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Source publication
To evaluate technique effectiveness, safety, and interoperator performance of stereotactic radiofrequency ablation (SRFA) of liver lesions.
Retrospective review including 90 consecutive patients from January 2008 to January 2010 with 106 computed tomography-guided SRFA sessions using both single and multiple electrodes for the treatment of 177 lesi...
Context in source publication
Citations
... Nevertheless, the micro-robotic system may also be operated hybridly in combination with optical tracking with excellent puncture accuracy [17]. In terms of clinical applications, the microrobotic system may be additionally used for a broad spectrum of image-guided interventions, such as stereotactic biopsy of liver, lung, and bone lesions, or stereotactic radiofrequency ablation of liver tumors [18][19][20][21][22][23][24][25]. ...
Purpose
Endovascular aneurysm repair has emerged as the standard therapy for abdominal aortic aneurysms. In 9–30% of cases, retrograde filling of the aneurysm sac through patent branch arteries may result in persistence of blood flow outside the graft and within the aneurysm sac. This condition is called an endoleak type II, which may be treated by catheter-based embolization in case of continued sac enlargement. If an endovascular access is not possible, percutaneous targeting of the perfused nidus remains the only option. However, this can be very challenging due to the difficult access and deep puncture with risk of organ perforation and bleeding. Innovative targeting techniques such as robotics may provide a promising option for safe and successful targeting.
Methods
In nine consecutive patients, percutaneous embolization of type II endoleaks was performed using a table-mounted micro-robotic targeting platform. The needle path from the skin entry to the perfused nidus was planned based on the C-arm CT image data in the angio-suite. Entry point and path angle were aligned using the joystick-operated micro-robotic system under fluoroscopic control, and the coaxial needle was introduced until the target point within the perfused nidus was reached.
Results
All punctures were successful, and there were no puncture-related complications. The pre-operative C-arm CT was executed in 11–15 s, and pathway planning required 2–3 min. The robotic setup and sterile draping were performed in 1–2 min, and the alignment to the surgical plan took no longer than 30 s.
Conclusion
Due to the small size, the micro-robotic platform seamlessly integrated into the routine clinical workflow in the angio-suite. It offered significant benefits to the planning and safe execution of double-angulated deeply localized targets, such as type II endoleaks.
... At a 9.7-year median follow-up, the mortality rates were 65% and 89.8% in the combined treatment and systemic treatment alone groups, respectively, with a statistically significant difference in OS (HR: 0.58, 95% CI: 0.38 to 0.88) [28]. MWA systems are considered superior alternatives to conventional RFA for larger lesions [29,30]. Notably, in a systematic review, local tumor progression rates ranged from 11 to 78% for RFA and 14% to 38% for MWA, suggesting a preference for lesions >3 cm for MWA [26]. ...
Introduction: The role of stereotactic body radiation therapy (SBRT) as a locally effective therapeutic approach for liver oligometastases from tumors of various origin is well established. We investigated the role of robotic SBRT (rSBRT) treatment on oligometastatic patients with liver lesions. Material and Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed and Scopus databases were accessed by two independent investigators concerning robotic rSBRT for liver metastases, up to 3 October 2023. Results: In total, 15 studies, including 646 patients with 847 lesions that underwent rSBRT, were included in our systematic review. Complete response (CR) after rSBRT was achieved in 40.5% (95% CI, 36.66–44.46%), partial response (PR) in 19.01% (95% CI, 16.07–22.33%), whereas stable disease (SD) was recorded in 14.38% (95% CI, 11.8–17.41%) and progressive disease (PD) in 13.22% (95% CI, 10.74–16.17%) of patients. Progression-free survival (PFS) rates at 12 and 24 months were estimated at 61.49% (95% CI, 57.01–65.78%) and 32.55% (95% CI, 28.47–36.92%), respectively, while the overall survival (OS) rates at 12 and 24 months were estimated at 58.59% (95% CI, 53.67–63.33%) and 44.19% (95% CI, 39.38–49.12%), respectively. Grade 1 toxicity was reported in 13.81% (95% CI, 11.01–17.18%), Grade 2 toxicity in 5.57% (95% CI, 3.82–8.01%), and Grade 3 toxicity in 2.27% (955 CI, 1.22–4.07%) of included patients. Conclusions: rSBRT represents a promising method achieving local control with minimal toxicity in a significant proportion of patients. Further studies are needed to evaluate the role of rSBRT in the management of metastatic liver lesions.
... We have extensively studied the factors that contribute to successful outcomes and effective training in SRFA through various studies. 51,52 In our opinion, a solid theoretical foundation, practical experience and supervision are essential components of effective training. Notably, trainees with prior experience in interventional radiology will likely exhibit higher success rates, signifying the positive impact of a relevant background on SRFA training outcomes. ...
Summary
For both primary and metastatic liver cancer, thermal ablation represents an interesting alternative to surgery. However, except for a small fraction of patients, conventional ultrasound- and CT-guided single-probe approaches have not achieved oncologic outcomes comparable with surgery. In this over-view, we describe our stereotactic ablation workflow and discuss the short- and long-term results of stereotactic radiofrequency ablation (SRFA) and stereotactic microwave ablation (SMWA) for the treatment of primary and secondary liver tumours. The advantages of this method are discussed together with a summary of the existing stereotactic techniques for thermal ablation and the clinical data that support them. Stereotactic ablation is based on an optical navigation system and a specialized aiming tool. The workflow includes advanced three-dimensional planning, precise needle/probe placements according to the plan and intraoperative image fusion to check the needle positions and the ablation margins. Stereotactic ablation offers all the advantages of a minimally invasive procedure while producing oncological results comparable with surgery. The number of locally treatable liver cancers may be significantly expanded with these cutting-edge instruments and methods. We firmly believe that it can become a cornerstone in the treatment of liver cancers.
... 34 However, long-term survival data showed a high local recurrence rate postablation. 61,62 Therefore, combining radiofrequency ablation with systemic cytotoxic therapy like liposomal doxorubicin was considered a possible strategy to improve outcomes in patients with liver metastasis. It has been observed that RFA followed by liposomal doxorubicin would increase the tumor destruction volume by 25% to 30% compared to RFA alone. ...
Metastasis to the liver, as one of the most frequent metastatic patterns, was associated with poor prognosis. Major drawbacks of conventional therapies in liver metastasis were the lack of metastatic-targeting ability, predominant systemic toxicities and incapability of tumor microenvironment modulations. Lipid nanoparticles-based strategies like galactosylated, lyso-thermosensitive or active-targeting chemotherapeutics liposomes have been explored in liver metastasis management. This review aimed to summarize the state-of-art lipid nanoparticles-based therapies in liver metastasis management. Clinical and translational studies on the lipid nanoparticles in treating liver metastasis were searched up to April, 2023 from online databases. This review focused not only on the updates in drug-encapsulated lipid nanoparticles directly targeting metastatic cancer cells in treating liver metastasis, but more importantly on research frontiers in drug-loading lipid nanoparticles targeting nonparenchymal liver tumor microenvironment components in treating liver metastasis, which showed promise for future clinical oncological practice.
... The heat is concentrated concentrically around the tip of the electrode needle in various shapes and diameters depending on how the probe is constructed, the energy applied, and the tissue characteristics of the lesion. Larger regions of ablation are achieved by overlapping ablative zones of multiple probes with the goal of obtaining a 1 cm tumor-free margin [6,[72][73][74]. In tissues adjacent to large blood vessels, a phenomenon known as "heat sink" occurs whereby blood flow causes perfusion-mediated tissue cooling prohibiting the tissue from reaching a minimum temperature for tissue necrosis [75]. ...
Simple Summary
Liver malignancy affects thousands of people, and its treatment is constantly evolving. Ablative therapies are a series of minimally invasive modalities that treat these tumors in combination with other established forms of treatment such as chemotherapy and surgery. Ablative therapy is well-studied in the case of the most common type of liver malignancy, hepatocellular carcinoma. There is much less information on ablative therapy in non-hepatocellular carcinoma liver malignancy treatment. Therefore, we have described the available literature, focusing on ablative therapy’s promising results, shortcomings, and detail areas for future research on the topic of non-hepatocellular carcinoma of the liver.
Abstract
Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.
... Important methodological components such as trajectory planning and aiming device adjustment can be practiced before their use in clinical cases. In an earlier study, Widmann et al. [10] have already shown that there was no significant difference between an experienced and an inexperienced interventional radiologist (IR) in the outcome of SRFA for liver tumors. ...
Purpose:
To compare the results of a novice with those of experienced interventional radiologists (IRs) for stereotactic radiofrequency ablation (SRFA) of malignant liver tumors in terms of safety, technical success, and local tumor control.
Methods:
A database, including all SRFA procedures performed in a single center between January 2011 and December 2018 was retrospectively analyzed. A total of 39 ablation sessions performed by a novice IR were compared to the results of three more experienced IRs. Comparative SRFA sessions were selected using propensity score matching considering tumor type, age, sex, tumor size, and tumor number as matching variables. Overall, 549 target tumors were treated in 273 sessions. Median tumor size was 2.2 cm (1.0-8.5 cm) for 178 hepatocellular carcinomas (HCCs) and 3.0 cm (0.5-13.0 cm) for 371 metastases. A median of 2 (1-11) tumors were treated per session.
Results:
No significant differences were observed when comparing the results of more experienced IRs with those of a novice IR regarding the rates of major complications (6.8% [16/234] vs. 5.1% [2/39]; p = 0.477), mortality (1.3% [2/234] vs. 0% [0/39]; p = 0.690), primary technical efficacy (98.5% [525/533] vs. 98.9% [94/95]; p = 0.735), and local recurrence (5.6% [30/533] vs. 5.3% [5/95]; p = 0.886). However, the median planning/placement time was significantly shorter for the experienced IRs (92 min vs. 119 min; p = 0.002).
Conclusions:
SRFA is a safe, effective, and reliable treatment option for malignant liver tumors and favorable outcomes can be achieved even by inexperienced operators with minimal supervision.
... From 1664 CT exams in patients with hepatocellular carcinoma, 229 exams were related to CT-guided sRFA [13][14][15]. sRFA demonstrated high technique effectiveness, safety, and inter-operator performance, even for treatment of large volume disease, subcapsular, subphrenic and multiple lesions [16]. There is currently no information about the radiation exposure of patients receiving sRFA. ...
Rationale and objectives
Patients receiving high cumulative effective doses (CED) from recurrent computed tomography (CT) in a real-life setting are not well identified. Evaluation of causes and patient characteristics may help to define individuals potentially at risk of radiation-induced secondary malignancies.
Materials and methods
Patients who received a CED > 100 mSv from CT scans during October 2012 and April 2020 at a tertiary university center were identified with the help of a radiological radiation dose monitoring system. The primary disease and referral diagnosis, number of CT exams, time period, age, BMI and gender distribution of the 1000 patients with the highest CED were analysed.
Results
3431 patients had a CED of more than 100 mSv, which corresponded to 2.75% of all patients who received a CT exam. From the 1000 patients with the highest CED, mean number of CT exams per patient was 14.6, mean CED was 257 mSv (SD 98, range 177–1339). Mean age of patients was 63.9 years (SD 10.6), male to female ratio 3:2, and mean BMI 28.7 kg/m2 (SD 5.5). 728 (72.9%) patients had cancer. The leading primary diagnosis was liver cirrhosis in 197 patients and 103 patients had a liver transplantation. In patients with liver cirrhosis, 750 exams were indicated for the follow-up of the disease, 662 for the clarification of an acute clinical condition, and 202 for CT-guided stereotactic radiofrequency ablation.
Conclusion
Recurrent CT scans of patients with cancer, liver cirrhosis and liver transplantation may lead to critically high CED.
... The majority of publications on thermal ablation concerned RFA. However, for larger-size tumours, recently, preference has started to shift towards newer generation MWA systems or tumour-bracketing multiprobe ablation techniques as potentially superior alternatives to conventional RFA [82,83]. Presumed benefits of MWA over RFA are consistently higher intratumoural temperatures, faster heating, shorter procedure time, larger ablation volumes, and less susceptibility to the "heat-sink" effect at the cost of a somewhat higher biliary tract complication rate [84][85][86]. ...
Purpose of Review
Based on good local control rates and an excellent safety profile, guidelines consider thermal ablation the gold standard to eliminate small unresectable colorectal liver metastases (CRLM). However, efficacy decreases exponentially with increasing tumour size. The preferred treatment for intermediate-size unresectable CRLM remains uncertain. This systematic review and meta-analysis compare safety and efficacy of local ablative treatments for unresectable intermediate-size CRLM (3–5 cm).
Recent Findings
We systematically searched for publications reporting treatment outcomes of unresectable intermediate-size CRLM treated with thermal ablation, irreversible electroporation (IRE) or stereotactic ablative body-radiotherapy (SABR). No comparative studies or randomized trials were found. Literature to assess effectiveness was limited and there was substantial heterogeneity in outcomes and study populations. Per-patient local control ranged 22–90% for all techniques; 22–89% (8 series) for thermal ablation, 44% (1 series) for IRE, and 67–90% (1 series) for SABR depending on radiation dose.
Summary
Focal ablative therapy is safe and can induce long-term disease control, even for intermediate-size CRLM. Although SABR and tumuor-bracketing techniques such as IRE are suggested to be less susceptible to size, evidence to support any claims of superiority of one technique over the other is unsubstantiated by the available evidence. Future prospective comparative studies should address local-tumour-progression-free-survival, local control rate, overall survival, adverse events, and quality-of-life.
... Hirooka et al. (59) reported the free-hand as opposed to the stereotactic approach to be significantly associated with "local residual recurrence" in Cox regression analysis. In univariable between-group comparisons, Widmann et al. (47) reported differences in "technique effectiveness" for lesion size </>5 cm and hollow viscera vicinity and no differences for tumor entity and lesion location. Bale et al. (45) found differences in "local recurrence" rates for lesions in proximity to vessels, bile ducts, and hollow organs. ...
... One way to optimize procedural efficiency when applying such novel technology is to invest in initial training of staff including anesthesia to create smooth and standardized clinical workflows in multidisciplinary teams. The latter allow relatively steep learning curves (36) and a reduction of inter-operator variance as a factor influencing outcomes after thermal ablation (47). The present study confirms enhanced reliability and reproducibility of outcomes as being one of the key advantages of using stereotactic ablation techniques (50). ...
Background
Stereotactic navigation techniques aim to enhance treatment precision and safety in minimally invasive thermal ablation of liver tumors. We qualitatively reviewed and quantitatively summarized the available literature on procedural and clinical outcomes after stereotactic navigated ablation of malignant liver tumors.
Methods
A systematic literature search was performed on procedural and clinical outcomes when using stereotactic or robotic navigation for laparoscopic or percutaneous thermal ablation. The online databases Medline, Embase, and Cochrane Library were searched. Endpoints included targeting accuracy, procedural efficiency, and treatment efficacy outcomes. Meta-analysis including subgroup analyses was performed.
Results
Thirty-four studies (two randomized controlled trials, three prospective cohort studies, 29 case series) were qualitatively analyzed, and 22 studies were included for meta-analysis. Weighted average lateral targeting error was 3.7 mm (CI 3.2, 4.2), with all four comparative studies showing enhanced targeting accuracy compared to free-hand targeting. Weighted average overall complications, major complications, and mortality were 11.4% (6.7, 16.1), 3.4% (2.1, 5.1), and 0.8% (0.5, 1.3). Pooled estimates of primary technique efficacy were 94% (89, 97) if assessed at 1–6 weeks and 90% (87, 93) if assessed at 6–12 weeks post ablation, with remaining between-study heterogeneity. Primary technique efficacy was significantly enhanced in stereotactic vs. free-hand targeting, with odds ratio (OR) of 1.9 (1.2, 3.2) (n = 6 studies).
Conclusions
Advances in stereotactic navigation technologies allow highly precise and safe tumor targeting, leading to enhanced primary treatment efficacy. The use of varying definitions and terminology of safety and efficacy limits comparability among studies, highlighting the crucial need for further standardization of follow-up definitions.
... RFA and MWA seem to be helpful for smaller tumors (< 3 cm), but lose part of their effectiveness when it comes to bigger or irregularly shaped tumors resulting in higher recurrence rates [144,145]. This issue may be overcome by using stereotactic RFA, which combines preinterventional three-dimensional imaging, computerized three-dimensional planning of electrode positions, and guided electrode placement at arbitrary angulations and orientations [146,147]. In a systematic review and meta-analysis regarding the efficacy of ablative therapies in the management of unresectable iCCA the pooled 1-, 3-, and 5year OS rates were 76%, 33% and 16%, respectively [148]. ...
Intrahepatic cholangiocarcinoma (iCCA) is a subgroup of cholangiocarcinoma that accounts for about 10%-20% of the total cases. Infection with hepatitis B virus (HBV) is one of the most important predisposing factors leading to the formation of iCCA. It has been recently estimated based on abundant epidemiological data that the association between HBV infection and iCCA is strong with an odds ratio of about 4.5. The HBV-associated mechanisms that lead to iCCA are under intense investigation. The diagnosis of iCCA in the context of chronic liver disease is challenging and often requires histological confirmation to distinguish from hepatocellular carcinoma. It is currently unclear whether antiviral treatment for HBV can decrease the incidence of iCCA. In terms of management, surgical resection remains the mainstay of treatment. There is a need for effective treatment modalities beyond resection in both first- and second-line treatment. In this review, we summarize the epidemiological evidence that links the two entities, discuss the pathogenesis of HBV-associated iCCA, and present the available data on the diagnosis and management of this cancer.
