Subscribe to RSS
DOI: 10.1055/s-2004-818744
© Georg Thieme Verlag Stuttgart · New York
Grenzen und Perspektiven ablativer Verfahren bei Lebertumoren
Limitations and Perspectives of Ablative Procedures in Liver TumorsPublication History
Publication Date:
21 April 2004 (online)
![](https://www.thieme-connect.de/media/viszeralchirurgie/200402/lookinside/thumbnails/10.1055-s-2004-818744-1.jpg)
Zusammenfassung
Primäre und sekundäre bösartige Neubildungen in der Leber stellen eine der häufigsten onkologischen Erkrankungen dar. Bislang steht die chirurgische Resektion als das einzige potenziell kurative Verfahren für die Behandlung von Lebertumoren zur Verfügung. Zum Zeitpunkt der Diagnosestellung kann jedoch aus prognostischen oder operationstechnischen Gründen nur eine Minderheit der Patienten einer chirurgischen Therapie zugeführt werden. Für diese Patientengruppe wurden in den letzten Jahren lokale Ablationsverfahren als Alternative zur chirurgischen Resektion entwickelt. Hierzu zählen laserinduzierte Thermotherapie, Radiofrequenztherapie, Kryotherapie, Mikrowellenkoagulation und perkutane Alkoholinstillation. Vor allem die laserinduzierte Thermotherapie und die Radiofrequenztherapie haben dabei breite klinische Verbreitung gefunden. Diese Verfahren bieten die Möglichkeit, komplikationsarm und minimalinvasiv Tumoren in situ zu zerstören. Obwohl randomisierte Studien bislang fehlen, scheinen vor allem Patienten mit lokal begrenzter Tumorerkrankung hiervon zu profitieren. Begrenzt wird der klinische Einsatz der Ablation vor allem durch onkologische und technische Kriterien. Hierzu zählen der Ausschluss einer systemischen Tumorerkrankung, die Induktion ausreichend großer Läsionen mit vollständiger intraläsionärer Tumorzerstörung und die Beurteilung des Therapieerfolges durch ein geeignetes Monitoringverfahren. Die lokale Ablation erweitert das Spektrum der therapeutischen Möglichkeiten für Patienten mit Lebertumoren und bietet unter Berücksichtigung strenger Indikationsstellung und Ausnutzung der technischen Möglichkeiten eine effektive Alternative zur chirurgischen Resektion.
Abstract
Primary and secondary malignant neoplasms in the liver are among the most common oncological diseases. Surgical resection is the only potentially curative procedure available thus far for the treatment of liver tumors. At the time of diagnosis, however, only a minority of patients can undergo surgery for prognostic or technical reasons. In recent years, local ablation procedures have been developed as an alternative to surgery for this patient group. They include laser-induced thermotherapy, radiofrequency therapy, cryotherapy, microwave coagulation and percutaneous alcohol installation. Especially laser-induced thermotherapy and radiofrequency therapy are widely applied in the clinical routine. These procedure enable the minimally invasive destruction of tumors in situ with few complications. Though randomized studies have not yet been performed, particularly patients with local tumor disease seem to profit from these treatments. However, the clinical application of ablation is especially limited by oncological and technical criteria. They include the exclusion of systemic tumor disease, the induction of sufficiently large lesions with complete intralesional tumor destruction and the evaluation of treatment success by a suitable monitoring procedure. Local ablation broadens the spectrum of therapeutic options for patients with liver tumors and is an effective alternative to surgical resection when adhering to strict indicational criteria and exploiting the technical possibilities.
Schlüsselwörter
Lebertumoren - Lebermetastasen - lokale Verfahren - In-situ-Ablation - laserinduzierte Thermotherapie - Radiofrequenztherapie - Kryotherapie
Key words
Liver tumors - liver metastases - local ablation - liver - In-situ ablation - radiofrequency - laserinduced thermotherapy - cryotherapy
Literatur
- 1 Ahmed M, Goldberg S N. Thermal ablation therapy for hepatocellular carcinoma. J Vasc Interv Radiol. 2002; 13 231-244
- 2 Albrecht D, Germer C T, Isbert C, Ritz J P, Roggan A, Müller G, Buhr H J. Interstitial Laser Coagulation: Evaluation of the Effect of Normal Liver Blood Perfusion and the Application Mode on Lesion Size. Lasers Surg Med. 1994; 23 40-47
- 3 Bosman S, Phoa S SK, Bosma A, Van Gemert M JC. Effect of percutaneous interstitial thermal laser on normal liver of pigs: sonographic and histopathological correlations. Brit J Surg. 1991; 78 572-575
- 4 Bowman H F, Cravalho E G, Woods M. Theory, measurement and application of thermal properties of biological tissue. Ann Rev Biophys Bioeng. 1975; 4 43-80
- 5 Bown S G. Phototherapy of tumours. World J Surg. 1983; 7 700-709
- 6 Costello A J, Agarwal D K, Crowe H R, Lynch W J. Evaluation of interstitial diode laser therapy for treatment of benign prostatic hyperplasia. Tech Urol. 1999; 5 202-206
- 7 Dachman A H, McGehee J A, Beam T E. US-guided percutaneous laser ablation of liver tissue in a chronic pig model. Radiology. 1990; 176 128-133
- 8 Elias D, De Baere T, Smayra T. et al . Percutaneous radiofrequency ablation as an alternative to surgery for tretament of liver tumour recurrence after hepatectomy. Br J Surg. 2002; 20 752-756
- 9 Fong Y, Cohen A M, Fortner J G, Enker W E. Liver resection for colorectal metastases. J Clin Oncol. 1997; 15 938-944
- 10 Frank F, Hessel S. Technische Voraussetzungen für die interstitielle Thermotherapie mit dem Nd:YAG-Laser. Lasermedizin. 1990; 10 36-40
- 11 Germer C T, Albrecht D, Isbert C, Ritz J, Roggan A, Buhr H J. Diffusing fibre tipp for minimally invasive treatment of liver tumours by interstitial laser coagulation (ILC): an experimental ex vivo study. Lasers Med Sci. 1999; 14 32-39
- 12 Germer C T, Albrecht D, Roggan A, Isbert C, Buhr H J. Experimental study of laparascopic laser-induced thermotherapy for liver tumors. Br J Surg. 1997; 84 317-320
- 13 Germer C T, Isbert C M, Albrecht D, Ritz J P, Schilling A, Roggan A, Wolf K J, Müller G, Buhr H J. Laser-induced thermotherapy for the treatment of liver metastasis. Surg Endosc. 1998; 12 1317-1325
- 14 Germer C T, Isbert C, Albrecht D, Roggan A, Pelz J, Ritz J P, Müller G, Buhr H J. Laser-induced thermotherapy combined with hepatic arterial embolization in the treatment of liver tumors in a rat model. Ann Surg. 1999; 230 55-62
- 15 Gewiese B, Beuthan J, Fobbe F, Stiller D, Müller G, Boese-Landgraf J, Wolf K J, Deimling M. Magnetic Resonance Imaging-Controlled Laser-Induced Interstitial Thermotherapy. Invest Radiol. 1994; 29 345-351
- 16 Goldberg S N, Hahn P F, Halpern E F, Fogle R M, Gazelle G S. Radiofrequency tissue ablation: effect of pharmacologic modulation of blood flow on coagulation diameter. Radiology. 1998; 209 761-767
- 17 Henriques F CJ, Moritz A R. Studies of thermal injuries. I: The conduction of heat to and through the skin and the temperature attained therein. Am J Pathol. 1947; 23 531-549
- 18 Holm A, Bradley E, Aldrete J S. Hepatic resection of metastases from colorectal carcinoma. Morbidity, mortality and pattern of recurrence. Ann Surg. 1989; 209 428-434
- 19 Isbert C, Ritz J P, Schilling A, Roggan A, Wolf K J, Muller G, Buhr H J, Germer C T. Laserinduced thermotherapy (LITT) of experimental livermetastasis-detection of residual tumors using Gd-DTPA enhanced MRI. Lasers Surg Med. 2002; 30 280-289
- 20 Jolesz F A, Bleier A R, Jakab P, Ruenzel P W, Huttl K, Jako G J. MR imaging of laser tissue interaction. Radiology. 1988; 168 853-857
- 21 Kemeny N. Review of regional therapy of liver metastases in colorectal cancer. Semin Oncol. 1992; 19 155-162
- 22 Kuvshinoff B W, Ota D M. Radiofrequency ablation of liver tumors: influence of technique and tumor size. Surgery. 2002; 132 605-612
- 23 Livraghi T, Goldberg S N, Solbiati T. et al . Percutaneous radiofrequency ablation of liver metastases from breast cancer. Initial experience with 24 patients. Radiology. 2001; 220 145-149
- 24 Livraghi T, Solbiati L, Meloni M F. et al . Treatment of focal liver tumors with percutaneous radiofrequency ablation: complications encountered in a multicenter study. Radiology. 2003; 226 441-451
- 25 Malone D B, Wyman D R, Moote D J, DeNardi F G, Mori H, Swift C, Lewis R, Stevenson G W, Wilson B C. Sonographic changes during hepatic interstitial laser photocoagulation: An investigation of three optical fiber tips. Invest Radiol. 1992; 27 804-813
- 26 Muralidharan M, Malcontenti-Wilson C, Christophi C. Effect of blood flow occlusion on laser hyperthermia for liver metastases. J Surg Res. 2002; 103 165-174
- 27 Muschter R, Hofstetter A. Technique and results of interstitial laser coagulation. World J Urol. 1995; 13 109-114
- 28 Parikh A A, Curley SA; Fornage B D. et al . Radiofrequency ablation of hepatic metastases. Seminar Oncol. 2002; 29 168-182
- 29 Parrish J A. New concepts in therapeutic photomedicine: photochemistry, optical targeting and the therapeutic window. J Invest Dermatol. 1981; 77 45-50
- 30 Ritz J P, Germer C T, Isbert C, Albrecht D, Roggan A, Pelz J, Buhr H J. Effektivitätssteigerung der laserinduzierten Thermotherapie von Lebermetastasen - Einfluss der selektiven arteriellen und portalvenösen Okklusion und passageren Mikroembolisation. Langenbecks Arch Chir. 1999; Suppl I 583-585
- 31 Ritz J P, Isbert C, Roggan A, Germer C T, Müller G, Buhr H J. Correlation of Intrahepatic Light and Temperature Distribution in Laser-Induced Thermotherapy of Liver Tumors and Liver Tissue. Laser in Medicine and Surgery. 2000; 15 174-182
- 32 Ritz J P, Roggan A, Germer C T, Isbert C, Müller G, Buhr H J. Continuous changes in the optical properties of liver tissue during laser-induced interstitial thermotherapy. Lasers Surg Med. 2001; 28 307-312
- 33 Roggan A. Dosimetrie thermischer Laseranwendungen in der Medizin - Untersuchung der optischen Gewebeeigenschaften und physikalisch-mathematische Modellentwicklung. In: Müller G, Berlien HP (eds). Fortschritte in der Lasermedizin. Vol. 16, Ecomed, Landsberg 1997
- 34 Roggan A, Knappe V, Ritz J P, Germer C T, Isbert C, Wacker F, Müller G. 3D-Bestrahlungsplanung für die laserinduzierte Thermotherapie (LITT). Z Med Phys. 2000; 10 157-167
- 35 Roggan A, Müller G. Dosimetry and computer based irradiation planning for laser-induced interstitial thermotherapy (LITT). In: Müller G, Roggan A (eds). Laser-induced Interstitial Thermotherapy. SPIE Press, Bellingham 1995; 114-157
- 36 Roggan A, Ritz J P, Knappe V, Germer C T, Isbert C, Schädel D, Müller G. Radiation planning for thermal laser treatment. Medical Laser Application. 2001; 16 65-72
- 37 Ruers T J, Joosten J, Jagher G J. et al . Long-term results of treating hepatic colorectal metastses with cryosurgery. Br J surg. 2001; 88 844-849
- 38 Scheele J, Altendorf-Hofmann A, Grube T, Hohenberger W, Stangl R, Schmidt K. Resektion colorectaler Lebermetastasen. Welche Prognosefaktoren bestimmen die Patientenselektion?. Chirurg. 2001; 72 547-560
- 39 Scheele J, Stangl R, Altendorf-Hofmann A, Paul M. Resection of colorectal liver metastases. World J Surg. 1994; 19 59
- 40 Stangl R, Altendorf-Hofmann A, Charnley R M, Scheele J. Factors influencing the natural history of colorectal liver metastases. Lancet. 1994; 343 1405
- 41 Steele G J r., Bleday R, Mayer R J, Lindblad A, Petrelli N, Weaver D. A prospective evaluation of hepatic resection for colorectal carcinoma metastases to the liver: Gastrointestinal Tumor Study Group Protocol 6584. J Clin Oncol. 1991; 9 1105-1112
- 42 Steger A C, Shorvon P, Walmley K, Chrisholm R, Bown S G, Lees W R. Ultrasound features of low power interstitial laser hyperthermia. Clinical Radiology. 1993; 46 88-93
- 43 Vogl T J, Mack M G, Roggan A, Straub R, Eichler K C, Müller P K, Knappe V, Felix R. Internally cooled power laser for MR-guided interstitial laser-induced thermotherapy of liver lesions: initial clinical results. Radiology. 1998; 209 381-385
- 44 Vogl T, Mack M, Straub R, Zangos S, Woitaschek D, Eichler K, Engelmann K. Thermische Ablation von Lebermetastasen. Aktueller Stand und Perspektiven. Radiologe. 2001; 41 49-55
- 45 Vogl T J, Muller P K, Mack M G, Straub R, Engelmann K, Neuhaus P. Liver metastases: interventional therapeutic techniques and results, state of the art. Eur Radiol. 1999; 9 675-684
- 46 Vogl T J, Straub R, Eichler K, Woitaschek D, Mack M G. Malignant liver tumors treated with MR imaging-guided laser-induced thermotherapy: experience with complications in 899 patients (2 520 lesions). Radiology.. 2002; 225 367-377
- 47 Vogl T J, Weinhold N, Mack M G, Müller P K, Scholz W R, Straub R, Roggan A, Felix R. Verification of MR thermometry by means of an in vivo intralesional, fluorooptic temperature measurement for laser-induced thermotherapy of liver metastases. Fortschr Röntgenstr. 1998; 169 182-188
- 48 Wacker F, Reither K, Ritz J P, Roggan A, Germer C T, Wolf K J. MR-guided interstitial laser-induced thermotherapy of hepatic metastases combined with arterial blood flow reduction: Technique and first clinical results in an open MR system. J Mag Res Imaging. 2001; 13 31-36
- 49 Zuber-Jerger I, Geissler M, Spangenberg H C, Mohr L, Weizsäcker F, Blum H E. Lokale Ablationsverfahren als Ergänzung der Therapie maligner Leberläsionen. Z Gastroenterol. 2004; 42 31-38
Dr. med. J.-P. Ritz
Chirurgische Klinik und Poliklinik I
Charité Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Phone: ++49-30-84 45-25 43
Fax: ++49-30-84 45-27 40
Email: joerg-peter.ritz@charite.de