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Ablation percutanée et nouvelles stratégies thérapeutiques du CHC : l’avènement des dispositifs micro-ondes de seconde génération sonne t’il le glas de la radiofréquence ? Olivier Seror Radiologie, Hôpital Jean Verdier, Bondy, AP-HP/Paris XIII

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  • 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 ?

  • Randomized controlled trials

    PEI/RF

    Palliative treatments

    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

  • Randomized controlled trials

    PEI/RF

    Palliative treatments

    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

    Long axis Small axis

    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

  • 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

    Long axis Small axis

    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

  • 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

    Long axis Small axis

    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

    Sizes of ablation area Long & small axis

  • 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