大于3cm肝癌302例射頻消融-治療策略及療效【課件】

TreatmentStrategiesfor>3cmHCCwithUSguidedRFAblation

(Longtermoutcomefrom302cases

)ChenMinHua,YangWei,YanKunPekingUniversity,SchoolofOncologyTreatmentStrategiesfor>3cm

HCCincidentaccountfor54％intheworld

withmortalityof200,000caseseveryyearAdvancedorlargeHCCcommonatfirstdiagnosisAssociatedwithlivercirrhosisand

poorliverfunctionCandidatesforsurgery<30﹪

recurrencerate70﹪Alotofnon-resectableorrecurrentHCCneedRFA

ProfileofHCCpatientsinChina

HCCincidentaccountfor54％TheeffectoftumorsizeonRFoutcomeLimitedbyRFequipment,RFAissuitablefor≤3.5cmlivertumor[1]Itisdifficulttoablatelargeorrichbloodsupplytumor[2]

3-yearsurvival>3cmHCC:24％[4]Withthesizeincrease,localrecurrencehigher

tumordiameter≤2.5cm:11.6﹪(18/155

cases)>2.5cm:20.5﹪(17/83cases)

1、LivraghiT.Radiology2000;214:761-768.2、SolbiatiL.Radiology1997;205:367-373.3、MarcoV.AnnalsofSurgery2004;2404、LamVWT.JAmCollSurg2008;207:20-29.TheeffectoftumorsizeonRFPurposeInvestigatethetreatmentstrategiesandoutcomeofultrasoundguidedRFablationof>3cmHCCPurposeInvestigatethetreatmPatients(1)

2000to2010year520patientswithHCCunderwentpercutaneousRFAAmongthem>3cmHCC302casesMale244,Female58Averageage60.4years(range,24-87years)Tumorsize

3.1-7.0cmaverage4.2±1.0cm3.1-5.0cm248

lesions5.1-7.5cm80

lesionsPatients(1)2000to2010Patients(2)Solitarytumor212cases,multiple90

cases

(29.8﹪)LiverfunctionChild-A196

cases,B94

casesC12cases58caseswererecurrentaftersurgery

(19.2﹪)Patients(2)Solitarytumor212TreatmentstrategiesPlanablationprotocolbasedoninvasiverangeoftumoronContrastEnhancedUltrasound(CEUS)PerformmultipleoverlappingablationsbasedonmathematicalmodelOptimalablationwith2-3bipolarelectrodesColorUSguidedablationoffeedingartery(orTACE)beforeRFablationTreatmentstrategiesPlanablat1、IdentifyinvasiverangebasedonCEUSObtainsamplesfromborderarea

whichbecamebiggerormoreirregularonCEUSCancercellwasfoundin88﹪ofthesespecimensandalternatelygrewwithnormalliverCD34immuhistochemistrystainingshowedstrongpositivestaininginvesselendotheliumcellofthisareaMVDwassignificantlyhigherthanthatincentralarea1、IdentifyinvasiverangebaUS:A3.6cmnodulewithunclearborderCEUS:thetumorenlarged

(5cm)

CentralnecrosisM/5410ysofhepatitisBSurgerysample:tumorwithpoorborderUS:A3.6cmnoduleCEUS:theHEstainingmalignantcellalternativelygrowswithnormallivercellwithoutclearborderbetweenthemCD34staining:Highdensityofmicro-vesselsinthemarginareaoftheHCCHEstainingCD34staining:

SetupmathematicalmodelforlargetumorsPlanoverlappingablationsprotocolLeast

ablationnumber

Properablationoverlappingmode

Optimalelectrodeplacementdesign2.MultipleablationsbasedonmathematicalmodelM.H.Chen,W,Yang,etal.Radiology.2004;232:260-271Setupmathematicalmodelfo

3.NewtechniqueforRFablationRecently,RFmachineandequipmentdevelopedfastCoolwatercirculationusedinallkindsofmachinesUmbrellaorCool-tipincreasedthecoagulationareabyoneablation

(5-6cm)2-3bipolarelectrodesimultaneously

achieve6.5cm

coagulationarea(40

mins)ItisgoodtimeforRFAtreatmentof5-6cmlivertumor

3.NewtechniqueforRFablat2bipolarelectrodes×2for6.2x6x5cm3

(22minx2)12122bipolarelectrodes×2for6313bipolarelectrodesfor6.5x6x6

cm3(40Min)2313bipolarelectrodesfor6.5Male,77years,6cmHCCunderdiaphragmMale,77years,6cmHCCund16Percutaneousplacetubeunderdiaphragmandinjwatertoseparatetumoranddiaphragm(↑)16Percutaneousplacetubeunde173bipolarelectrodessimultaneously2times(80mins)173bipolarelectrodessimultaOnemonthCT:noenhancementOnemonthCT:noenhancement

4.Individualprotocolforrichsupplyandlargetumor

CooleffectofflowduringRFablationwouldlimitcoagulationareaandresultinrecurrenceitisachallengeforRFablation

Needeffectivetreatmentprincipleandnewmethods

ControlfeedingarteryfortumorwithrichbloodsupplyChenMH,W,Yang,etal.JVIR2006;17:671-683.ChenMH,W,Yang,etal.AbdominalImaging

2007;17:567-595.4.IndividualprotocolforriIthasbeenconfirmedcombinationof

TACE＋RFAcandecreasetumorsupplyandincreasecoagulationareaimproveefficiencyInourcenter,weuse1-2coursesofTACE

followedbyRFAforthesecases1.YangW,ChenMH.Hepatologyresearch20092.ShenSQ,etal.Hepatogastroenterology.2005.3.GaspariniD,etal.RadiolMed.2002.TraditionalstrategyIthasbeenconfirmedcombinatMale,64years,hepatitisBandlivercirrhosisformorethan10yearsHCCwasinrightlobeandafter2timesofTACEMale,64years,hepatitisBandCEUSPre-RF:

(left)CEUS:Lesionenhancedwithsizeof5.8x4.7cm,irregular

closetorightbranchofPV

(right)US:HeterogeneouslesionwithunclearborderPVCEUSPre-RF:

(left)CEUS:Lesio

(Left)T403bipolarelectrodeswith3cmspace

(Middle)T402bipolarelectrodeswith2.1cmspace

(Right)post-RFAlesionpresenthyperechoicDuringRFA(Left)T403bipolarelectrod1Monpost-RFA:(Left)US:lesionsizeabout6.0x4.5cm

(Middle)CT-AP:noenhancement

(Right)CT-PP:welldefinedmargin1Monpost-RFA:(Left)US:lesiPercutaneousablationoffeedingarteryLargeHCCnotsuitableforTACEorstillhaveviabilityafterTACE

PercutaneousArteryAblation(PAA)

PercutaneousablationoffeediChenMH,YangW,etal.JVIR2006;17:671-83.ChenMH,YangW,etal.AbdominalImaging2007;17:587-95.ColorUSguidedPercutaneousAblation

blockingfeedingArtery(PAA)

Additional2-3smallablationstoablatetheentranceareaoffeedingarterytoenhancethecoagulationeffect

ChenMH,YangW,etal.JVIR2Case.WangXX,male,58years.HepatitisBfor10years

HCCwasfound2monsagoandsize5.5x4.8cm

Case.WangXX,male,58years.Tumorinrightlobeandthesizewas6x5cm

had2bigfeedingarteries

firstablationthemainfeedingarteryTumorinrightlobeandthesiPost-PAAcontrastUS(Aphase):MainfeedingAwasblocked(↑)AnotherfeedingAstillopen(△)ParenchymaphaseRing-likeenhanced─

“annularsolareclipse

”signPost-PAAcontrastUS(AphaseColorUSguidedPAAforthesecondfeedingAColorUSguidedPAAforthesePost-secondPAAContrastUS:Theentiretumorperfusiondefection–“totalsolareclipse

”signPost-firstPAAcontrastUSRimlikeenhancedPost-secondPAAContrastUS:PPerformmultipleablationsundertumorischemiaconditionPerformmultipleablations24h1Mon5MonFollowupCT:noviabilityintu24h1Mon5MonFollowupCT:Result(1)Earlynecrosisrate

92.4﹪(303/328tu)3.1~5.0cmtumor

94.0﹪(233/248tu)5.1~7.0cmtumor

87.5﹪(70/80tu)(P﹦0.059)Result(1)EarlynecrosisrateResult(2)─Long-termoutcomeFollowup3~122months,average29

monthsLocalrecurrence14.3﹪(47/328tu)Newlesionincidence38.4﹪(116/302tu)Long-termsurvival1Y3Y5Y7YPValue3-5cm83.955.642.632.50.1745-7cm83.347.025.418.2Total83.753.138.627.0Result(2)─Long-termoutcomeFo>5cmHCClong-termsurvivallowerthan3-5cmHCCSurvivalcurvesafterRFAfordifferentsizesofHCC>5cmHCClong-termsurvivalloComplicationIncidenceofmajorcomplications3.9﹪(12/302cases)includingliverfunctionfailure(n﹦1)Bowelperforation(n﹦3)Intraperitonealhemorrhage(n﹦3)Hemothorax(n﹦2)Needletractseeding(n﹦3)ComplicationIncidenceofmajorConclusion:Thestrategiesfortumor>3cmcanachieveahighsuccessratewithalowcomplicationrateandthenbenefitfor