Dr Fabio Farinati Gastroenterologia, Padova Point/TRATTAMENTO PERCUTANEO HCC.pdf · Dr Fabio...
Transcript of Dr Fabio Farinati Gastroenterologia, Padova Point/TRATTAMENTO PERCUTANEO HCC.pdf · Dr Fabio...
Nuove metodiche strumentali inteventistiche e diagnostiche in gastroenterologia
Dr Fabio FarinatiDr Fabio FarinatiGastroenterologia, Gastroenterologia,
PadovaPadova
“Terapie locoregionali percutanee dell’HCC”
Clinical management of HCC: the problems
1. 1. SurveillanceSurveillance2. 2. ChemopreventionChemoprevention3. 3. BiopsyBiopsy : : yesyes or or notnot4. 4. StagingStaging : : imagingimaging and and methodologymethodology5. 5. Treatment of Treatment of earlyearly HCCHCC6. 6. RFA o PEI ?RFA o PEI ?7. 7. IsIs Tace Tace effectiveeffective ??8. 8. TamoxifenTamoxifen , , megestrolmegestrol ,,
octreotideoctreotide , , ……..?..?
“Early” HCC: treatment
Chirurgia Chirurgia 64%64%
PEI/RFA PEI/RFA 30%30%
OLTxOLTx 6%6%
Chirurgia se Chirurgia se a basso a basso rischio rischio
(LFT!).PEI(LFT!).PEI **..
OLTxOLTx <65 <65 aaaaChildChild B/CB/C
SurgerySurgery , , ifif
notnot PEIPEI**..
OltxOltx basedbasedon on availableavailableresourcesresources
Single Single nodenode ,,ChildChild A A (B?)(B?)
SURVEYSURVEYAISFAISF(2001)(2001)
EASLEASL(2000)(2000)
* RFA not validated
Locoregional transparietal Txs
��PEI (PEI (PercutaneousPercutaneous ethanolethanol injectioninjection ))��RadiofrequencyRadiofrequency --mediatedmediated thermalthermal treattreat ..��InterstitialInterstitial laser treatmentlaser treatment��MicrowaveMicrowave treatmenttreatment��IntratumoralIntratumoral chemotherapychemotherapy��IntratumoralIntratumoral immunomodulationimmunomodulation��IntratumoralIntratumoral gene gene therapytherapy
PEI : results
0
20
40
60
80
100
1 2 3 4 5
Curative Palliative Years
Shiina, Cancer 1994
%
Pei versus no treatment
0
20
40
60
80
100
1 2 3
PEI No TxYears
Omata, 1992
Retrospective analysis
%
PEI: Padua experience
0
20
40
60
80
100
1 2 3 4 5
Overall Curative Palliative Years
218 treated patients
%
PEI: tumor size
0
20
40
60
80
100
1 2 3 4 5
<3 cm 3 - 5 cm > 5 cm 2 nodes
p<0.05
%
years
PEI: Child status
0
20
40
60
80
100
1 2 3 4 5
Child A Child B
%
years
p<0.01
PEI: αααα Fetoprotein levels
0
20
40
60
80
100
1 2 3 4 5
< 20 < 50 =/>100
%
Years
p=0.002
PEI versus surgery
0
20
40
60
80
100
1 2 3 4 5
PEI Surgery
%
years
p=n.s.
Castells, Hepatology, 1996
PEI plus TACE : survival
0
20
40
60
80
100
1 2 3 4 5
PEI PEI+TACE
%
years
p=n.s
Nodes < 3 cm
PEI plus TACE : survival
0
20
40
60
80
100
1 2 3 4 5
PEI PEI+TACE
%
years
p<0.05 Nodes > 3 cm
Percutaneous RadioFrequencyInterstitial Thermal Ablation
�� InterstitialInterstitial hyperthermiahyperthermia��MonopolarMonopolar needleneedle , 2 , 2 -- 12 min.12 min.��LimitLimit : : tissuetissue impedanceimpedance��LimitLimit : : largelarge sizesize of the of the needleneedle��LimitLimit : : needneed forfor anesthesiaanesthesia��LimitLimit : 3 cm : 3 cm diameterdiameter of of necrosisnecrosis
RF thermal ablation:developments
�� New New developmentsdevelopments ::–– cold H2Ocold H2O --refrigerated refrigerated needlesneedles ((toto reduce reduce
impedanceimpedance ))–– multiple terminal multiple terminal needleneedle ((toto increaseincrease sizesize of of
necrosisnecrosis ))–– stopstop --flowflow arterialarterial catheterismcatheterism ((toto block block bloodblood --
flowflow thatthat reducesreduces necrosisnecrosis ))
RF thermal ablation
0
20
40
60
80
100
1 2 3 4 5
RFTA
%
Years
Rossi, A.J.R., 1996
RFA or PEI ?
0
20
40
60
80
100
RFA PEI
% Tumoral control
Livraghi, Radiol. 99 Lencioni, Radiol. 99
PEI and RFA: prospective evaluation
0
20
40
60
80
100
1 year2 years
1 year REC2 year REC
PEI RFA
Lencioni, Radiology, 2003
RFA IN EXPLANTED LIVERS
“Early” HCC: RF thermal ablation
�� EASL = EASL = promisingpromising , , similarsimilar or or eveneven betterbetterresponseresponse rate, rate, fewerfewer sessionssessions , , higherhigher rate rate of side of side effectseffects , , lowerlower applicabilityapplicability
�� AISF = the AISF = the locoregionallocoregional treatment of treatment of choicechoice isis PEIPEI
Forget about ethanol !!!
Barcelona, EASL, AGA, JCSJune 2005
ETOH
Forget about ethanol !!!
Barcelona, EASL, AGA, JCSJune 2005
ETOH
PEI is…• Less efficient• More time consuming• Similar costs (JPN)
RFA has…• Very high applicability (?)• Few complications
HOWEVER…..
Barcelona, EASL, AGA, JCSJune 2005
ETOH
ETOH < 2 cmDifficult position
RFA < 3 CM> 3 = SURGERY
Why 3 cm ???
> 3 cm
1 cm cancer-freemargin (as in surg.)
“Our” data
COMPLICANCE (34% pts)EC immediati (11%)
% EC ricovero (22%)
% EC post-ricovero(7%)
%
Dolore 42 Febbre 45 Febbre 38
Spasmo diaframmatico
19 Dolore 37 Ascite 23
Conati di vomito 19 Ascite 6 Fistola 15
Pneumotorace 4 Colica biliare 4 Ascesso 7
Pneumoperitoneo 4 Ematoma 2 Dolore 7
Extrasistolia 4 Emobilia 2 7
Stillicidio ematico 4 2Morte-Ictus
Morte-perfor. intest
MortalityMortality: 0,5%: 0,5%
Seeding 0.8%
RFA: caveats !!!
�� RapidRapid progressionprogression of HCC after RFAof HCC after RFA�� RuzzenenteRuzzenente etet al.al.�� World Journal of World Journal of GastroenterologyGastroenterology , 2004, 2004
4/87 patients (5%), with lesions proximalto major portal branches or with elevated AFP
Unexpected and rapid HCC progression
Dopo RFA, rapida progressione non clinicamente o biologicamente plausibile. 11 casi /359 (3%) pazienti nel nostro studio
# localizzazioni MULTIPLE anche di nodi di dimensioni rilevanti a 1-6 mesi dal trattamento# 1 paziente metastatizzazione polmonare massiva con malattia epatica trattata
MECHANISMS ?
vaporizzazione della massa tumorale
T°C
ESPLOSIONE ESPLOSIONE DISSEMINAZIONEDISSEMINAZIONE
TGFTGFββββββββ11
LBFLBF --GFGFCRESCITA CRESCITA
TUMORALETUMORALE
Ohno T et al, J.Hepatol., 2002
TAC dopo 1 mese dalla RFTA
Residuo di malattia
TAC dopo 4 mesi, multiple lesioni
nodulari bilobari
M.M.
a. 73
TAC torace: quadro
plurimetastatico a livello polmonare
TAC (12 mesi) HCC trattato con
successo
C.V.
a 50
RFA
• Large scale study
• Long time observation
• End of honey-moon effect
Surgery OLTx
RFA/PEI