Treatment Strategies for 3 cm HCCwith US guided RF Ablation ( Long term outcome from 302 cases ),Chen Min Hua, Yang Wei, Yan Kun Peking University, School of Oncology,HCC incident account for 54 in the world with mortality of 200, 000 cases every year Advanced or large HCC common at first diagnosis Associated with liver cirrhosis and poor liver function Candidates for surgery 3 cm HCC: 244 With the size increase, local recurrence highertumor diameter 2.5 cm:11.6(18/155 cases) 2.5 cm: 20.5 (17/83 cases),1、Livraghi T. Radiology 2000;214:761-768. 2、 Solbiati L. Radiology 1997;205:367-373. 3、Marco V. Annals of Surgery 2004;240 4、Lam VWT. J Am Coll Surg 2008;207:20-29.,Purpose,Investigate the treatment strategies andoutcome of ultrasound guided RF ablation of 3cm HCC,Patients (1),2000 to 2010 year 520 patients with HCC underwent percutaneous RFA Among them 3cm HCC 302 cases Male 244, Female 58 Average age 60.4 years(range, 24-87 years) Tumor size 3.1-7.0cm average 4.21.0cm 3.1-5.0cm 248 lesions 5.1-7.5cm 80 lesions,Patients(2),Solitary tumor 212 cases,multiple 90 cases (29.8) Liver function Child-A 196 cases, B 94 cases C 12 cases 58 cases were recurrent after surgery (19.2),Treatment strategies,Plan ablation protocol based on invasive range of tumor on Contrast Enhanced Ultrasound (CEUS) Perform multiple overlapping ablations based on mathematical model Optimal ablation with 2-3 bipolar electrodes Color US guided ablation of feeding artery (or TACE) before RF ablation,1、Identify invasive range based on CEUS,Obtain samples from border area which became bigger or more irregular on CEUS Cancer cell was found in 88 of these specimensand alternately grew with normal liver CD34 immuhistochemistry staining showedstrong positive staining in vessel endothelium cell of this areaMVD was significantly higher than that in central area,US: A 3.6 cm nodule with unclear border,CEUS: the tumor enlarged ( 5cm) Central necrosis,M/54 10 ys of hepatitis B,Surgery sample: tumor with poor border,HE staining malignant cell alternatively grows with normal liver cell without clear border between them,CD34 staining: High density of micro-vessels in the margin area of the HCC,Set up mathematical model for large tumorsPlan overlapping ablations protocol Least ablation numberProper ablation overlapping modeOptimal electrode placement design,2. Multiple ablations based on mathematical model,M.H. Chen, W, Yang, et al. Radiology. 2004;232:260-271,3. New technique for RF ablation,Recently, RF machine and equipment developed fast Cool water circulation used in all kinds of machines Umbrella or Cool-tip increased the coagulation area by one ablation (5-6cm) 2-3 bipolar electrode simultaneously achieve 6.5 cm coagulation area (40 mins ) It is good time for RFA treatment of 5-6cm liver tumor,2 bipolar electrodes 2 for 6.2x6x5 cm3 (22 min x2),1,2,1,2,3,1,3 bipolar electrodes for 6.5x6x6 cm3 (40 Min),2,Male, 77 years, 6 cm HCC under diaphragm,16,Percutaneous place tube under diaphragm and inj water to separate tumor and diaphragm (),17,3 bipolar electrodes simultaneously 2 times (80mins),One month CT: no enhancement,4. Individual protocol for richsupply and large tumor Cool effect of flow during RF ablation would limit coagulation area and result in recurrence it is a challenge for RF ablation Need effective treatment principle and new methodsControl feeding artery for tumor with rich blood supply,Chen MH, W, Yang, et al. JVIR 2006;17: 671-683. Chen MH, W, Yang, et al. Abdominal Imaging 2007;17:567-595.,It has been confirmed combination of TACERFA can decrease tumor supply and increase coagulation area improve efficiency In our center, we use 1-2 courses of TACE followed by RFA for these cases,1. Yang W, Chen MH. Hepatology research 2009 2. Shen SQ, et al. Hepatogastroenterology. 2005. 3. Gasparini D, et al. Radiol Med. 2002.,Traditional strategy,Male,64 years, hepatitis B and liver cirrhosis for more than 10 years HCC was in right lobe and after 2 times of TACE,CEUS Pre-RF: (left)CEUS:Lesion enhanced with size of 5.8x4.7cm,irregular close to right branch of PV (right)US:Heterogeneous lesion with unclear border,PV,(Left) T40 3 bipolar electrodes with 3 cm space (Middle) T40 2 bipolar electrodes with 2.1cm space (Right)post-RFA lesion present hyperechoic,During RFA,1 Mon post-RFA :(Left)US: lesion size about 6.0x4.5cm(Middle) CT-AP: no enhancement (Right)CT-PP: well defined margin,Percutaneous ablation of feeding artery,Large HCC not suitable for TACE or still have viability after TACE Percutaneous Artery Ablation ( PAA),