (c) and late phase (d) (arrowhead)
Table 1 Laboratory data on admission
WBC
8300
/ll
TP
6.9
g/dl
Cre
0.67
mg/dl
RBC
461
104/ll
Alb
4.3
g/dl
Na
143
mEq/dl
Hb
14.8
g/dl
T-Bil
0.63
mg/dl
K
4.2
mEq/dl
Hct
43.6
%
AST
21
IU/l
Cl
105
mEq/dl
MCV
94
fl
ALT
23
IU/l
MCH
32.1
pg
LDH
199
IU/l
HBsAg
0.00
(-)
MCHC
34.0
%
ALP
337
IU/l
HCVAb
15.14
(?)
Plt
15.2
104/ll
cGTP
24
IU/l
%
ChE BUN
348 12
IU/l mg/dl
AFP PIVKA-II
15 88
ng/ml mAU/ml
PT
99.6
123
512
Fig. 2 Multipolar laparoscopic radiofrequency ablation (LRA) for the tumor at the surface of the liver. a Laparoscopy shows the prominent tumor at the hepatic surface of the left lobe, and two
Clin J Gastroenterol (2014) 7:510–515
applicators inserted at the perimeter of the tumor. b After 3 min ablation while depressing the stomach with forceps, the tumor was sufficiently ablated without affecting the adjacent organs
Fig. 3 Multipolar laparoscopic radiofrequency ablation (LRA) for the tumor inside the liver in segment 8. Multipolar LRA was performed using a 14-G guide sheath to locate the electrodes exactly in parallel as planned
did not involve insertion of electrodes into the tumor, to prevent dissemination. A CelonPOWER system generator and needle-type bipolar applicators with electrodes 3 cm in length were used. The HCC on the hepatic surface in segment 3 was treated with two bipolar electrode applicators inserted to the right and left perimeters of the tumor, rather than into the tumor directly, using both laparoscopic direct observation and laparoscopic ultrasonography (Fig. 2). For the treatment of the HCC within the liver in segment 8, after adequately changing the position of the patient, three applicators were inserted under laparoscopic ultrasonography guidance to surround the tumor (Fig. 3). We set the total energy and output according to the standard dosimetry table. The RF current was generated using automated control of the output with the resistancecontrolled automatic power (RCAP) function. Ablation
123
times using 2 and 3 applicators were 3 and 12 min, respectively. Four days after ablation, CT showed sufficient ablated areas around each lesion and no complications related to therapy were noted (Fig. 4). The patient was discharged from hospital 5 days after therapy in accordance with the clinical pathway. At 6 months after the ablation therapy, serum AFP and PIVKA-II levels decreased from 5 to 3 ng/ ml and from 88 to 21 mAU/mL, respectively. No recurrence has been seen.
Discussion HCC is one the most common malignancies around the world and is often the cause of death in patients with chronic liver disease [7]. Surgical resection is the definitive
Clin J Gastroenterol (2014) 7:510–515
513
Fig. 4 CT 4 days after multipolar LRA shows sufficient ablated area in segments 8 (a) and 3 (b) without damage to the other adjacent organs
treatment for HCC, but few patients meet the indications for surgery because of the underlying liver damage caused by background cirrhosis [8]. RFA was first reported as an effective treatment for HCC in 1995 [9], and is now widely used as a standard treatment, in place of percutaneous ethanol injection and microwave coagulation therapy, for local treatment of HCCs B3 cm in diameter [10–12]. RFA is minimally invasive compared to hepatic resection, and because the treatment can be repeated without affecting hepatic functional reserve, this modality can also be safely employed in elderly patients [13, 14]. RFA can be performed using a percutaneous, endoscopic, or open laparotomy approach; most institutions adopt percutaneous RFA under local anesthesia. However, RFA with percutaneous approach is often difficult for tumors on the liver surface, lesions adjacent to other organs, or subdiaphragmatic lesions [15, 16]. RFA with artificial pleural effusion and/or ascites has been performed [17], but relatively high local recurrence rates have been reported after treatment of difficult lesion sites [18, 19]. Laparoscopic ablation therapy has been very useful for the treatment of lesions on the liver surface [20, 21], and good local ablation can be achieved by maintaining a sufficient fluid space between the target lesion and the diaphragm or other organs, while avoiding damage to adjacent organs [6, 22–25]. Bipolar RFA became available in Europe and the United States in the 1990s and is now used for the treatment of HCC [26, 27]. In Japan, multipolar RFA using the CelonPOWER System was approved for coverage by the health insurance system in 2012, and has been clinically available since 2013. This multipolar RFA system enables insertion of up to three bipolar applicators at the same time. These needle-type applicators offer excellent insertion ability, do not require a grounding pad, and do not cause thermal
injury to the skin. In addition, these applicators are not prone to vascular heat sink effects that can unexpectedly decrease the ablated area [4]. For tumors B3 cm in diameter, ‘‘no-touch ablation’’ is possible. In other words, without inserting the applicator into the tumor, ablation can be performed by electrodes positioned at the perimeter of the tumor [28–30]. Local recurrence after RFA has been reported and performing ablation with sufficient safety margins is important to increase the likelihood of curative treatment [31, 32]. In a no-touch ablation procedure, the applicator is located adjacent to the tumor perimeter, so an ablated area of at least 1 cm around the applicator can be reliably achieved. The tumor itself is not punctured, so, as well as prevention of tumor cell dissemination, a more reliable safety margin is ensured. This is expected to reduce the risk of local recurrence [29, 30]. However, to achieve a large coagulation area in accordance with planned thermal dosimetry, each applicator electrode must be inserted in parallel at fixed distance intervals. When using a percutaneous approach, accurate puncture is difficult in some cases because of echo window problems due to ribs or poor visualization of the tumor itself. Because our patient underwent laparoscopic treatment, sufficient distances between the treated lesions and the diaphragm, parietal structures, and adjacent organs were maintained, and all applicators could be inserted as planned in parallel with the tumor perimeter. No-touch ablation was performed, and a good ablated area was achieved without affecting surrounding organs. Since prevention of bleeding and/or seeding from the tumor was expectable, no-touch ablation was especially useful for the treatment of the lesion on the liver surface. Moreover, LRA of the tumor located deep in the liver could be performed safely and satisfactorily under ultrasonography guidance.
123
514
Clin J Gastroenterol (2014) 7:510–515
Also in multipolar RFA, as reported for single needle insertion [5, 6, 33, 34], the laparoscopic procedure was a reliable treatment for HCC regardless of the tumor location.
Conclusion We reported a case of HCCs treated with multipolar LRA without affecting the adjacent organs. With multipolar RFA, there is no thermal injury to the skin, ablation time is shorter, and patient burden is reduced. Multipolar LRA may become an attractive option for treatment of localized HCC. The effectiveness and safety of multipolar LRA should be confirmed in a larger number of patients. The appropriate use of multipolar LRA compared to conventional monopolar RFA should also be further investigated. Disclosures Conflict of Interest: of interest.
The authors declare that they have no conflict
Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Minami Y, Kudo M. Radiofrequency ablation of hepatocellular carcinoma: current status. World J Radiol. 2010;2:417–24. 2. Sutherland LM, Williams JAR, Padbury RTA, et al. Radiofrequency ablation of liver tumors: a systematic review. Arch Surg. 2006;141:181–90. 3. Salhab M, Canelo R. An overview of evidence-based management of hepatocellular carcinoma: a meta-analysis. J Cancer Res Ther. 2011;7:463–75. 4. Osaki Y, Ikeda K, Izumi N, et al. Clinical effectiveness of bipolar radiofrequency ablation for small liver cancers. J Gastroenterol. 2013;48:874–83. 5. Kawamoto C, Ido K, Isoda N, et al. Long-term outcomes for patients with solitary hepatocellular carcinoma treated by laparoscopic microwave coagulation. Cancer. 2005;103:985–93. 6. Nagae G, Ido K, Isoda N, et al. Laparoscopic ablation therapy for hepatocellular carcinoma. Dig Endosc. 2005;17:1–8. 7. Ferlay J, Shin H-R, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893–917. 8. Lai EC, Fan ST, Lo CM, et al. Hepatic resection for hepatocellular carcinoma. Ann Surg. 1995;221:291–8. 9. Rossi S, Di Stasi M, Buscarini E, et al. Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular carcinoma. Cancer J Sci Am. 1995;1:73–81. 10. Shiina S, Tateishi R, Arano T, et al. Radiofrequency ablation for hepatocellular carcinoma: 10-year outcome and prognostic factors. Am J Gastroenterol. 2012;107:569–77.
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11. Bouza C, Lo´pez-Cuadrado T, Alca´zar R, et al. Meta-analysis of percutaneous radiofrequency ablation versus ethanol injection in hepatocellular carcinoma. BMC Gastroenterol. 2009;9:31–9. 12. Ohmoto K, Yoshioka N, Tomiyama Y, et al. Comparison of therapeutic effects between radiofrequency ablation and percutaneous microwave coagulation therapy for small hepatocellular carcinomas. J Gastroenterol Hepatol. 2009;24:223–7. 13. Bove A, Bongarzoni G, Di Renzo RM, et al. Efficacy and safety of ablative techniques in elderly HCC patients. Ann Ital Chir. 2011;82:457–63. 14. Yamazaki H, Tsuji K, Nagai K, et al. Efficacy and long-term outcomes of radiofrequency ablation in the elderly with hepatocellular carcinoma. Hepatol Res. 2013. doi:10.1111/hepr.12233. 15. Huang J-W, Hernandez-Alejandro R, Croome KP, et al. Surgical vs percutaneous radiofrequency ablation for hepatocellular carcinoma in dangerous locations. World J Gastroenterol. 2011;17:123–9. 16. Teratani T, Yoshida H, Shiina S, et al. Radiofrequency ablation for hepatocellular carcinoma in so-called high-risk locations. Hepatology. 2006;43:1101–8. 17. Minami Y, Kudo M, Kawasaki T, et al. Percutaneous ultrasoundguided radiofrequency ablation with artificial pleural effusion for hepatocellular carcinoma in the hepatic dome. J Gastroenterol. 2003;38:1066–70. 18. Komorizono Y, Oketani M, Sako K, et al. Risk factors for local recurrence of small hepatocellular carcinoma tumors after a single session, single application of percutaneous radiofrequency ablation. Cancer. 2003;97:1253–62. 19. Hori T, Nagata K, Hasuike S, et al. Risk factors for the local recurrence of hepatocellular carcinoma after a single session of percutaneous radiofrequency ablation. J Gastroenterol. 2003;38:977–81. 20. Tsuji K, Nishimori H, Sakurai Y, et al. Efficacy and long-term outcome of laparoscopic microwave coagulation or radiofrequency ablation therapy for surface-type hepatocellular carcinoma. Dig Endosc. 2004;16:117–21. 21. Yokoyama T, Egami K, Miyamoto M, et al. Percutaneous and laparoscopic approaches of radiofrequency ablation treatment for liver cancer. J Hepatobiliary Pancreat Surg. 2003;10:425–7. 22. Chung MH, Wood TF, Tsioulias GJ, et al. Laparoscopic radiofrequency ablation of unresectable hepatic malignancies. A phase 2 trial. Surg Endosc. 2001;15:1020–6. 23. Santambrogio R, Podda M, Zuin M, et al. Safety and efficacy of laparoscopic radiofrequency ablation of hepatocellular carcinoma in patients with liver cirrhosis. Surg Endosc. 2003;17:1826–32. 24. Herbold T, Wahba R, Bangard C, et al. The laparoscopic approach for radiofrequency ablation of hepatocellular carcinoma—indication, technique and results. Langenbecks Arch Surg. 2013;398:47–53. 25. Sakoda M, Ueno S, Iino S, et al. Endoscopic versus open radiofrequency ablation for treatment of small hepatocellular carcinoma. World J Surg. 2013;37:597–601. 26. Tacke J, Mahnken A, Roggan A, et al. Multipolar radiofrequency ablation: first clinical results. Rofo. 2004;176:324–9. 27. Frericks BB, Ritz JP, Roggan A, et al. Multipolar radiofrequency ablation of hepatic tumors: initial experience. Radiology. 2005;237:1056–62. 28. Kawamura Y, Ikeda K, Fukushima T, et al. Potential of a notouch pincer ablation procedure for small hepatocellular carcinoma that uses a multipolar radiofrequency ablation system: an experimental animal study. Hepatol Res. 2013. doi:10.1111/hepr. 12240. 29. Seror O, N’kontchou G, Van Nhieu JT, et al. Histopathologic comparison of monopolar versus no-touch multipolar radiofrequency ablation to treat hepatocellular carcinoma within Milan criteria. J Vasc Interv Radiol. 2014;25:599–607.
Clin J Gastroenterol (2014) 7:510–515 30. Eisele RM, Neuhaus P, Schumacher G. Radiofrequency ablation of liver tumors using a novel bipolar device. J Laparoendosc Adv Surg Tech A. 2008;18:857–63. 31. Kudo M. Local ablation therapy for hepatocellular carcinoma: current status and future perspectives. J Gastroenterol. 2004;39:205–14. 32. Zytoon AA, Ishii H, Murakami K, et al. Recurrence-free survival after radiofrequency ablation of hepatocellular carcinoma. A registry report of the impact of risk factors on outcome. Jpn J Clin Oncol. 2007;37:658–72.
515 33. Ido K, Isoda N, Sugano K. Microwave coagulation therapy for liver cancer: laparoscopic microwave coagulation. J Gastroenterol. 2001;36:145–52. 34. Sakaguchi H, Seki S, Tsuji K, et al. Endoscopic thermal ablation therapies for hepatocellular carcinoma: a multi-center study. Hepatol Res. 2009;39:47–52.
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CASE REPORT
A case of small hepatocellular carcinoma treated with laparoscopic multipolar radiofrequency ablation with a no-touch ablation procedure Naoki Morimoto • Norio Isoda • Shunji Watanabe • Toshiya Otake • Takuya Hirosawa • Mamiko Tsukui • Natsumi Miyata • Kozue Murayama Chihiro Iwashita • Yoshinari Takaoka • Hironori Yamamoto
•
Received: 16 July 2014 / Accepted: 28 September 2014 / Published online: 9 October 2014 Ó Springer Japan 2014
Abstract A 77-year-old man with hepatocellular carcinoma was admitted to our institution. Computed tomography revealed two nodules, one at the surface and one within the liver, B3 cm in diameter. We performed laparoscopic radiofrequency ablation using a bipolar system with a ‘‘no-touch ablation’’ procedure using multiple applicators for insertion, not into the tumor directly, but to the perimeter of the tumor. A sufficient ablated area was obtained regardless of tumor location. No operative complications were encountered and adequate therapeutic effect was achieved safely. Laparoscopic multipolar radiofrequency ablation is a feasible procedure for treating hepatocellular carcinoma. Keywords Laparoscopic radiofrequency ablation Multipolar Bipolar Hepatocellular carcinoma No-touch ablation Abbreviations HCC Hepatocellular carcinoma RFA Radiofrequency ablation LRA Laparoscopic radiofrequency ablation CT Computed tomography
Introduction The therapeutic options for patients with hepatocellular carcinoma (HCC) must be selected with attention to the concomitant underlying liver disease. Surgical resection is a curative therapy for HCC and is considered the first-choice treatment, but is only suitable for a minority of patients because of impaired liver function due to underlying cirrhosis. Radiofrequency ablation (RFA) is a minimally invasive method that can obtain radical localized therapeutic effects and has played a key role worldwide in the management of small HCCs B3 cm in diameter [1]. The safety and therapeutic efficacy of RFA have been confirmed in systematic reviews and meta-analyses [2, 3]. Osaki et al. [4] confirmed that a percutaneous approach using a bipolar RFA system (CelonPOWER System; Olympus Medical Systems, Tokyo, Japan) offered effective and safe RFA for treating HCC, and this system was approved in 2012 for use in Japan. We have employed laparoscopic RFA (LRA) to minimize complications and local recurrence since 1999, and report herein a case of HCCs treated with LRA using a bipolar RFA system.
Case report
N. Morimoto (&) N. Isoda S. Watanabe T. Otake T. Hirosawa M. Tsukui N. Miyata K. Murayama C. Iwashita Y. Takaoka H. Yamamoto Division of Gastroenterology and Hepatology, Department of Internal Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi 329-0498, Japan e-mail: [email protected]
123
The patient was a 77-year-old man, without drinking history, who had been diagnosed with chronic hepatitis C in 1994 and achieved sustained viral response with interferon therapy. In 2009, LRA was performed for HCCs in bilateral lobes of the liver. Although he suffered from diffuse largecell lymphoma, he underwent chemotherapy and achieved complete response in 2013. No recurrence of HCC was noted for 5 years, but computed tomography (CT) and
Clin J Gastroenterol (2014) 7:510–515
511
magnetic resonance imaging in 2014 revealed new HCCs located in segments 3 and 8 with diameters of 1.3 and 2.5 cm, respectively (Fig. 1). Since the recurrences of HCC occurred in bilateral lobes and he had been recently receiving chemotherapy for malignant lymphoma, it was thought that the burden of a hepatic resection was heavy for him and he was hospitalized to undergo LRA. At the time of admission, hepatitis C virus was not detected and liver function was Child–Pugh class A with 5 points (Table 1).
LRA was performed under general anesthesia, following the technique described previously [5, 6]. Laparoscopic examination revealed a nodule projecting from the hepatic surface of segment 3, adjacent to the stomach. After detailed observation of the tumors and the vicinity under laparoscopic ultrasonography with a linear probe (PEF704LA; Toshiba Medical, Tokyo, Japan), we employed three internally cooled bipolar electrode applicators for multipolar LRA in a ‘‘no-touch ablation’’ procedure that
Fig. 1 Abdominal enhanced CT before treatment. a, b CT shows HCC in segment 8 in early phase (a) and late phase (b) (arrow). c, d CT shows HCC in the hepatic surface of segment 3 in early phase (c) and late phase (d) (arrowhead)
Table 1 Laboratory data on admission
WBC
8300
/ll
TP
6.9
g/dl
Cre
0.67
mg/dl
RBC
461
104/ll
Alb
4.3
g/dl
Na
143
mEq/dl
Hb
14.8
g/dl
T-Bil
0.63
mg/dl
K
4.2
mEq/dl
Hct
43.6
%
AST
21
IU/l
Cl
105
mEq/dl
MCV
94
fl
ALT
23
IU/l
MCH
32.1
pg
LDH
199
IU/l
HBsAg
0.00
(-)
MCHC
34.0
%
ALP
337
IU/l
HCVAb
15.14
(?)
Plt
15.2
104/ll
cGTP
24
IU/l
%
ChE BUN
348 12
IU/l mg/dl
AFP PIVKA-II
15 88
ng/ml mAU/ml
PT
99.6
123
512
Fig. 2 Multipolar laparoscopic radiofrequency ablation (LRA) for the tumor at the surface of the liver. a Laparoscopy shows the prominent tumor at the hepatic surface of the left lobe, and two
Clin J Gastroenterol (2014) 7:510–515
applicators inserted at the perimeter of the tumor. b After 3 min ablation while depressing the stomach with forceps, the tumor was sufficiently ablated without affecting the adjacent organs
Fig. 3 Multipolar laparoscopic radiofrequency ablation (LRA) for the tumor inside the liver in segment 8. Multipolar LRA was performed using a 14-G guide sheath to locate the electrodes exactly in parallel as planned
did not involve insertion of electrodes into the tumor, to prevent dissemination. A CelonPOWER system generator and needle-type bipolar applicators with electrodes 3 cm in length were used. The HCC on the hepatic surface in segment 3 was treated with two bipolar electrode applicators inserted to the right and left perimeters of the tumor, rather than into the tumor directly, using both laparoscopic direct observation and laparoscopic ultrasonography (Fig. 2). For the treatment of the HCC within the liver in segment 8, after adequately changing the position of the patient, three applicators were inserted under laparoscopic ultrasonography guidance to surround the tumor (Fig. 3). We set the total energy and output according to the standard dosimetry table. The RF current was generated using automated control of the output with the resistancecontrolled automatic power (RCAP) function. Ablation
123
times using 2 and 3 applicators were 3 and 12 min, respectively. Four days after ablation, CT showed sufficient ablated areas around each lesion and no complications related to therapy were noted (Fig. 4). The patient was discharged from hospital 5 days after therapy in accordance with the clinical pathway. At 6 months after the ablation therapy, serum AFP and PIVKA-II levels decreased from 5 to 3 ng/ ml and from 88 to 21 mAU/mL, respectively. No recurrence has been seen.
Discussion HCC is one the most common malignancies around the world and is often the cause of death in patients with chronic liver disease [7]. Surgical resection is the definitive
Clin J Gastroenterol (2014) 7:510–515
513
Fig. 4 CT 4 days after multipolar LRA shows sufficient ablated area in segments 8 (a) and 3 (b) without damage to the other adjacent organs
treatment for HCC, but few patients meet the indications for surgery because of the underlying liver damage caused by background cirrhosis [8]. RFA was first reported as an effective treatment for HCC in 1995 [9], and is now widely used as a standard treatment, in place of percutaneous ethanol injection and microwave coagulation therapy, for local treatment of HCCs B3 cm in diameter [10–12]. RFA is minimally invasive compared to hepatic resection, and because the treatment can be repeated without affecting hepatic functional reserve, this modality can also be safely employed in elderly patients [13, 14]. RFA can be performed using a percutaneous, endoscopic, or open laparotomy approach; most institutions adopt percutaneous RFA under local anesthesia. However, RFA with percutaneous approach is often difficult for tumors on the liver surface, lesions adjacent to other organs, or subdiaphragmatic lesions [15, 16]. RFA with artificial pleural effusion and/or ascites has been performed [17], but relatively high local recurrence rates have been reported after treatment of difficult lesion sites [18, 19]. Laparoscopic ablation therapy has been very useful for the treatment of lesions on the liver surface [20, 21], and good local ablation can be achieved by maintaining a sufficient fluid space between the target lesion and the diaphragm or other organs, while avoiding damage to adjacent organs [6, 22–25]. Bipolar RFA became available in Europe and the United States in the 1990s and is now used for the treatment of HCC [26, 27]. In Japan, multipolar RFA using the CelonPOWER System was approved for coverage by the health insurance system in 2012, and has been clinically available since 2013. This multipolar RFA system enables insertion of up to three bipolar applicators at the same time. These needle-type applicators offer excellent insertion ability, do not require a grounding pad, and do not cause thermal
injury to the skin. In addition, these applicators are not prone to vascular heat sink effects that can unexpectedly decrease the ablated area [4]. For tumors B3 cm in diameter, ‘‘no-touch ablation’’ is possible. In other words, without inserting the applicator into the tumor, ablation can be performed by electrodes positioned at the perimeter of the tumor [28–30]. Local recurrence after RFA has been reported and performing ablation with sufficient safety margins is important to increase the likelihood of curative treatment [31, 32]. In a no-touch ablation procedure, the applicator is located adjacent to the tumor perimeter, so an ablated area of at least 1 cm around the applicator can be reliably achieved. The tumor itself is not punctured, so, as well as prevention of tumor cell dissemination, a more reliable safety margin is ensured. This is expected to reduce the risk of local recurrence [29, 30]. However, to achieve a large coagulation area in accordance with planned thermal dosimetry, each applicator electrode must be inserted in parallel at fixed distance intervals. When using a percutaneous approach, accurate puncture is difficult in some cases because of echo window problems due to ribs or poor visualization of the tumor itself. Because our patient underwent laparoscopic treatment, sufficient distances between the treated lesions and the diaphragm, parietal structures, and adjacent organs were maintained, and all applicators could be inserted as planned in parallel with the tumor perimeter. No-touch ablation was performed, and a good ablated area was achieved without affecting surrounding organs. Since prevention of bleeding and/or seeding from the tumor was expectable, no-touch ablation was especially useful for the treatment of the lesion on the liver surface. Moreover, LRA of the tumor located deep in the liver could be performed safely and satisfactorily under ultrasonography guidance.
123
514
Clin J Gastroenterol (2014) 7:510–515
Also in multipolar RFA, as reported for single needle insertion [5, 6, 33, 34], the laparoscopic procedure was a reliable treatment for HCC regardless of the tumor location.
Conclusion We reported a case of HCCs treated with multipolar LRA without affecting the adjacent organs. With multipolar RFA, there is no thermal injury to the skin, ablation time is shorter, and patient burden is reduced. Multipolar LRA may become an attractive option for treatment of localized HCC. The effectiveness and safety of multipolar LRA should be confirmed in a larger number of patients. The appropriate use of multipolar LRA compared to conventional monopolar RFA should also be further investigated. Disclosures Conflict of Interest: of interest.
The authors declare that they have no conflict
Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Minami Y, Kudo M. Radiofrequency ablation of hepatocellular carcinoma: current status. World J Radiol. 2010;2:417–24. 2. Sutherland LM, Williams JAR, Padbury RTA, et al. Radiofrequency ablation of liver tumors: a systematic review. Arch Surg. 2006;141:181–90. 3. Salhab M, Canelo R. An overview of evidence-based management of hepatocellular carcinoma: a meta-analysis. J Cancer Res Ther. 2011;7:463–75. 4. Osaki Y, Ikeda K, Izumi N, et al. Clinical effectiveness of bipolar radiofrequency ablation for small liver cancers. J Gastroenterol. 2013;48:874–83. 5. Kawamoto C, Ido K, Isoda N, et al. Long-term outcomes for patients with solitary hepatocellular carcinoma treated by laparoscopic microwave coagulation. Cancer. 2005;103:985–93. 6. Nagae G, Ido K, Isoda N, et al. Laparoscopic ablation therapy for hepatocellular carcinoma. Dig Endosc. 2005;17:1–8. 7. Ferlay J, Shin H-R, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893–917. 8. Lai EC, Fan ST, Lo CM, et al. Hepatic resection for hepatocellular carcinoma. Ann Surg. 1995;221:291–8. 9. Rossi S, Di Stasi M, Buscarini E, et al. Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular carcinoma. Cancer J Sci Am. 1995;1:73–81. 10. Shiina S, Tateishi R, Arano T, et al. Radiofrequency ablation for hepatocellular carcinoma: 10-year outcome and prognostic factors. Am J Gastroenterol. 2012;107:569–77.
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