Aktueller Stand zu perkutanen lokalablativen Verfahren beim hepatozellulären Karzinom

Zusammenfassung

Hintergrund Das hepatozelluläre Karzinom (HCC) ist das fünfthäufigste Tumorleiden weltweit. Da viele HCCs bereits zum Zeitpunkt der Erstdiagnose nicht resektabel sind, haben sich in den letzten Jahrzenten perkutane Tumorablationen als kurativer Therapieansatz für das sehr frühe (BCLC 0) und frühe (BCLC A) HCC etabliert. Ziel dieser Arbeit ist es, einen kompakten Überblick über die aktuell zur Anwendung kommenden perkutanen lokalablativen Verfahren zu geben, basierend auf den technischen Besonderheiten sowie der klinischen Relevanz unter Berücksichtigung der aktuellen Studienlage.

Methode Die Literaturrecherche umfasste alle über MEDLINE und PubMed verfügbaren Originalarbeiten, Reviews und Metaanalysen zu den jeweiligen perkutanen Ablationsverfahren, hierbei wurde vor allem ein Fokus auf randomisiert kontrollierte Studien und Veröffentlichungen aus den letzten 10 Jahren gelegt.

Ergebnisse und Schlussfolgerung Die Radiofrequenzablation (RFA) und Mikrowellenablation (MWA) sind etablierte Verfahren, welche aufgrund ihrer starken Evidenz in internationalen und nationalen Leitlinien bei der Behandlung von HCCs im Stadium BCLC 0 und A mit einem Diameter bis zu 3 cm der chirurgischen Resektion gleichgestellt sind. Für HCCs mit einem Diameter zwischen 3 und 5 cm wird in den aktuellen S3-Leitlinien eine Kombination aus transarterieller Chemoembolisation (TACE) und Thermoablation mittels RFA oder MWA empfohlen, da bei HCCs dieser Größe die Kombinationstherapie der alleinigen Thermoablation überlegen ist und mit der chirurgischen Resektion vergleichbare Ergebnisse bezüglich des Gesamtüberlebens zeigt. Alternative, deutlich seltener eingesetzte thermische Verfahren sind die Kryotherapie (KT) und die Laserablation (LA). Zu den nicht thermischen Verfahren zählen die irreversible Elektroporation (IRE), die interstitielle Brachytherapie (IBT) und als neuestes Verfahren die Elektrochemotherapie (ECT). Aufgrund der noch nicht ausreichenden Evidenz kommen diese bis dato allerdings nur in Einzelfällen und im Rahmen von Studien zum Einsatz. Die nicht thermischen Verfahren stellen jedoch eine sinnvolle Alternative für die Ablation von HCCs in Nachbarschaft zu großen Blutgefäßen und Gallengängen dar, da sie diese Strukturen im Gegensatz zu den thermischen Ablationsverfahren deutlich weniger schädigen. Durch Fortschritte in der Technik der jeweiligen Verfahren, zunehmend gute Evidenz sowie Weiterentwicklungen bei unterstützenden Techniken wie Navigationsgeräten und Fusionsbildgebung könnten die perkutanen Ablationsverfahren in den kommenden Jahren ihre Indikationsstellung zur Behandlung größerer und weiter fortgeschrittener HCCs erweitern.

Kernaussagen:

• RFA und MWA sind für die kurative Therapie von HCC im Stadium BCLC 0 und A bis zu einer Größe von 3 cm der chirurgischen Resektion als Erstlinientherapie gleichgestellt.

• Für HCC mit einer Größe zwischen 3 und 5 cm wird eine Kombination aus TACE und RFA oder MWA empfohlen. Diese Kombinationstherapie zeigt bezüglich Gesamtüberleben der chirurgischen Resektion ähnliche Ergebnisse.

• Alternative Ablationsverfahren kommen bis dato aufgrund der mangelhaften Datenlage nur in Einzelfällen oder im Rahmen von Studien zum Einsatz. Insbesondere nichtthermische Verfahren wie die IRE, die IBT und neuerdings ECT stellen jedoch eine sinnvolle Alternative für die Ablation von HCCs in Nachbarschaft zu großen Blutgefäßen und Gallengängen dar, da sie diese Strukturen im Gegensatz zu thermischen Ablationsverfahren deutlich weniger schädigen.

Zitierweise

• Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Röntgenstr 2022; 194: 1075 – 1087

Key words

abdomen - ablation procedures - percutaneous

Publication History

Received: 13 August 2021

Accepted: 31 January 2022

Article published online:
11 May 2022

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