Chemoembolization, Cryotherapy and Microwave Thermotherapy

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Chemoembolization, Cryotherapy and Microwave
Thermotherapy

• Fred T. Lee Jr., MD
• University of Wisconsin Dept. of Radiology

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• Chemoembolization
• ChemoembolizationRF
• Cryotherapy
• Microwave thermotherapy
• Comparison of techniques

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Chemoembolization

• Delivery of concentrated chemotherapy to liver
  via hepatic artery
• Used for hepatocellular carcinoma and metastases
  (lobar or segmental)
• Less systemic side effects than IV chemotherapy

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• Chemoembolization
• Indications
• Unresectable HCC or liver mets
• Nonsurgical candidates
• Single or multiple lesions
• Palliation/selective prolongation of life

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ChemoembolizationContraindications

• Total bilirubingt3.5
• Portal Vein Thrombosis
• Active Infection

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Chemoembolization

• Prep bowel, skin, Abx, steroids, hydration
• Selective, superselective catherization of tumor
  vessels bypass GDA, cystic artery
• Slowly inject cocktail

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Wisconsin cocktail

• Cisplatin 100 mg
• Mitomycin C 10 mg
• Adriamycin 50 mg
• Ethiodol 10 cc
• Contrast 8 cc
• Ivalon particles 300-500 µ

McDermott J, Wojtowycz M, Sproat I, Omary
R, Salem R, Wagner HJ
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Results (many different cocktails, protocols)

• Mets ? response rates, but probably no survival
  advantage. Palliation.
• HCC High local tumor response rates. Probably
  no survival advantage vs. symptomatic rx. Less
  effective than surgery in resectable patients.
• Pelletier. J Hep 1998
• Kanematsu. Cancer 1993

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Chemoembolization as adjuvant therapy

• Chembo ETOH for HCC
• Chembo ETOH prior to Ltxp
• Chembo RF?
• Tanaka. Radiology 1992
• Lencioni. Radiology 1994
• Troisi. Clin Transpl 1998

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RF Ablation Why We Fail

• Mets local failures30-50
• Miss lesion
• Cover, but dont kill entire tumor
• Most failures occur in the rim vessels!

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Cooled-tip electrode Porcine Liver Slice
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3-days post
2 months post
Pre-ablation
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Pre-ablation
5 months post
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Conventional RF Current Density
tumor
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Current density1/r
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Conventional RF Current Density
vessel
tumor
4
Current density1/r
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Vessels as cause of RF failures

• Lu DS, RSNA 2000
• Gillams AR, Lees W. RSNA 1999, 2000

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Better RF Lesion Size/Shape with Vascular
Occlusion

• Bodie AW, Cancer Res 1986
• Goldberg SN, Radiology, JVIR 1998
• Patterson EJ, Ann Surg 1998
• Chinn SB, Lee FT, AJR 2001

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Decreased local recurrence (19) of HCC with
bland vascular occlusion

• Rossi S, Garbagnati F, Lencioni R, et al.
  Radiology 2000217

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RF lesion volume with vascular occlusion

• Vessel Volume shape
• None 4.3 cc irreg
• HA 7.6 sltly irreg
• PV 8.6 round
• Pringle 12.6 round

Chinn AJR, 2001
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Effect of vascular occlusion on lesion size/shape
Hepatic Artery
No Occlusion
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Effect of vascular occlusion on lesion size/shape
Portal vein
Pringle
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RF ablationchemoembolizationRationale

• Embo increases size, rounder
• Deposits chemo in tumor, EDGES!
• RF increases dwell time of chemo
• Need long term results

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RF Chembo RSNA 2001

• Yamakado K
• Pereira P
• Good local control of large HCC

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1 month post
4 months post
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Courtesy Riad Salem, MD
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Chemoembolization RF ablation
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Post Chemoembolization
Post ChemboRF
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Pre-treatment
Post chemboRF
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Microwave Coagulation Therapy
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UW coach's son gets 10 days for parrot's
microwave death Chad Alvarez will begin jail
term on Dec. 20 By Dennis Chaptman of the
Journal Sentinel staff Last Updated Dec. 10,
1999 Madison - The microwave-oven killing of
Iago, a Quaker parrot owned by a fraternity
brother, landed Chad Alvarez two felony
convictions and a sentence of probation and
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Microwave Coagulation Therapy

• Used in Japan for gt10 years
• No system currently available in the USA
• Microwave field causes tissue heating
• Net effect is much like RF

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RF ablation
generator
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Current drop 1/r
2
Heating drop 1/r
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MCT ablation
generator
No grounding pads necessary
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RF ablation
Active zone
Several mms
Microwave
2 cm
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Microwave Coagulation Therapy
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Microwave vs RF

• Microwave Hotter, possibly faster, multiple
  probes, no ground pads. No USA experience
• RF Available, robust technology, increasing
  lesion size

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Microwave vs RF
RF
MW
Immediate
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MW vs. RF
RF
MW
48 Hours
4 Weeks
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Hepatic Cryoablation

• Very powerful local ablation technique
• Multiple probes can be used together to ablate a
  tumor of virtually any size
• Freezes tissue to app. -150 degrees C.
• Tissue death due to cellular rupture, vascular
  occlusion

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Cryoablation of liver tumors

• First focal tumor ablation technology
• Performed clinically since the early 1960s
• Combined with IOUS in 1980s (Onik)

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Courtesy of G. Onik, MD
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In era of RF, is cryo still needed?

• Very powerful. Multiple probes make a large
  iceball in a short period of time, can ablate up
  to large vessels.

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4 months post
Precryo
POD 5
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In era of RF, is cryo still needed?

• Very powerful. Multiple probes make a large
  iceball in a short period of time, can ablate
  adjacent to large vessels.
• Low local recurrence rates

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Cryoablation Local Recurrence

• Deaconess (Kane) 5-year followup 12
• Wisconsin (Lee) 28 mo f/u 9 Surgical margin
  recurrences 11
• RSNA 97
• J GI Surg, 2001
• RF local recurrence 54 (Livraghi, Radiology 2001)

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Hepatic Cryoablation
Cryoablation
RF ablation
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In era of RF, is cryo still needed?

• Very powerful. Multiple probes make a large
  iceball in a short period of time, can ablate
  adjacent to large vessels.
• Low local recurrence rates
• Visualize area being ablated

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In era of RF, is cryo still needed?

• Very powerful. Multiple probes make a large
  iceball in a short period of time, can ablate up
  to large vessels.
• Low local recurrence rates (10 vs 40-50
• Intraoperative Dont miss lesionsgt3mm

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Precryo
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Precryo
POD 5
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Liver cryosurgery

• Laparotomy
• Mini-laparotomy
• Percutaneous

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Liver cryosurgery

• Laparotomy
• Monitored by IOUS
• Can detect tumorslt3.0 mm
• Often combined with hepatic resection
• Place probes to cover lesion
• margin with iceball

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Cryosurgery at open laparotomy

• Need to mobilize liver for many tumor locations
• Can access virtually any lesion

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IVC
IVC
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Hepatic Cryosurgery Minilaparotomy

• Use transvaginal US transducer
• Small incision, direct puncture of lesion

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Laparoscopic vs. Minilaparotomy
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Cryosurgery via minilaparotomy
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Percutaneous CT-guided cryosurgery
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Percutaneous Cryotherapy
Courtesy Peter J. Littrup, MD
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Balloon Protection
Courtesy Peter J. Littrup, MD
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MRI guided Cryotherapy
Courtesy Stuart Silverman, MD
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Cryoablation - complications (n869 pooled
worlds literature)

• Mortality 1.6
• Hemorrhage 3.9
• Coagulopathy 3.8

• ARF 1.4
• Biloma 2.9

Seifert. J Roy Coll Surg Edin 1998
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Survival statistics for hepatic cryosurgery
Ref N Med. F/u (mo) Disease-free survival () Alive with disease () Overall survival ()
Ravikumar 32 24 34 28 62
Ravikumar 24 24 29 33.5 62.5
Onik 18 28.8 (mean) 22 67 89
Onik 50 18 (mean) 27 25 52
Zhou 75 60, 120 7.3, 0
Zhou 32 60, 120 48.8, 17.1
HCC gt5.0 cm HCC lt5.0 cm
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RF vs. Cryo (no trials)
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Cryoablation vs. Resection Survival
1
(20)
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Followup of cryolesions

• Hole in liver where tumor was
• Enhancing rim for several months
• Eventual shrinkage and scarring

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1 month post
4 months post
1 year post
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Cryoablation Complications (n869)

• Mortality1.6
• Hemorrhage 3.9
• Coagulopathy 3.8
• Renal Failure 1.4
• Biloma 2.9

Seifert, J Royal Coll Surg 1998
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SummaryChemoembolization

• Used alone for palliation of unresectable/unablata
  ble tumor
• Powerful when used in combination with RF

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Summary Microwave

• Theoretical advantages over RF
• (hotter, faster, multiple probes)
• Extensive experience in Asia, little in USA
• Awaiting optimization of technology

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Summary Cryoablation

• Very powerful, easy to see (CT,US,MRI)
• Generally used at surgery, emerging percutaneous
  applications
• Probably few more complications than thermal
  ablation

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Cryoablation vs. RF
Cryo
RF

• Surgery, rare perc
• Very powerful, multiple probes
• Few more comps
• Easy to monitor
• More mature technology

• Perc, rare surgery
• Less powerful
• Less complications
• Tough to monitor
• Rapid technological advances