In den letzten Jahren stehen bei Patienten mit Lebertumoren interdisziplinäre Therapieansätze mit Betonung minimalinvasiver Verfahren zur Reduktion der Tumorlast zunehmend im Fokus. Lokal ablative Verfahren zur Behandlung des HCC und von Lebermetastasen kolorektaler Tumoren sind bereits in Behandlungsempfehlungen und Leitlinien integriert. Der folgende Beitrag stellt die häufigsten Verfahren vor und beschreibt ihre Relevanz für den klinischen Alltag.
Abstract
The past years have seen a paradigm shift in the treatment strategies of liver tumors. Due to increasing data interdisciplinary therapy regimens focusing on minimally invasive image guided interventions in combination with surgical procedures and chemotherapy are more and more employed. At present image guided local ablations are part of the international guidelines for the treatment of hepatocellular carcinoma and liver metastases of colon carcinoma with more indications to come in the near future.
Image guide local ablations of liver tumors offer various advantages such as a low peri- and post-interventional morbidity and mortality as well as a short hospital stay when compared to classic liver surgery. Owing to the fact that local ablations are confined to the malignant lesion itself and thus spare the residual liver parenchyma they can be repetitively used and easily combined with surgical resections and systemic chemotherapy. Nowadays a multitude of local ablation approaches exists but by far the most common utilized is radiofrequency ablation. When malignant liver lesions are extensive a high-dose brachytherapy is promising. The ablation procedure to be used is chosen by the interdisciplinary oncology team in charge taking into consideration both the individual patient situation as well as the local expertise.
Kernaussagen
Interdisziplinäre Therapieansätze unter Einbeziehung bildgeführter lokal ablativer Therapien stehen bei der Therapie von Lebertumoren zunehmend im Fokus und sind inzwischen auch in den Leitlinien vertreten.
Zu den Vorteilen minimalinvasiver bildgeführter Lebereingriffe zählen unter anderem eine relativ geringe Morbidität und Mortalität, wie auch die kurze Krankenhausverweildauer infolge der geringen Invasivität.
Aufgrund des parenchymsparenden Vorgehens können lokale Ablationen wiederholt im Krankheitsverlauf eingesetzt und in Kombination mit einer operativen Resektion und Systemtherapie angewandt werden.
Die Radiofrequenzablation ist das am häufigsten eingesetzte lokale Ablationsverfahren. Bei großen Leberraumforderungen ist die Hochdosis-Brachytherapie vielversprechend.
Die Wahl des eingesetzten lokalen Ablationsverfahrens ist eine interdisziplinäre Entscheidung des onkologischen Teams vor Ort.
1
Van Cutsem E,
Cervantes A,
Adam R.
et al.
ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol 2016; 27: 1386-1422
4
Elias D,
Baton O,
Sideris L.
et al.
Local recurrences after intraoperative radiofrequency ablation of liver metastases: a comparative study with anatomic and wedge resections. Ann Surg Oncol 2004; 11: 500-505
5
Bruners P,
Schmitz-Rode T,
Gunther RW.
et al.
Multipolar hepatic radiofrequency ablation using up to six applicators: preliminary results. Rofo 2008; 180: 216-222
7
Hoffmann R,
Rempp H,
Erhard L.
et al.
Comparison of four microwave ablation devices: an experimental study in ex vivo bovine liver. Radiology 2013; 268: 89-97
15
Hinshaw JL,
Lubner MG,
Ziemlewicz TJ.
et al.
Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation – what should you use and why?. Radiographics 2014; 34: 1344-1362
19
Dollinger M,
Zeman F,
Niessen C.
et al.
Bile duct injury after irreversible electroporation of hepatic malignancies: evaluation of MR imaging findings and laboratory values. J Vasc Interv Radiol 2016; 27: 96-103
21
Kanas GP,
Taylor A,
Primrose JN.
et al.
Survival after liver resection in metastatic colorectal cancer: review and meta-analysis of prognostic factors. Clin Epidemiol 2012; 4: 283-301
25
Berber E,
Pelley R,
Siperstein AE.
Predictors of survival after radiofrequency thermal ablation of colorectal cancer metastases to the liver: a prospective study. J Clin Oncol 2005; 23: 1358-1364
26
Stang A,
Fischbach R,
Teichmann W.
et al.
A systematic review on the clinical benefit and role of radiofrequency ablation as treatment of colorectal liver metastases. Eur J Cancer 2009; 45: 1748-1756
28
Fong Y,
Fortner J,
Sun RL.
et al.
Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999; 230: 309-318 discussion 318–321
30
Lordick F,
Knodler M,
Hacker U.
et al.
Neoadjuvant chemotherapy or primary surgery for colorectal liver metastases. Pro adjuvant chemotherapy. Chirurg 2014; 85: 11-16
31
Settmacher U,
Scheuerlein H,
Rauchfuss F.
Assessment of resectability of colorectal liver metastases and extended resection. Chirurg 2014; 85: 24-30
32
Mantke R,
Niepmann D,
Gastinger I.
et al.
Hepatic resections. Analysis of data from the Tumor Documentation Center in the state of Brandenburg, Germany, focusing on liver metastases of colorectal carcinoma. Chirurg 2006; 77: 1135-1143
33
Mulier S,
Ni Y,
Jamart J.
et al.
Radiofrequency ablation versus resection for resectable colorectal liver metastases: time for a randomized trial?. Ann Surg Oncol 2008; 15: 144-157
34
Tanis E,
Nordlinger B,
Mauer M.
et al.
Local recurrence rates after radiofrequency ablation or resection of colorectal liver metastases. Analysis of the European Organisation for Research and Treatment of Cancer #40004 and #40983. Eur J Cancer 2014; 50: 912-919
35
Vigano L,
Capussotti L,
Lapointe R.
et al.
Early recurrence after liver resection for colorectal metastases: risk factors, prognosis, and treatment. A LiverMetSurvey-based study of 6,025 patients. Ann Surg Oncol 2014; 21: 1276-1286
36
Welsh FK,
Tekkis PP,
Oʼrourke T.
et al.
Quantification of risk of a positive (R1) resection margin following hepatic resection for metastatic colorectal cancer: an aid to clinical decision-making. Surg Oncol 2008; 17: 3-13
37
Smith MD,
Mccall JL.
Systematic review of tumour number and outcome after radical treatment of colorectal liver metastases. Br J Surg 2009; 96: 1101-1113
40
Ruers T,
Punt C,
Van Coevorden F.
et al.
Radiofrequency ablation combined with systemic treatment versus systemic treatment alone in patients with non-resectable colorectal liver metastases: a randomized EORTC Intergroup phase II study (EORTC40004). Ann Oncol 2012; 23: 2619-2626
42
Milano MT,
Katz AW,
Zhang H.
et al.
Oligometastases treated with stereotactic body radiotherapy: long-term follow-up of prospective study. Int J Radiat Oncol Biol Phys 2012; 83: 878-886
43
Evrard S,
Poston G,
Kissmeyer-Nielsen P.
et al.
Combined ablation and resection (CARe) as an effective parenchymal sparing treatment for extensive colorectal liver metastases. PLoS One 2014; 9: e114404
45
European Association for the Study of The L,
European Organisation For R.
Treatment Of C.
EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 56: 908-943
47
Liu PH,
Hsu CY,
Hsia CY.
et al.
Surgical resection versus radiofrequency ablation for single hepatocellular carcinoma ≤ 2 cm in a propensity score model. Ann Surg 2016; 263: 538-545
49
Yamakado K,
Nakatsuka A,
Takaki H.
et al.
Early-stage hepatocellular carcinoma: radiofrequency ablation combined with chemoembolization versus hepatectomy. Radiology 2008; 247: 260-266
50
Park EK,
Kim HJ,
Kim CY.
et al.
A comparison between surgical resection and radiofrequency ablation in the treatment of hepatocellular carcinoma. Ann Surg Treat Res 2014; 87: 72-80
51
Verslype C,
Rosmorduc O,
Rougier P.
et al.
Hepatocellular carcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23 (Suppl. 07) vii41-48
52
Lee DH,
Lee JM,
Lee JY.
et al.
Radiofrequency ablation of hepatocellular carcinoma as first-line treatment: long-term results and prognostic factors in 162 patients with cirrhosis. Radiology 2014; 270: 900-909
53
Wang Y,
Luo Q,
Li Y.
et al.
Radiofrequency ablation versus hepatic resection for small hepatocellular carcinomas: a meta-analysis of randomized and nonrandomized controlled trials. PLoS One 2014; 9: e84484
54
Lencioni RA,
Allgaier HP,
Cioni D.
et al.
Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology 2003; 228: 235-240
55
Streitparth F,
Pech M,
Bohmig M.
et al.
In vivo assessment of the gastric mucosal tolerance dose after single fraction, small volume irradiation of liver malignancies by computed tomography-guided, high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 2006; 65: 1479-1486
57
Park MH,
Rhim H,
Kim YS.
et al.
Spectrum of CT findings after radiofrequency ablation of hepatic tumors. Radiographics 2008; 28: 379-390 discussion 390–392
58
Mitsuzaki K,
Yamashita Y,
Nishiharu T.
et al.
CT appearance of hepatic tumors after microwave coagulation therapy. AJR Am J Roentgenol 1998; 171: 1397-1403
59
Kim SK,
Lim HK,
Kim YH.
et al.
Hepatocellular carcinoma treated with radio-frequency ablation: spectrum of imaging findings. Radiographics 2003; 23: 107-121
60
Onishi H,
Matsushita M,
Murakami T.
et al.
MR appearances of radiofrequency thermal ablation region: histopathologic correlation with dog liver models and an autopsy case. Acad Radiol 2004; 11: 1180-1189
61
Fischbach F,
Bunke J,
Thormann M.
et al.
MR-guided freehand biopsy of liver lesions with fast continuous imaging using a 1.0-T open MRI scanner: experience in 50 patients. Cardiovasc Intervent Radiol 2011; 34: 188-192
63
Mueller-Lisse UG,
Thoma M,
Faber S.
et al.
Coagulative interstitial laser-induced thermotherapy of benign prostatic hyperplasia: online imaging with a T2-weighted fast spin-echo MR sequence-experience in six patients. Radiology 1999; 210: 373-379
65
Stoffner R,
Schullian P,
Widmann G.
et al.
Magnetic resonance imaging of radiofrequency current-induced coagulation zones in the ex vivo bovine liver. Rofo 2010; 182: 690-697
66
Fischbach F,
Lohfink K,
Gaffke G.
et al.
Magnetic resonance-guided freehand radiofrequency ablation of malignant liver lesions: a new simplified and time-efficient approach using an interactive open magnetic resonance scan platform and hepatocyte-specific contrast agent. Invest Radiol 2013; 48: 422-428
69
Dodd GD,
3rd
Frank MS,
Aribandi M.
et al.
Radiofrequency thermal ablation: computer analysis of the size of the thermal injury created by overlapping ablations. AJR Am J Roentgenol 2001; 177: 777-782
71
Poon RT,
Ng KK,
Lam CM.
et al.
Learning curve for radiofrequency ablation of liver tumors: prospective analysis of initial 100 patients in a tertiary institution. Ann Surg 2004; 239: 441-449
72
Lu DS,
Raman SS,
Limanond P.
et al.
Influence of large peritumoral vessels on outcome of radiofrequency ablation of liver tumors. J Vasc Interv Radiol 2003; 14: 1267-1274
75
Ricke J,
Thormann M,
Ludewig M.
et al.
MR-guided liver tumor ablation employing open high-field 1.0 T MRI for image-guided brachytherapy. Eur Radiol 2010; 20: 1985-1993
77
Ohmoto K,
Tsuduki M,
Kunieda T.
et al.
CT appearance of hepatic parenchymal changes after percutaneous microwave coagulation therapy for hepatocellular carcinoma. J Comput Assist Tomogr 2000; 24: 866-871
78
Carrafiello G,
Lagana D,
Ianniello A.
et al.
Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works. Australas Radiol 2007; 51: 550-554
