High Intensity Focused Ultrasound (HIFU) for Liver Tumour Dr Dai Wing Chiu Queen Mary Hospital.
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Transcript of High Intensity Focused Ultrasound (HIFU) for Liver Tumour Dr Dai Wing Chiu Queen Mary Hospital.
High Intensity Focused Ultrasound (HIFU) for Liver Tumour
Dr Dai Wing Chiu
Queen Mary Hospital
Background
Treatment options for hepatocellular carcinoma
Resection Liver transplantation Local ablative therapy Transarterial chemoembolization (TACE)
Local Ablation Therapy
The first description of percutaneous ethanol injection (PEI)
Liveraghi T et al. Radiology 1986
Thermal techniques were first performed in the liver using single bare tip neodymium yttrium aluminium garnet (NdYAG) laser fibres
Steger A et al. BMJ 1989
Five thermal techniques Radiofrequency ablation Laser Microwave Cryotherapy High intensity focused ultrasound (HIFU)
High Intensity Focused Ultrasound The first investigation of HIFU for non-invasiv
e ablation were reported in the early 1940s
Animal studies
High Intensity Focused Ultrasound Ultrasound
High intensity 1000W/cm2 to 25000W/cm2
Focus
Mechanism
Heating effect Cavitation
Ultrasound
Target organ (e.g. liver)
Tumor
‘Lesion’ of coagulation necrosis at focus
Skin
Transducer
Undamaged tissue surrounding focus
HIFU at Queen Mary Hospital
HIFU service for HCC started in Oct 2006 thanks to donation of the USG-guided HIFU system by Chongqing Haifu Co.
HIFU
Advantages Disadvantages
No scar Long treatment time
No risk of tumour seeding USG is obstructed by bone and air-filled viscera
Precise ablation No histological diagnosis
No cooling effect of perfusion (heat sink effect)
HIFU – Current evidence 50 consecutive patients with stage IVA HCC Group 1 (n=26) - TACE alone Group 2 (n=24) – TACE with HIFU performed 2-4 weeks afterwards Tumours size 4-14cm (mean 10.5cm) FU 3-24 months (mean 8 months)
F Wu et al. Radiology 2005
Group 1 Group 2
Median survival (months) 4.0 11.3 P=0.004
Survival
6 months 13.2% 80.4% P=0.003
1 year 0% 42.9%
Median reduction in tumour size
1 month 4.8% 28.6%
6 month 10% 52.9%
1 year 0% 50% P<0.01
HIFU – Current evidence
55 patients with HCC Prospective, non-randomized clinical trial Tumour size 4-14cm in diameter (mean 8.14cm) Serum AFP returned to normal level in 34% of patient Overall survival rates at 6, 12 and 18 months were 86.1%, 61.5%
and 35.3%, respectively Survival rates were significantly higher in patients in stage II than
those in stage IIIA (p=0.0132) and in stage IIIC (p=0.0265).
Wu F et al. Ann Surg Oncol 2004
HIFU at Queen Mary Hospital
From October 2006 to April 2008, totally 41 patients with unresectable HCC received HIFU treatment
Initial 21 patients received HIFU with transarterial embolization (TAE) (Period 1), and subsequent 20 patients received HIFU without TAE (Period 2)
Demographic and Clinical Data
Period 1
(n=21)
Period 2
(n=20)
P-value
Age, years 65 (48 – 84) 68 (55 – 77) 0.271
Sex ratio, M:F 17:4 17:3 1.000
Hepatitis B surface antigen positive 14 (66.7%) 17 (85%) 0.277
Hepatitis C virus antibody positive 4 (19%) 3 (15%) 1.000
Child-Pugh classification 0.643
Class A 17 (81%) 19 (95%)
Class B 4 (19%) 3 (15%)
Previous hepatic resection 8 (34.7%) 5 (38.4%) 1.000
Previous TACE 8 (38.1%) 7 (35%) 0.837
Serum alpha fetoprotein, ng/ml 10 (2-3951) 10 (3-8840) 0.766
Tumor and Treatment Data
Period 1
(n=21)
Period 2
(n=20)
P-value
Size of largest tumor, cm 2.7 (0.9 – 5) 2.1 (1 – 5) 0.733
No. of tumors treated
(solitary / 2 lesions)
19 / 2 16 / 4 0.410
Artificial right pleural effusion during HIFU
13 (61.9%) 13 (65%) 1.000
Total treatment duration, min 43 (10 – 125) 24 (3 – 122) 0.039
Average acoustic power, watt 351 (230 – 467) 429 (155 – 473) 0.074
Results
Period 1
(n=21)
Period 2
(n=20)P-value
Treatment-related mortality 1 (4.8%) - 1.000
Treatment-related complications 3 (14.2%) 2 (10%) 1.000
Second degree skin burn 2 -
Chest wall bruising 1 2
Hospital stay, days 3 (2 – 16) 4 (2 – 11) 0.792
Complete tumor ablationa 13 (65%) 19 (95%) 0.044
Complete tumor ablationb 15 (68%) 23 (96%) 0.009
a: Complete ablation rate in terms of number of patientsb: Complete ablation rate in terms of number of tumor nodules
Overall SurvivalO
ve
rall
Su
rviv
al
Months20100
100
90
80
70
60
50
40
30
20
10
0
P = 0.074
Period 2
Period 1
Short-term survival outcome between the two groups
(period 1 vs. period 2) were similar
(86.5% vs. 79% at 1 year, P = 0.074)
Period 2
Period 1
Indications for HIFU at QMH
Unresectable primary or recurrent HCC
(inadequate liver function, multifocal HCC, proximity to major vessels) Curative intent Tumor size < 10 cm < 3 tumor nodules No venous invasion No extrahepatic metastasis General condition fit for general anesthesia
Discussion
Its application as a non-invasive surgical tool is still in its infancy
Limitations and challenges Indications Limited evidence