FIRST CASE OF PER OPERATIVE RFA IN PUBLIC SECTOR HOSPITALS Prof.
Muhammad Umar Dr. Jahangir Khan Dr. Tariq Nawaz Dr. Zahid Mahmood
Minhas Dr. Sadia Ahmed Slide 2 BIO DATA Name:Munir Ahmed Age:67 yrs
Gender:Male Occupation:Businessman Address:Rawalpindi MOA:ER Slide
3 HISTORY AND EXAMINATION My patient known Diabetic for 10 years,
well controlled on insulin, was otherwise up and about. Presented
with one episode of hematemesis. No previous history of
hematemesis, melena, encephalopathy or bleeding from any other
site. Positive findings on examination were: Pallor Splenomegaly
Slide 4 Investigations BLOOD CPReference Range TLC 9 4000-11000/ l
Hb10.7 13-18g/dl PLT123 150-400k/ l LFTsReference Range
bilirubin1.0 0.2 1.2 mg/dl ALT21 0 55 IU/L AST26 5-34U/L GGT78 0-51
IU/L ALP203 40 150 IU/L Prothrombin time13 APTT34 RFTSReference
Range Urea 59 10-50mg/dl Creatinine 1.0 0.72-1.25mg/dl AFPReference
Range AFP level9.78 0-8.78n g/ml Serology Anti HCV-ve HBsAg-ve
UPPER GI ENDOSCOPYTwo Column Grade 2 Esophageal Varices. Slide 5
ULTRASOUND ABDOMEN Liver 15.7 cm in size, showing Coarse Parenchyma
with irregular margins. A moderate sized well defined rounded mixed
ecogenicity lesion is seen in right lobe abutting the gall bladder
measuring 4.9 x 4.2 x 4.5 cm. Gall bladder has echogenic calculi
seen in the lumen with accumulative volume of 27mm. 14 cm Spleen is
enlarged measuring 14 cm. CBD, PV, pancreas and kidney are
unremarkable. CONCLUSION Cirrhotic Liver Morphology with SOL.
Triphasic CT Scan Advised Slide 6 Slide 7 TRIPHASIC CT SCAN ABDOMEN
Liver measures 170 mm in craniocaudal dimension, with irregular
margins. There is about 41 x 49 x 45mm lesion in segment VIII of
right lobe of liver. The lesion shows intense arterial enhancement
with rapid washout on venous phase and appears isodense on delayed
phase. Gall bladder contains a single large calculus measuring 28mm
in size. Conclusion: Chronic Liver Disease with hepatoma in segment
VIII of right lobe of liver, splenomegaly with splenic hilum
varices. Paraesophageal varices cholilethiasis and dilated portal
vein. Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 Slide 13 Final
Diagnosis Non Hepatitis B & C - Chronic Liver Disease Child
Class A Meld Score: 8 Hepatocellular Carcinoma (HCC) BCLC Grade: A
ECOG status: 0 Slide 14 Management Plan Per Operative RFA with
Cholecystectomy. Slide 15 HEPATOCELLULAR CARCINOMA (HCC) Slide 16
Geographic distribution of hepatocellular carcinoma. Tumor
incidence varies significantly, depending on geographical location.
Incidence rates (%) in total population A, female; B, male. Slide
17 Etiology Hepatitis BHepatitis B -increase risk 100 -200 fold -
90% of HCC are positive for (HBs Ag) Hepatitis CHepatitis C
CirrhosisCirrhosis - 70% of HCC arise on top of cirrhosis Toxins -
Alcohol -Tobacco - AflatoxinsToxins - Alcohol -Tobacco - Aflatoxins
Autoimmune hepatitisAutoimmune hepatitis States of insulin
resistance- Overweight in males Diabetes mellitus States of insulin
resistance- Overweight in males Diabetes mellitus Slide 18
Incidence according to etiology Abbreviations: WD, Wilson s
disease; PBC, primary biliary cirrhosis, HH, hereditary
hemochromatosis; HBV, hepatitis B virus infection; HCV, hepatitis C
virus infection. Slide 19 Diagnostic Modalities Tumor Markers USG
Abdomen Tri phasic CT vs MRI Liver Biopsy Alpha-fetoprotein (AFP)
Des-gamma-Carboxy Prothrombin (DCP) Slide 20 Management of HCC
Slide 21 Performance Status (Eastern Cooperative Oncology Group)
Slide 22 BCLC staging system Slide 23 Slide 24 RADIOFREQUENCY
ABLATION Slide 25 Radiofrequency Ablation MECHANISM: In
radiofrequency ablation (RFA), the heat is created from electrical
energy. The heat is generated at a specific target from the
frictional heat created by rapidly vibrating adjacent cells. The
end point that defines adequate necrosis can be based on either
temperature or impedance, depending on the needle manufacturer.
During an RFA procedure, an ablation needle is placed directly into
the target tissue with ultrasonological guidance. Slide 26 Slide 27
Indications for open RFA In patients with lesions adjacent to the
gallbladder or the hepatic hilum, in whom RFA poses a risk of
thermal injury to the biliary tract. Patients with lesions located
near hepatic vessels, in whom the blood flow cools the vascular
wall but the heat loss poses the risk of incomplete ablation of the
area of neoplastic tissue adjacent to the vessel, are also
candidates for intraoperative RFA. Patients with multiple
metastases in both lobes are better treated with partial
hepatectomy and intraoperative RFA. Lesion > 5cm Slide 28 Slide
29 Slide 30 Slide 31 Slide 32 Slide 33 Three Months After Ablation
Slide 34 Slide 35 Evaluation of Patient for RFA Slide 36 Slide 37
Slide 38 CLD Team Slide 39 THANKS Slide 40 Slide 41 Slide 42 Slide
43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Slide 50
INTRODUCTION Hepatocellular carcinoma (HCC) is a primary malignancy
of the hepatocyte, generally leading to death within 6-20 months.
Hepatocellular carcinoma frequently arises in the setting of
cirrhosis, appearing 20-30 years following the initial insult to
the liver. However, 25% of patients have no history or risk factors
for the development of cirrhosis. The extent of hepatic dysfunction
limits treatment options, and as many patients die of liver failure
as from tumor progression. Slide 51 Incidence Hepatocellular
carcinoma is the fifth most common cancer in men and the eighth
most common cancer in women worldwide. An estimated 560,000 new
cases are diagnosed annually. Asia and sub-Saharan Africa with high
rates of infectious hepatitis have incidences as high as 120 cases
per 100,000. Over the past 20 years, the incidence of HCC has more
than doubled, from 2.6 to 5.2 per 100,000 population. Mortality has
similarly increased from 2.8 to 4.7 per 100,000 population over the
past decade alone. Slide 52 Risk Factors The main risk factors for
hepatocellular carcinoma are; Hepatitis C (25% of causes globally)
Hepatitis B Alcoholism Aflatoxin Cirrhosis of the liver
Nonalcoholic steatohepatitis (if progression to cirrhosis has
occurred) Hemochromatosis Wilson's disease Type 2 diabetes
(probably aided by obesity) Hemophilia. Slide 53 Pathogenesis Slide
54 Diagnosis Patients with hepatocellular carcinoma (HCC) are
discovered either during routine screening or when symptomatic
because of their size or location. A biopsy is not needed to
confirm the diagnosis of HCC if these imaging criteria are met
Slide 55 Tumor Markers Alpha-fetoprotein (AFP) Elevated in 75% of
cases. The level of elevation correlates inversely with prognosis.
An elevation of greater than 400 ng/mL predicts for hepatocellular
carcinoma with specificity greater than 95%. In the setting of a
growing mass, cirrhosis, and the absence of acute hepatitis, many
centers use a level greater than 1000 ng/mL as presumptive evidence
of hepatocellular carcinoma (without biopsy). Des-gamma-Carboxy
Prothrombin (DCP) has been studied as a biomarker for early
diagnosis of hepatocellular carcinoma. Slide 56 Staging The tumor,
node, and metastases (TNM) staging system is useful in patients who
undergo surgical resection. This is a small minority of patients.
Most patients have unresectable disease and prognosis actually
depends more on the state of the liver than on the size of the
tumor Several staging systems have been evaluated that incorporate
clinical features of the liver and the patient, such as ascites,
portal vein involvement, and performance status. Currently, the
most widely accepted and reproducible of such staging systems is
the Barcelona Clinic Liver Cancer (BCLC) system Slide 57 Slide 58
BCLC staging system Slide 59 Treatment Resection may benefit
certain patients, albeit mostly transiently. Many patients are not
candidates given the advanced stage of their cancer at diagnosis or
their degree of liver disease and, ideally, could be cured by liver
transplantation. Globally, only a fraction of all patients have
access to transplantation, and, even in the developed world, organ
shortage remains a major limiting factor. In these patients, local
ablative therapies, including radiofrequency ablation (RFA),
chemoembolization, and potentially novel chemotherapeutic agents,
may extend life and provide palliation Slide 60 RADIOFREQUENCY
ABLATION FOR HCC Slide 61 Percutaneous RFA is a minimally invasive,
repeatable procedure with few complications. It is performed under
radiological guidance. It is an exciting approach to destroying
inoperable primary or metastasis tumors in the liver. RFA serves as
a bridge for transplant candidates, especially in relation to small
primary lesions. Slide 62 Approaches Percutaneous, in which needle
electrodes are inserted through the skin and into the site of the
tumor. Surgical or operative or open. Laparoscopic Slide 63
Indications Hepatocellular carcinoma at an early stage. Primary
treatment for small tumors. A meta-analysis by Jansen et al has
described local ablative techniques as the treatment of choice for
small HCC. Inoperable primary liver tumor. Treatment of patients
who cannot undergo general anesthesia or are not operative
candidates because of comorbidity or advanced age. Liver
metastasis, most commonly colorectal, especially if the patient is
not an operative candidate. Can be used for breast, thyroid, and
neuroendocrine metastasis. Treatment of patients who have a
hepatoma or multiple small lesions and are waiting for liver
transplantation Recurrent and progressive lesion. Slide 64
Contraindications Bile duct or major vessel invasion Significant
extrahepatic disease Child class C cirrhosis or active infection.
Lesions that are difficult to reach with electrodes or when
electrode placement is impaired (In such cases, open rather than
percutaneous approach should be used. ) Tumors that occupy >40%
of the volume of the liver (Tumors of this size cannot be safely
ablated because the liver reserve left after radiofrequency
ablation [RFA] might not be sufficient to preserve hepatic
function.) Slide 65 Proximity to vital structures like vessels and
adjacent organs (relative contraindication; open RFA is suggested )
Lesions larger than 5 cm (relative contraindication) RFA should be
used cautiously for lesions larger than 5 cm. One study suggests
the use of open RFA for lesions larger than 5 cm. Patients with
metastatic lesions larger than 3 cm (These lesions are not optimal
for RFA, as the risk of recurrence is high. ) Large or numerous
tumors (Multiple studies recommend RFA as a choice if fewer than 3
tumors are present, each lesion measuring less than 3 cm Slide 66
RADIOLOGICAL DIAGNOSIS Ultrasound (Hypo to iso to Hyper echoic
lesion) Triphasic CT Scan a. Plain CT (Hypo to iso to Hyperdense
lesion) b. Arterial phase at 2030 Seconds. (Enhancement) c. Venous
Phase at 60 Seconds. (Washout) MRI. Slide 67 Imaging Ultrasound
First imaging and screening modality. HCC often appears as a small
hypo-echoic lesion with poorly defined margins and coarse irregular
internal echoes. When the tumor grows, it can sometimes appear
heterogeneous with fibrosis, fatty change, and calcifications. This
heterogeneity can look similar to cirrhosis and the surrounding
liver parenchyma. A systemic review found that the sensitivity was
60 percent (95% CI 44- 76%) and specificity was 97 percent (95% CI
95-98%) compared with pathologic examination of an explanted or
resected liver as the reference standard. The sensitivity increases
to 79% with AFP correlation Slide 68 Triple Phase Helical CT Due to
the increased vascularity of hepatocellular carcinoma, the classic
finding on CT imaging is hypervascularity in the arterial phase
with washout in the portal and delayed phases. A pseudocapsule, a
mosaic pattern and both calcifications and intralesional fat may be
appreciated. A systemic review found that the sensitivity was 68
percent (95% CI 55-80%) and specificity was 93 percent (95% CI 89-
96%) Slide 69 Chen et al Conducted a RCT on 180 patients with a
solitary HCC 5 cm to receive either percutaneous RFA or surgical
resection. [54] This RCT showed percutaneous RFA to give similar
overall and disease-free survivals as surgical resection for
patients with solitary and small HCC. The 1-, and 4-year overall
survival rates after percutaneous RFA and surgery were 95.8%, 67.9%
and 93.3%, 64.0%, respectively. The corresponding disease-free
survival rates were 85.9%, 46.4% and 86.6%, 51.6%, respectively.
Percutaneous RFA had the advantage over liver resection in giving
better short-term postoperative results because percutaneous RFA is
a less invasive procedure. Slide 70 Lu et al Conducted another RCT
on 105 patients with early HCC (single tumor nodule 5 cm in
diameter, or 3 nodules with 3 cm in diameter). [55] The patients
were randomly allocated to partial hepatectomy (n = 54) and
percutaneous RFA/MCT (n = 51). The RFA/MCT group achieved similar
local therapeutical effectiveness and 3-year survival outcomes as
the hepatectomy group. Three nonrandomized controlled studies
showed similar findings. [56-58] However, there is a nonrandomized
study that showed surgical resection to be significantly better in
the patients' overall survival and disease-free survival when
compared with RFA. [59] In the subgroup analysis of Slide 71
Guglielmi et al Surgical resection had significantly better overall
survival and disease-free survival when compared with RFA in
patients with HCC >3 cm. [59] In a selectedgroup of patients
(Child-Pugh class B, multiple HCC, or HCC 3 cm), there was no
significant difference in the results between the 2 treatments.
Currently, there is no data on RFA for resectable HCC >5 cm.
Slide 72 CONCLUSION RFA is more effective than the other modalities
of local ablative therapy; RFA should be considered as the
first-line treatment for patients with small HCC (HCC sized less
than 5 cm in size, preferably less than or equal to 3 cm) who are
not suitable for liver resection or liver transplantation; RFA is a
safe bridging therapy before liver transplantation. However,
insufficient evidence exists to determine if RFA improves
transplantation rates and posttransplantation outcomes; RFA can be
used as an alternative treatment to surgery for resectable HCC
sized less than or equal to 3 cm; RFA is a safe and promising
therapy for recurrent and unresectable HCC. However, insufficient
evidence exists to determine if RFA really improves outcomes. Slide
73 One or more electrodes are deployed from the end of the needle
into the tissue. The generator is turned on, and a target
temperature is set. The RF energy flows through the electrodes and
causes ionic agitation. This agitation and friction of ions creates
heat, and, once sufficient temperatures have been reached, the heat
kills the target tissue. Tiny thermometers (thermocouples)
incorporated into the tips of the electrodes allow continuous
monitoring of tissue temperatures. Power is automatically adjusted
so that the target temperatures remain constant. As tissue
temperature increases above 50C, cell protein is permanently
damaged and coagulation necrosis starts. Above 60C, cell death
occurs almost instantly. Approximately 15-30 minutes are required
to perform a 3-5 cm ablation. Slide 74 Ultrasonography is used to
monitor the treatment process for increased echogenicity. This
increase in echogenicity corresponds to the formation of tissue and
water vapor bubbles from the treated tissue and is used as a rough
estimate of the size of the ablation site. Multiple ablations can
be overlapped to decrease the chance of local tumor recurrence. The
size of the ablated area is determined largely by the size of the
electrode needle, the temperature of the tissue, and the duration
of time the energy is applied. A sharp boundary separates dead
tissue and unaffected surrounding tissue. Slide 75 Complications
Postablation syndrome is a common phenomenon after RFA of solid
abdominal tumors. Studies have observed its occurrence in
approximately one third of patients. The symptoms of postablation
syndrome are flulike and include low-grade fever, delayed pain,
malaise, myalgia, nausea, and vomiting. Patients should be informed
about postablation syndrome and its self- limiting nature before
the procedure. Most patients should be able to resume normal
activity in 7-10 days. Slide 76 Shoulder pain Cholecystitis Damage
to the bile ducts, resulting in biliary obstruction Bleeding
Capsular hematoma Hemoperitoneum Pneumothorax
Hemothorax/hydrothorax Pleural effusion Intraperitoneal bleeding or
ascites Hemobilia Infection and portal thrombosis Liver abscess
Needle tract seeding (This is recognized as a long-term
complication of RFA. It occurs mainly in lesions close to the
surface or capsule of the liver.) Collateral damage to proximal
vital organs (The predictable nature of RFA generally prevents this
complication.) Self-limiting subcutaneous cellulitis. Incidence of
other complications is less than 5%. Slide 77 THANKS Slide 78 Slide
79 Slide 80 HCC CT CT evaluation of the liver during the early
arterial (2a), late arterial (2b), and portal venous (2c) phase of
enhancement. The mass in segment III (white arrow) demonstrates the
classic pattern of enhancement for HCC. Slide 81 RF Ablation:
Technique Slide 82 THANKS Slide 83 Slide 84 Slide 85 Slide 86 Slide
87 Slide 88 Slide 89 Slide 90 Slide 91
