Ablation percutanée et nouvelles stratégies ... -...

Ablation percutane et nouvelles stratgies thrapeutiques du CHC : lavnement des dispositifs micro-ondes de seconde gnration sonne til le glas de la radiofrquence ?

Olivier Seror Radiologie, Hpital Jean Verdier, Bondy, AP-HP/Paris XIII

Traitements chimiques : Dnaturation protique et micro thromboses chimiques

I OH

AA

Hot NaCl

Chx

I

Cryo

RF Mw

IEP

E

Traitements physiques : Dnaturation protique par dpt nergtique localis

USf E 0

+60

-40

C

Laser () 1064 nm

Multiapplicateurs

Cot/efficacit

0 d (cm)

T (C)

2 cm max

60

- 40

- 20

Cryothrapie Argon (-185C)/Hlium haute pression

Moins de dommage collatraux

Visibilit du glaon (US TDM IRM) Multi applicateurs Cot

Isothermes :

-20C : 20 x 40 mm Zone ltale

-40C : 14 x 32 mm

--

++

++

--

Mw 915/2450MHz

O H H

O H H

O H H

O H H

O H H

O H H

O H H

O H H

Rapide

Trs (trop) efficace Cot

M

++

--

IEP : Electroporation irrversible 90 pulses (?? kHz) x 20-100s de 100-3000v 50A

++

--

-

+

-

+ -

+

-

+ lvation brutale du

potentiel trans membranaire

Ce nest pas une thermothrapie !

Rapide

Insensible au . heat sink effect

AG

Cot

CHC : Indication princeps

Tumeur 3 cm

3 nodules Inoprable (cirrhose)

Randomized controlled trials

PEI/RF

Palliative treatments

New agents Sorafenib

BCLC (AASLD) 2005

Stades 0 et A

Child-Pugh A-B

Alcoolisation, Actisation ou RF ?


PEI/RF


RF New agents Sorafenib

BCLC (AASLD) 2011

Stades 0 et A

Child-Pugh A-B

RF ou MW ou Cryo ou EPI ou ?

Laparoscopic-assisted microwave ablation for hepatocellular carcinoma : Safety and efficacy in comparison with radiofrequency ablation Simo KA, Sereika SE, Newton KN, Gerber DA.

RFA (n=27)

MWA (n=15) P

Volume dablation (cm3) 23 29 0,69

Temps dablation (min) 14935 11240 0,004

Ncrose complte (%) 100 100

Volume 104, December 2011


PEI/RF


RF New agents Sorafenib

BCLC (EASL) 2012

Stades 0 et A

Child-Pugh A-B

Ablation Ablation

MW vs RF: Some physical differences

RFA [300-400 KHz] Ionique agitation

Active heating (Impedance)

MWA [915 MHz or 2.45GHz] Water agitation

Active heating (Permittivity)

Heat

conduction

2.45GHz 915 MHz ?

of active heating

with RF 90 % of ablation relies on heat conduction

MWA is less controllable on lesion size Generates detrimental backward heating

MWA versus RFA: Some (potential) disadvantages

As many devices available on the market as much technological options !

2nd generation MWA technologies: Cornelian choice for operators

Sizes of ablation area Long & small axis

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W

Long axis Small axis

N = 24 N = 20 N = 29

Long axis along probes axis

Retraction (up to 40% !)

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W


N = 24 N = 20 N = 29

Sizes of ablation area Long & small axis / Application time

2.45 GHz 180W

915 MHz 32W

2.45 GHz 130W

Average 3.71.9min 6.94min 7.25min

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W

Long axis/ Applicat time

Small axis/ Applicat time

N = 24 N = 20 N = 29


Sizes of ablation area Long & small axis / antenna repositioning

2.45 GHz 180W

915 MHz 32W

2.45 GHz 130W

Average 1.71 1.61 1.40.7

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W


N = 24 N = 20 N = 29

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W

Long axis/ N positioning

Small axis/ N positioning

N = 24 N = 20 N = 29


Sizes of ablation area Long & small axis / forward power

mm

10

20

30

40

50

60

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W


N = 24 N = 20 N = 29

2.45 GHz 180W

915 MHz 32W

2.45 GHz 130W

Average 16030W 301,6W 6016W

mm.10-2

20 40

60

80

100

120

2.45 GHz 180 W

915 MHz 32 W

2.45 GHz 130 W

Long axis/ Forward power

Small axis/ Forward power

N = 24 N = 20 N = 29 140


Complications 43 patients, 75 tumors, 126 energy cycles

7 burns (16%, 9.3%, 5.5%) (Tract ablation systematically performed) 1 portal thrombosis (liver decompensation) 4 antenna breakings 1 pleural effusion (drainage) 1 bilioma (asymptomatic) 1 segmentary bile ducts dilatations (asymptomatic)

A worse safety profile than RFA

Complications : RF vs MW

Mortality Major Morbidity Minor

Morbidity Thermal damages

Mechanical damages

MWA N = 736 Livraghi, CVIR 2011

0% 2.9% 7.3% 3.8% 1.9%

RFA N = 2320 Livraghi, Radiology 2003

0.3% 2.4% 5% 0.3% 0.5%

3 main causal factors Induction of fast and less controlled ablation area no effective protective procedures inside the 2 cm active heating area!

Burns along transmission line due to backward energy Less protective effect of blood flow

Local tumor control

1 month

11 months Incomplete local control :

Incomplete primary

ablation or local recurrence

Taux de ncrose complte en anatomopathologie (analyse par nodule)

N Radiological (CT) Histological

Mazzaferro, Ann Surg, 2004 60 70 41.5

Brillet, AJR, 2006 22 75 37.5

RF monopolaire des CHC 3 cm : < 50% de ncrose complte Et aprs MWA ?

Qualit du contrle local en RF CHC 3 cm (RF monopolaire)

Annals of Surgery . Volume 245, Number 1, January 2007

Recurrence-free survival curves

for narrow and wide resection margin groups

0.0

0.2

0.4

0.6

0.8

1.0

Recu

rren

ce F

ree S

urv

ival

0 20 40 60 80

Months after resection

Wide margin group (n=85)

Narrow margin group (n=84)

Overal survival curves for narrow and wide

resection margin groups

0.0

0.2

0.4

0.6

0.8

1.0

Cu

mu

lati

ve S

urv

ival

0 20 40 60 80

Months after resection

Wide margin group (n=85)

Narrow margin group (n=84)

In your opinion what should be the best way to perform in situ thermal ablation of a malignant liver tumor? First option: from the center to the periphery

Second option: from the periphery to the center

Learn from liver oncologic surgery practice

Intra tumoral RFA

Technologie RF : mono vs multipolaire

Ablation margins Quite predicable Poorly predicable

Spread of heating Centripetal Centrifugal

No touch RFA

From single to multi applicators and

multipolar devices

Ablation planning according to tumor size (cm)

M&M : Procedures " Ultrasound guidance " General anesthesia " From two to four internaly cooled electrodes

4 3 2

Maximum distance between two adjacent electrodes 3 cm

Imagerie post no touch : fantme tumoral

Avant RF Apres RF

Histologie post no touch : Safety Margin

Avant RF Apres RF

RF no touch

RF monopolaire

BCLC (EASL) 2012

Randomized controlled trials Palliative treatments

New agents Sorafenib

Stades 0 et A

PEI/RF RF

Child-Pugh A-B

Ablation Ablation

RFA possible en technique no touch

Single

Oui Non

RFA no touch

1/ Transplantation

2/ Rsection

3/ Ablation (RFA, MW)

4/

Ablation possible

3 nodules

Oui Non

1/ MW

2/ RFA

3/

1/ Transplantation

2/

B ndy CLC 2012

CHC multifocal oligonodulaire: Avantage MW! 57 ans cirrhose thylique C-P B7 (TDM 11/09 : pas de CHC)

Octobre 2011 : 4 CHCs < 3 cm

Dcembre 2011 : 3 CHCs 1 cm

Mars 2012 : 1 CHC 1,5 cm

MW 1h45

MW 35

MW 1h15

TH

Traitements combine ?

N % 2-Years local Recurrence

TACE + RFA 46 17 RFA 43 14

Randomized trial of TACE + RFA compared with RFA alone

Combinaison des technologies dablation ? 71 ans cirrhose post HVC C-P B6

Nov. 11 : 3 CHCs < 3,5 cm Dec. 11 : reliquat prportal MW Mar. 12 : 0 CHC actif visible IEP

Et les gros CHC ?

Tumeur 5 cm

Tumeur infiltrante Extension portale (intra hpatique)

Inoprables +++

BCLC (EASL) 2012 : Gros CHC

+/- Ablations

!

Ablations

? ?????

RF monopolaire du gros CHC

N Size

[range] mean (cm)

Complete radiological response

(%)

Local recurrence

(%)

Incomplete local tumor

control (%)

Livraghi T et al. Radiology, 2000

RFA 114 [3-9,5] 5.4 47.6 5.5 58

Yin XY et al. Cancer, 2009

RFA 109 [3-7] 3.9 92.6 22 29.4

N Size

[range] mean (cm)

Complete radiological response

(%)

Local recurrence

(%)

Incomplete local tumor

control (%)

Livraghi T et al. Radiology, 2000

RFA 114 [3-9,5] 5.4 47.6 5.5 58

Yin XY et al. Cancer, 2009

RFA 109 [3-7] 3.9 92.6 22 29.4

Veltri A et al. Eur Radiol, 2006

TACE +

RFA 46 [3-8] 4.8 66.7 10 43.3

Lencioni R et al. J Hepatol, 2008

RFA +

DC beads 20 [3.3-7] 5 60 10 50

Et si on ajoutait la CEL

Monopolar Multipolar

Resort to overlapping ablations Limited Mandatory

Ablation margins Quite predicable Poorly predicable

Ablation volume Summation of all inter applicators ablation areas

Summation of all surrounding applicator ablation areas

Spread of heating Centripetal Centrifugal

Multi applicators devices

Technologie RF : mono vs multipolaire

Ablation planning according to tumor size

" Ultrasound guidance " General anesthesia " Up to six internaly cooled linear electrodes

3 cm as maximal distance between 2 adjacent electrodes

5 cm diameter 6 cm diameter

M&M : Procedures

" 87% de rponse complte (47/54)

" 6/7 des checs taient des formes infiltrantes

Rsultats: Rponse prcoce

Rponse complte en imagerie

Before RFA 1 month after RFA

4 months after RFA

Liver transplantation

59 years old, Child-Pugh A HCV cirrhosis, referred for MP RFA for a 55 mm nodular HCC located in segment VIII/IV

CHC infiltrants sur 1-3 segments ? 50 ans, CHC infiltrant V/VIII & VII + nodules mtastatiques bilobaires sur cirrhose thylique C-P A, rponse < 50% la CEL

Novembre 2010

Alcoolisation intra artrielle Cest pas cher et a peut rapporter gros ! Sous Echo et sous AG

Une aiguille Chiba 18G et un raccord flexible

5-50 cc dOH 90%

Mars 2012 Hpatectomie droite

Radiofrquence multipolare A tenter si AIA impossible ou en chec 83 ans, prsentant une quadruple rcidive de CHC dont une volumineuse lsion infiltrante du III 5 ans aprs une RFA initiale pour CHC bifocal (rupture de surveillance, cirrhose OH C-P B6)

Aout 2011

Janvier 2012

Plus de CHC actif visible mais dgradation de la fonction hpatique

Mthode 1

Technique ancienne = Technique obsolte ?

Spectre des indications en intention curative

Mthode 2 Mthode 3

Pas de mthode omnipotente Pas de substitution ad integratum

Mono-segmentaire

En pratique Bondy CHC " curable "

2

>5cm

MW

RF MP

CP>B6

Bi-segmentaire

AIA

RF MP

3cm

CEL & Co

AIA

CEL & Co

>5cm

Ablation percutanée et nouvelles stratégies ... -...

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