Commentary
2
42. Kumada T, Nakano S, Takeda I, et al.: Patterns of recurrence after initial treatment in patients with small hepatocellular carcinoma. Hepatology 1997;25:87–92. 43. Ido K, Isoda N, Kawamoto C, et al.: Laparoscopic microwave coagulation therapy for solitary hepatocellular carcinoma per- formed under laparoscopic ultrasonography. Gastrointest Endosc 1997;45:415–420. 44. Dupuy DE, Goldberg SN: Image-guided radiofrequency tumor ablation: Challenges and opportunities—Part II. J Vasc Interv Radiol 2001;12:1135–1148. 45. Azoulay D, Johann M, Raccuia JS, et al.: ‘‘Protected’’ double needle biopsy technique for hepatic tumors. J Am Coll Surg 1996;183:160–163. COMMENTARY The article ‘Survival and intra-hepatic recurrences after laparoscopic radiofrequency of hepatocellular carci- noma in patients with liver cirrhosis’ by Santambrogio et al. in this months journal adds important information to the evolving field of hepatobiliary oncologic surgery and the exploding field of ablative technologies. It is impor- tant to remember that when possible liver transplantation and hepatic resection are the gold standard of treatment for hepatocellular carcinoma (HCC) [1]. The authors have carefully selected a cohort of patients who are not candidates for resection or transplantation. The authors should be commended for their precise accounting of a large series of cirrhotic patients with unresectable HCC treated with laparoscopic radiofrequency ablation. At 1 month, CT imaging revealed an 87% complete ablation rate with a very low morbidity (27%) and no mortality in this notoriously difficult patient population. In addition, the authors were able to show that laparoscopic ultra- sound detected 26 new lesions (25% of cases) which altered the intra-operative management of these patients. The authors have demonstrated that laparoscopic radio- frequency ablation can technically be completed with low peri-operative morbidity and mortality. Radiofrequency ablation uses an alternating current via an electrode implanted into the center of the lesion with a reference electrode placed on the patients thigh. Ionic agitation around the active electrode leads to frictional heating and coagulative necrosis [2]. The dissimination and use of this technology for the destruction of liver tumors has been rapid and widespread [3]. Despite a paucity of prospective trials comparing RFA to other established therapies, its use outside of clinical trials has been widespread. A recent Cochrane Database Systema- tic Review concluded that ‘RF thermal ablation is an insufficiently studied intervention for HCC’ [4]. When clinical efficacy and safety have not yet been clearly established, prior to the widespread dissemination of new unproven techniques; it is important that they are studied in prospective trials after appropriate Institutional Re- view Board (IRB) review, approval, and regulation. These issues and concerns have been raised and discussed comprehensively by Strasberg and Helton recently [5–7]. Its rapid dissemination throughout the world, lack of evidence regarding efficacy and safety, and the myriad of techniques/instruments employed have rightfully made RFA of hepatic lesions a ‘lightning rod’ for standardized reporting and IRB regulation and approval of new tech- nologies [5,7]. Standardized reporting includes the defi- nitions and technical considerations with regards to the implementation of new techniques/technology, response to treatment, and the complications arising from treat- ment. There are vast differences in the local recurrence rates reported for RF ablated HCCs [3]. In this study, with a mean follow-up of 22.5 months, 42% of the patients treated had a recurrence in the same segment of liver treated originally. This value is difficult to interpret pre- sently as a consequence of the heterogeneity of ins- truments, techniques, and patient populations used for hepatic RFA in the published literature. Previously Dodd et al. showed that ablation of a 4.25 cm lesion with a 1 cm margin required six precise needle deployments of a 5 cm ablation zone [8,9]. This emphasizes the precise nature of the procedure, along with the possibility of widely dis- parate results based solely on differences in the technique used. Assessment of a liver lesions response to treatment with RFA can be difficult [10,11]; this issue requires a consensus regarding the follow-up of these patients along with standardized definitions of residual, recurrent, and new disease. The reporting of complications in the sur- gical literature has been inconsistent and makes com- parison of techniques and results difficult [12]. The use of a standardized and widely accepted system for reporting complications such as proposed by Clavien et al. [13,14] Elijah Dixon is an Assistant Professor of Surgery and Oncology. *Correspondence to: Elijah Dixon, MD, BSc, MSc, FRCSC, Divisions of General Surgery and Surgical Oncology, Faculty of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331-29th Street SW, Calgary, AB, Canada. Fax: 403 283 1651. E-mail: [email protected] DOI 10.1002/jso.20205 Published online in Wiley InterScience (www.interscience.wiley.com). Laparoscopic Radiofrequency 225
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Transcript of Commentary
42. Kumada T, Nakano S, Takeda I, et al.: Patterns of recurrence afterinitial treatment in patients with small hepatocellular carcinoma.Hepatology 1997;25:87–92.
43. Ido K, Isoda N, Kawamoto C, et al.: Laparoscopic microwavecoagulation therapy for solitary hepatocellular carcinoma per-formed under laparoscopic ultrasonography. Gastrointest Endosc1997;45:415–420.
44. Dupuy DE, Goldberg SN: Image-guided radiofrequency tumorablation: Challenges and opportunities—Part II. J Vasc IntervRadiol 2001;12:1135–1148.
45. Azoulay D, Johann M, Raccuia JS, et al.: ‘‘Protected’’ doubleneedle biopsy technique for hepatic tumors. J Am Coll Surg1996;183:160–163.
COMMENTARY
The article ‘Survival and intra-hepatic recurrencesafter laparoscopic radiofrequency of hepatocellular carci-noma in patients with liver cirrhosis’ by Santambrogioet al. in this months journal adds important information tothe evolving field of hepatobiliary oncologic surgery andthe exploding field of ablative technologies. It is impor-tant to remember that when possible liver transplantationand hepatic resection are the gold standard of treatmentfor hepatocellular carcinoma (HCC) [1]. The authorshave carefully selected a cohort of patients who are notcandidates for resection or transplantation. The authorsshould be commended for their precise accounting of alarge series of cirrhotic patients with unresectable HCCtreated with laparoscopic radiofrequency ablation. At1 month, CT imaging revealed an 87% complete ablationrate with a very low morbidity (27%) and no mortality inthis notoriously difficult patient population. In addition,the authors were able to show that laparoscopic ultra-sound detected 26 new lesions (25% of cases) whichaltered the intra-operative management of these patients.The authors have demonstrated that laparoscopic radio-frequency ablation can technically be completed with lowperi-operative morbidity and mortality.
Radiofrequency ablation uses an alternating current viaan electrode implanted into the center of the lesion with areference electrode placed on the patients thigh. Ionicagitation around the active electrode leads to frictionalheating and coagulative necrosis [2]. The dissiminationand use of this technology for the destruction of livertumors has been rapid and widespread [3]. Despite apaucity of prospective trials comparing RFA to otherestablished therapies, its use outside of clinical trials hasbeen widespread. A recent Cochrane Database Systema-tic Review concluded that ‘RF thermal ablation is aninsufficiently studied intervention for HCC’ [4]. Whenclinical efficacy and safety have not yet been clearlyestablished, prior to the widespread dissemination of newunproven techniques; it is important that they are studiedin prospective trials after appropriate Institutional Re-view Board (IRB) review, approval, and regulation. These
issues and concerns have been raised and discussedcomprehensively by Strasberg and Helton recently [5–7].Its rapid dissemination throughout the world, lack ofevidence regarding efficacy and safety, and the myriad oftechniques/instruments employed have rightfully madeRFA of hepatic lesions a ‘lightning rod’ for standardizedreporting and IRB regulation and approval of new tech-nologies [5,7]. Standardized reporting includes the defi-nitions and technical considerations with regards to theimplementation of new techniques/technology, responseto treatment, and the complications arising from treat-ment. There are vast differences in the local recurrencerates reported for RF ablated HCCs [3]. In this study, witha mean follow-up of 22.5 months, 42% of the patientstreated had a recurrence in the same segment of livertreated originally. This value is difficult to interpret pre-sently as a consequence of the heterogeneity of ins-truments, techniques, and patient populations used forhepatic RFA in the published literature. Previously Doddet al. showed that ablation of a 4.25 cm lesion with a 1 cmmargin required six precise needle deployments of a 5 cmablation zone [8,9]. This emphasizes the precise nature ofthe procedure, along with the possibility of widely dis-parate results based solely on differences in the techniqueused. Assessment of a liver lesions response to treatmentwith RFA can be difficult [10,11]; this issue requires aconsensus regarding the follow-up of these patients alongwith standardized definitions of residual, recurrent, andnew disease. The reporting of complications in the sur-gical literature has been inconsistent and makes com-parison of techniques and results difficult [12]. The use ofa standardized and widely accepted system for reportingcomplications such as proposed by Clavien et al. [13,14]
Elijah Dixon is an Assistant Professor of Surgery and Oncology.
*Correspondence to: Elijah Dixon, MD, BSc, MSc, FRCSC, Divisions ofGeneral Surgery and Surgical Oncology, Faculty of Medicine, University ofCalgary, Tom Baker Cancer Centre, 1331-29th Street SW, Calgary, AB,Canada. Fax: 403 283 1651. E-mail: [email protected]
DOI 10.1002/jso.20205
Published online in Wiley InterScience (www.interscience.wiley.com).
Laparoscopic Radiofrequency 225
would go a long way in allowing the surgical commun-ity to reasonably compare results between centers. Theheterogeneity of the published literature for the reasonsoutlined, along with a lack of prospective comparativeclinical trials makes it difficult to draw meaningful con-clusions regarding the efficacy and safety of radio-frequency ablation of hepatic lesions.The present study by Santambrogio et al. adds impor-
tant information to the surgical community regardingthe safe use of laparoscopic radiofrequency ablation.Future studies should endeavor to describe the techniquesused, responses to treatment, and the complicationsarising from treatment in a standardized manner tofacilitate comparisons between institutions from acrossthe world.
Elijah Dixon, MD, BSc, MSc, FRCSC*Divisions of General Surgery and Surgical OncologyFaculty of MedicineUniversity of Calgary, Tom Baker Cancer CentreCalgary, AB, Canada
REFERENCES
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226 Santambrogio et al.
