Treatment Strategies for 3 cm HCC with US guided RF Ablation ( Long term outcome from 302 cases )Chen Min Hua, Yang Wei, Yan KunPeking University, School of Oncologyl lHCC incident account for 54HCC incident account for 54 in the worldin the world with mortality of 200, 000 cases every year with mortality of 200, 000 cases every year l lAdvanced or large HCC common at first diagnosisAdvanced or large HCC common at first diagnosisl lAssociated with liver cirrhosis andAssociated with liver cirrhosis and poor liver functionpoor liver functionlCandidates for surgery 3 cm HCC: 244lWith the size increase, local recurrence higher tumor 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.Livraghi T. Radiology 2000;214:761-768.2 2、 Solbiati L. Radiology 1997;205:367-373.Solbiati L. Radiology 1997;205:367-373.3 3、Marco V. Annals of Surgery 2004;240Marco V. Annals of Surgery 2004;2404 4、Lam VWT. J Am Coll Surg 2008;207:20-29.Lam VWT. J Am Coll Surg 2008;207:20-29.Purpose Investigate the treatment strategies and outcome of ultrasound guided RF ablation of 3cm HCC Patients (1) 2000 to 2010 yearl520 patients with HCC underwent percutaneous RFA lAmong them 3cm HCC 302 caseslMale 244, Female 58lAverage age 60.4 years(range, 24-87 years)60.4 years(range, 24-87 years)lTumor size 3.1-7.0cm average 3.1-7.0cm average 4.21.0cm4.21.0cml l3.1-5.0cm 2483.1-5.0cm 248 lesions lesions 5.1-7.5cm 805.1-7.5cm 80 lesionslesionsPatients(2)l lSolitary tumor 212 cases,Solitary tumor 212 cases,multiple 90multiple 90 casescases (29.8(29.8 ) )l lLiver function Child-A 196Liver function Child-A 196 cases, B 94cases, B 94 cases C 12 casescases C 12 casesl l58 cases 58 cases were recurrent after surgery were recurrent after surgery (19.2(19.2 ) )Treatment strategies1.Plan ablation protocol based on invasive range of tumor on Contrast Enhanced Ultrasound (CEUS)2.Perform multiple overlapping ablations based on mathematical model3.Optimal ablation with 2-3 bipolar electrodes4.Color US guided ablation of feeding artery (or TACE) before RF ablation 1、Identify invasive range based on CEUSlObtain samples from border area which became bigger or more irregular on CEUS lCancer cell was found in 88 of these specimens and alternately grew with normal liverlCD34 immuhistochemistry staining showed strong positive staining in vessel endothelium cell of this area MVD was significantly higher than that in central area US: A 3.6 cm nodule with unclear borderCEUS: the tumor enlarged ( 5cm) Central necrosisM/54 10 ys of hepatitis BSurgery sample: tumor with poor borderHE stainingmalignant cell alternatively grows with normal liver cell without clear border between themCD34 staining: High density of micro-vessels in the margin area of the HCCl Set up mathematical model for large tumorsl Plan overlapping ablations protocol Least ablation number Proper ablation overlapping mode Optimal electrode placement design2. Multiple ablations based on mathematical modelM.H. Chen, W, Yang, et al. Radiology. 2004;232:260-2713. New technique for RF ablationRecently, RF machine and equipment developed fast Recently, RF machine and equipment developed fast Cool water circulation used in all kinds of machines Cool water circulation used in all kinds of machines l lUmbrella or Cool-tip increased the coagulation area Umbrella or Cool-tip increased the coagulation area by one ablation by one ablation (5-6cm)(5-6cm)l l2-3 bipolar electrode simultaneously 2-3 bipolar electrode simultaneously achieve 6.5 cmachieve 6.5 cm coagulation area (40coagulation area (40 mins )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 12 21 12 23 31 13 bipolar electrodes for 6.5x6x6 cm3 (40 Min) 2 2 Male, 77 years, 6 cm HCC under diaphragm 1616Percutaneous place tube under diaphragm and inj water to separate tumor and diaphragm ()17173 bipolar electrodes simultaneously 2 times (80mins)One month CT: no enhancement 4. Individual protocol for rich supply and large tumor l Cool effect of flow during RF ablation would limit coagulation area and result in recurrence it is a challenge for RF ablation l Need effective treatment principle and new methodsl Control feeding artery for tumor with rich blood supplyChen MH, W, Yang, et al. JVIR 2006;17: 671-683. Chen MH, W, Yang, et al. Abdominal Imaging 2007;17:567-595.lIt has been confirmed combination of TACERFA can decrease tumor supply and increase coagulation area improve efficiencylIn our center, we use 1-2 courses of TACE1-2 courses of TACE followed followed by RFA for these casesby RFA for these cases1. Yang W, Chen MH. Hepatology research 20092. Shen SQ, et al. Hepatogastroenterology. 2005.3. Gasparini D, et al. Radiol Med. 2002.Traditional strategyMale,64 years, hepatitis B and liver cirrhosis for more than 10 yearsHCC was in right lobe and after 2 times of TACECEUS 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 RFA1 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 arteryl lLarge HCC Large HCC not suitable for TACE or not suitable for TACE or still have viability after TACE still have viability after TACE l lPercutaneous Artery Ablation Percutaneous Artery Ablation ( PAA)( PAA) Chen MH, Yang W, et al. JVIR 2006; 17: 671-83.Chen MH, Yang W, et al. Abdominal Imaging 2007;17:587-95.Color US guided Percutaneous Ablationblocking feeding Artery(PAA) Additional 2-3 small ablations to ablate the entrance area of feeding artery to enhance the coagulation effectCase. Wang XX, male, 58 years. Hepatitis B for 10 years HCC was found 2 mons ago and size 5.5 x 4.8 cmTumor in right lobe and the size was 6x5 cmhad 2 big feeding arteriesfirst ablation the main feeding arteryPost-PAA contrast US ( A phase ) :Main feeding A was blocked ( )Another feeding A still open ( )Parenchyma phaseRing-like enhanced “annular solar eclipse ” signColor US guided PAA for the second feeding APost-second PAA Contrast US:The entire tumor perfusion defection “total solar eclipse ”signPost-first PAA contrast USRim like enhancedPerform multiple ablations under tumor ischemia condition24 h1 Mon5 MonFollow up CT: no viability in tuResult (1)l lEarly necrosis rate Early necrosis rate 92.492.4 (303/328 tu) (303/328 tu)l l3.15.0cm tumor3.15.0cm tumor 94.094.0 (233/248 tu)(233/248 tu)l l5.17.0cm tumor5.17.0cm tumor 87.587.5 (70/80 tu)(70/80 tu) (P (P 0.059)0.059)Result(2) Long-term outcomelFollow up 3122 months,average 29 monthslLocal recurrence 14.3 (47/328 tu)lNew lesion incidence 38.4 (116/302 tu)lLong-term survival 1 Y3 Y5 Y7 YP Value3-5 cm83.955.642.632.50.1745-7 cm83.347.025.418.2Total83.753.138.627.05cm HCC long-term survival lower than 3-5cm HCCSurvival curves after RFA for different sizes of HCCComplicationl lIncidence of major complications 3.9 Incidence of major complications 3.9 (12/302 cases) (12/302 cases) including liver function failure (n including liver function failure (n 1)1) Bowel perforation (nBowel perforation (n 3)3) Intraperitoneal hemorrhage (n Intraperitoneal hemorrhage (n 3) 3) Hemothorax (nHemothorax (n 2) 2) Needle tract seeding (n Needle tract seeding (n 3) 3)Conclusion: l lThe strategies for tumor 3 cm can achieve a high The strategies for tumor 3 cm can achieve a high success rate with a low complication ratesuccess rate with a low complication rate and then benefit for survival. and then benefit for survival. l lBut the patients with 5 cm HCC tended have lower But the patients with 5 cm HCC tended have lower survival than 3.1-5.0 HCC patients, thus optimized survival than 3.1-5.0 HCC patients, thus optimized multi-modalities treatment should be investigated for multi-modalities treatment should be investigated for these tumors in the future.these tumors in the future. lCombine target chemotherapy and local physical therapy can interact actively and further improve efficiency lInternational multiple center randomized trail is going on lThermoDox IV drop 30mins prior RFA treat HCC 3cmlOur department was served as one of these centersProspective Combination with RFACombination with RFA and target chemotherapyand target chemotherapyGoldberg SN, et al. AJR 2002;179:93-101.Poon PT, et al. Expert Opin Pharmacother 2009;10:333-43. Thank you for your attention!( 2009 KunMing China)2011, Dec 16 KunMing (Prof. CHEN chairman) 13TH INTERNATIONAL CONFERRENCE ON ULTRASOUND CONTRAST IMAGING AND TUMOR ABLATION