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DOI: 10.1055/s-2007-981251
© Georg Thieme Verlag Stuttgart · New York
Interventionelle Verfahren zur Therapie von Lebertumoren
Interventional Treatment of Liver TumorsPublication History
Publication Date:
23 August 2007 (online)
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Zusammenfassung
Metastasen gastrointestinaler Tumoren repräsentieren in der westlichen Welt die häufigste Ursache für sekundäre, das Leberzellkarzinom (HCC) für primäre Lebertumoren. Aus der Gesamtheit dieser Patienten mit primären oder sekundären Lebermalignomen sind lediglich 20-30% einer operativen Therapie mit kurativem Ansatz zuführbar. In nicht-resektablen Situationen sind interventionelle Therapieverfahren wie die transarterielle Chemoembolisation (TACE), die perkutane Alkoholinstillationstherapie (PAIT), die perkutane Radiofrequenzablation (RFA) und die selektive interne Radiotherapie (SIRT) alternative Therapieoptionen, welche im Therapiekonzept aufgrund niedriger Nebenwirkungs- und guter Tumorkontrollraten zunehmend an Bedeutung gewinnen. Aktuelle Studienergebnisse an großen Patientenkollektiven demonstrieren den guten und langfristigen Erfolg der TACE bei nicht-operablen HCCs. Eine mehrzeitige interventionelle Kombinationstherapie ist möglich und sinnvoll. Eine Kombinationstherapie von TACE und PAIT verbessert nachweislich selbst bei großen HCCs (bis 7 cm) die Überlebensrate. Gemäß international anerkannter Empfehlungen der EASL (European Association for the Study of the Liver) wird die PAIT nach der Resektion als Verfahren zweiter Wahl bei der Therapie bis zu drei HCCs kleiner 3 cm gesehen. Die RFA findet sowohl bei primären als auch sekundären hepatischen Malignomen Einsatz. Neuere Studien belegen die Überlegenheit der RFA gegenüber der PAIT hinsichtlich Invasivität, lokaler Ansprechrate und Überleben. Die SIRT findet Einsatz bei multifokalem, ansonsten nicht mehr behandelbarem Leberbefall. Die SIRT verhindert in den meisten Fällen den Tumorprogress insbesondere auch nach vorangegangener erfolgloser Chemotherapie mit modernen Kombinationen (Oxalaplatin, Irinotecan). Aufgrund eines niedrigen Evidenzlevels der meisten Studien ist eine abschließende Bewertung lokal-ablativer Verfahren verfrüht, eine deutliche Lebenszeitverlängerung bei Patienten mit ursprünglich schlechter Prognose zeichnet sich jedoch ab.
Schlüsselwörter
minimalinvasive Therapie - Lebermetastasen - hepatozelluläres Karzinom - Radiofrequenzablation - Alkoholablation - transarterielle Chemoembolisation - selektive interne Radiotherapie
Literatur
- 1 El-Serag H B, Mason A C. Rising incidence of hepatocellular carcinoma in the United States. N Engl J Med. 1999; 340 745-750
- 2 Lencioni R, Crocetti L, Cioni D, della Pina C, Bartolozzi C. Percutaneous radiofrequency ablation of hepatic colorectal metastases. Invest Radiol. 2004; 39 689-697
- 3 Choti M A, Bulkley G B. Management of hepatic metastases. Liver Transplantation Surg. 1999; 5 65-80
- 4 Llovet J M, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet. 2003; 362 1907-1917
- 5 Jonker D J, Maroun J A, Kocha W. Survival benefit of chemotherapy in metastatic colrectal cancer: a meta-analysis of randomized controlled trials. Br J Cancer. 2000; 82 1789-1794
- 6 Huppert P E, Lauchart W, Duda S H, Torkler C, Kloska S P, Weinlich M, Benda N, Pereira P, Claussen C D. Chemoembolization of hepatocellular carcinomas: Which factors determine therapeutic response and survival?. Fortschr Röntgenstr. 2004; 176 375-385
- 7 Llado L, Virgili J, Figueras J, Valls C, Dominguez J, Rafecas A, Torras J, Fabregat J, Guardiola J, Jaurrieta E. A prognostic index of the survival of patients with unresectable hepatocellular carcinoma after transcatheter arterial chemoembolization. Cancer. 2000; 88 50-57
- 8 Lewis A L, Gonzalez M V, Lloyd A W, Hall B, Tang Y, Willis S L, Leppard S W, Wolfenden L C, Palmer R R, Stratford P W. DC bead: in vitro characterization of a drug-delivery device for transarterial chemoembolization. J Vasc Interv Radiol. 2006; 17 335-342
- 9 Varela M, Real M I, Burrel M, Forner A, Sala M, Brunet M, Ayuso C, Castells L, Montana X, Llovet J M, Bruix J. Chemoembolization of hepatocellular carcinoma with drug eluting beads: efficacy and doxorubicin pharmacokinetics. J Hepatol. 2007; 46 474-481
- 10 Ueno K, Miyazono N, Inoue H, Nishida H, Kanetsuki I, Nakajo M. Transcatheter arterial chemoembolization therapy using iodized oil for patients with unresectable hepatocellular carcinoma. Cancer. 2000; 88 1574-1581
- 11 Matsui O, Kadoya M, Yoshikawa J, Gaabata T, Arai K, Demachi H, Miyayama S, Takashima T, Unoura M, Kogayashi K. Small hepatocellular carcinoma: treatment with subsegmental transcatheter arterial embolization. Radiology. 1993; 188 79-83
- 12 Llovet J M, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 2003; 37 429-442
- 13 Takayasu K, Arii S, Ikai I, Omata M, Okita K, Ichida T, Matsuyama Y, Nakanuma Y, Kojiro M, Makuuchi M, Yamaoka Y. Liver Cancer Study Group of Japan . Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8 510 patients. Gastroenterology. 2006; 131 461-469
- 14 Ho A S, Picus J, Darcy M D, Tan B, Gould J E, Pilgram T K, Brown D B. Long-term outcome after chemoembolization and embolization of hepatic metastatic lesions from neuroendocrine tumors. Am J Roentgenol. 2007; 188 1201-1207
- 15 Koda M, Murawaki Y, Mitsuda A, Oyama K, Okamoto K, Idobe Y, Suou T, Kawasaki H. Combination therapy with transcatheter arterial chemoembolization and percutaneous ethanol injection compared with percutaneous ethanol injection alone for patients with small hepatocellular carcinoma: a randomized control study. Cancer. 2001; 92 1516-1524
- 16 Lubienski A, Bitsch R G, Schemmer P, Grenacher L, Düx M, Kauffmann G W. Long-term results of interventional treatment of large unresectable hepatocellular carcinoma (HCC): significant survival benefit from combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) compared to TACE monotherapy. Fortschr Röntgenstr. 2004; 176 1794-1802
- 17 Livraghi T, Goldberg S N, Lazzaroni S, Meloni F, Solbiati L, Gazelle G S. Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. Radiology. 1999; 210 655-661
- 18 Lencioni R A, Allgaier H P, Cioni D, Olschewski M, Deibert P, Crocetti L, Frings H, Laubenberger J, Zuber I, Blum H E, Bartolozzi C. Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermalablation versus percutaneous ethanol injection. Radiology. 2003; 228 235-240
- 19 Livraghi T, Giorgio A, Marin G, Salmi A, Sio I, Bolondi L, Pompili M, Brunello F, Lazzaroni S, Torzilli G, Zucchi A. Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection. Radiology. 1995; 197 101-108
- 20 Lin S M, Lin C J, Lin C C, Hsu C W, Chen Y C. Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less. GUT. 2005; 54 1151-1156
- 21 Livraghi T, Benedini V, Lazzaroni S, Meloni F, Torzilli G, Vettori C. Long term results of single session percutaneous ethanol injection in patients with large hepatocellular carcinoma. Cancer. 1998; 83 48-57
- 22 Lencioni R, Pinto F, Armillotta N, Bassi A M, Moretti M, Di Giulio M, Marchi S, Uliana M, Della Capanna S, Lencioni M, Bartolozzi C. Long-term results of percutaneous ethanol injection therapy for hepatocellular carcinoma in cirrhosis: a European experience. Eur Radiol. 1997; 7 514-519
- 23 Lencioni R, Crocetti L. A critical appraisal of the literature on local ablative therapies for hepatocellular carcinoma. Clin Liver Dis. 2005; 9 301-314
- 24 Bleicher R J, Allegra D P, Nora D T, Wood T F, Foshag L J, Bilchik A J. Radiofrequency ablation in 447 complex unresectable liver tumors: lessons learned. Ann Surg Oncol. 2003; 10 52-58
- 25 Bruix J, Sala M, Llovet J M. Chemoembolization for hepatocellular carcinoma. Gastroenterology. 2004; 127 (Suppl 1) 179-188
- 26 Choi B I, Kim H C, Han J K, Park J H, Kim Y I, Kim S T, Lee H S, Kim C Y, Han M C. Therapeutic effect of transcatheter oily chemoembolization therapy for encapsulated nodular hepatocellular carcinoma: CT and pathologic findings. Radiology. 1992; 182 709-713
- 27 Gillams A R, Lees W R. Radio-frequency ablation of colorectal liver metastases in 167 patients. Eur Radiol. 2004; 14 2261-2267
- 28 Bruix J, Sherman M, Llovet J M, Beaugrand M, Lencioni R, Burroughs A K, Christensen E, Pagliaro L, Colombo M, Rodes J. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. 2001; 35 421-430
- 29 Shiina S, Tagawa K, Unuma T, Takanashi R, Yoshiura K, Komatsu Y, Hata Y, Niwa Y, Shiratori Y, Terano A. et al . Percutaneous ethanol injection therapy for hepatocellular carcinoma. A histopathologic study. Cancer. 1991; 68 1524-1530
- 30 Sakamoto M, Hirohashi S. Natural history and prognosis of adenomatous hyperplasia and early hepatocellular carcinoma: multi-institutional analysis of 53 nodules followed up for more than 6 months and 141 patients with single early hepatocellular carcinoma treated by surgical resection or percutaneous ethanol injection. Jpn J Clin Oncol. 1998; 28 604-608
- 31 Arii S, Yamaoka Y, Futagawa S, Inoue K, Kobayashi K, Kojiro M, Makuuchi M, Nakamura Y, Okita K, Yamada R. Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan. Hepatology. 2000; 32 1224-1229
- 32 Livraghi T, Meloni F, Morabito A, Vettori C. Multimodal image-guided tailored therapy of early and intermediate hepatocellular carcinoma: long-term survival in the experience of a single radiologic referral center. Liver Transpl. 2004; 10 (Suppl 1) 98-106
- 33 Omata M, Tateishi R, Yoshida H, Shiina S. Treatment of hepatocellular carcinoma by percutaneous tumor ablation methods: Ethanol injection therapy and radiofrequency ablation. Gastroenterology. 2004; 127 (Suppl 1) 159-166
- 34 Ebara M, Okabe S, Kita K, Sugiura N, Fukuda H, Yoshikawa M, Kondo F, Saisho H. Percutaneous ethanol injection for small hepatocellular carcinoma: therapeutic efficacy based on 20-year observation. J Hepatol. 2005; 43 458-464
- 35 Di Stasi M, Buscarini L, Livraghi T, Giorgio A, Salmi A, De Sio I, Brunello F, Solmi L, Caturelli E, Magnolfi F, Caremani M, Filice C. Percutaneous ethanol injection in the treatment of hepatocellular carcinoma. A multicenter survey of evaluation practices and complication rates. Scand J Gastroenterol. 1997; 32 1168-1173
- 36 Khan K N, Yatsuhashi H, Yamasaki K, Yamasaki M, Inoue O, Koga M, Yano M. Prospective analysis of risk factors for early intrahepatic recurrence of hepatocellular carcinoma following ethanol injection. J Hepatol. 2000; 32 269-278
- 37 Koda M, Murawaki Y, Mitsuda A, Ohyama K, Horie Y, Suou T, Kawasaki H, Ikawa S. Predictive factors for intrahepatic recurrence after percutaneous ethanol injection therapy for small hepatocellular carcinoma. Cancer. 2000; 88 529-537
- 38 Shibata T, Iimuro Y, Yamamoto Y, Maetani Y, Ametani F, Itoh K, Konishi J. Small hepatocellular carcinoma: comparison of radio-frequency ablation and percutaneous microwave coagulation therapy. Radiology. 2002; 223 331-337
- 39 Lin S M, Lin C J, Lin C C, Hsu C W, Chen Y C. Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma ≤ 4 cm. Gastroenterology. 2004; 127 1714-1723
- 40 Akamatsu M, Yoshida H, Obi S, Sato S, Koike Y, Fujishima T, Tateishi R, Imamura M, Hamamura K, Teratani T, Shiina S, Ishikawa T, Omata M. Evaluation of transcatheter arterial embolization prior to percutaneous tumor ablation in patients with hepatocellular carcinoma: a randomized controlled trial. Liver International. 2004; 24 625-630
- 41 Huang G T, Lee P H, Tsang Y M, Lai M Y, Yang P M, Hu R H, Chen P J, Kao J H, Sheu J C. Percutaneous ethanol injection versus surgical resection for the treatment ofsmall hepatocellular carcinoma: a prospective study. Ann Surg. 2005; 242 36-42
- 42 Shiina S, Teratani T, Obi S, Sato S, Tateishi R, Fujishima T, Ishikawa T, Koike Y, Yoshida H, Kawabe T, Omata M. A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma. Gastroenterology. 2005; 129 122-130
- 43 Shibata T, Shibata T, Maetani Y, Isoda H, Hiraoka M. Radiofrequency ablation for small hepatocellular carcinoma: prospective comparison of internally cooled electrode and expandable electrode. Radiology. 2006; 238 346-353
- 44 Goldberg S N, Gazelle G S, Compton C C, Mueller P R, Tanabe K K. Treatment of intrahepatic malignancy with radiofrequency ablation: radiologic-pathologic correlation. Cancer. 2000; 88 2452-2463
- 45 Livraghi T, Goldberg S N, Lazzaroni S, Meloni F, Ierace T, Solbiati L, Gazelle G S. Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions. Radiology. 2000; 214 761-768
- 46 Goldberg S N, Grassi C J, Cardella J F, Charboneau J W, Dodd III G D, Dupuy D E, Gervais D, Gillams A R, Kane R A, Lee Jr F T, Livraghi T, McGahan J, Phillips D A, Rhim H, Silverman S G. Image-guided tumor ablation: standardization of terminology and reporting criteria. Radiology. 2005; 235 728-739
- 47 Pereira P, Boss A, Clasen S, Gouttefangeas C, Schmidt D, Claussen C D. Radiofrequency ablation: the percutaneous approach. Recent Result Cancer Res. 2006; 167 39-52
- 48 Stroszczynski C, Gaffke G. Use of imaging modalities for the guidance of minimally invasive tumor therapies (MITT). Recent Result Cancer Res. 2006; 167 3-12
- 49 Lubienski A, Leibecke T, Helmberger T. Liver metastases. Recent Results Cancer Res. 2006; 167 79-89
- 50 Solbiati L, Goldberg S N, Ierace T, Livraghi T, Meloni F, Dellanoce M, Sironi S, Gazelle G S. Hepatic metastases: percutaneous radio-frequency ablation with cooled tipp electrodes. Radiology. 1997; 205 367-373
- 51 Lencioni R, Goletti O, Armillotta N, Paolicchi A, Moretti M, Cioni D, Donati F, Cicorelli A, Ricci S, Carrai M, Conte P F, Cavina E, Bartolozzi C. Radio-frequency thermal ablation of liver metastases with a cooled-tip electrode needle: results of a pilot clinical trial. Eur Radiol. 1998; 8 1205-1211
- 52 Gillams A R, Lees W R. Survival after percutaneous, image-guided, thermal ablation of hepatic metastases from colorectal cancer. Dis Colon Rectum. 2000; 43 656-661
- 53 Solbiati L, Ierace T, Tonolini M, Osti V, Cova L. Radiofrequency thermal ablation of hepatic metastases. Eur J Ultrasound. 2001; 13 149-158
- 54 Oshowo A, Gillams A, Harrison E, Lees W R, Taylor I. Comparison of resection and radiofrequency ablation for treatment of solitary colorectal liver metastases. Br J Surg. 2003; 90 1240-1243
- 55 Abdalla E K, Vauthey J N, Ellis L M, Ellis V, Pollock R, Broglio K R, Hess K, Curley S A. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg. 2004; 239 818-825 , discussion 825-827
- 56 Tateishi R, Shiina S, Teratani T, Obi S, Sato S, Koike Y, Fujishima T, Yoshida H, Kawabe T, Omata M. Percutaneous radiofrequency ablation for hepatocellular carcinoma. An analysis of 1 000 cases. Cancer. 2005; 103 1201-1209
- 57 Chen M H, Wei Y, Yan K, Gao W, Dai Y, Huo L, Yin S S, Zhang H, Poon R T. Treatment strategy to optimize radiofrequency ablation for liver malignancies. J Vasc Interv Radiol. 2006; 17 671-683
- 58 Choi D, Lim H K, Rhim H, Kim Y S, Lee W J, Paik S W, Koh K C, Lee J H, Choi M S, Yoo B C. Percutaneous radiofrequency ablation for early stage hepatocellular carcinoma as a first line treatment: long-term results and prognostic factors in a large single-institution series. Eur Radiol. 2007; 17 684-692
- 59 Choi D, Lim H K, Rhim H, Kim Y S, Yoo B C, Paik S W, Joh J W, Park C K. Percutaneous radiofrequency ablation for recurrent hepatocellular carcinoma after hepatectomy: long-term results and prognostic factors. Ann Surg Oncol. 2007; , ; Epub ahead of print
- 60 Sorensen S M, Mortensen F V, Nielsen D T. Radiofrequency ablation of colorectal liver metastases: long-term survival. Acta Radiol. 2007; 48 253-258
- 61 Mulier S, Mulier P, Ni Y, Miao Y, Dupas B, Marchal G, De Wever I, Michel L. Complications of radiofrequency coagulation of liver tumours. Br J Surg. 2002; 89 1206-1222
- 62 De Baere T, Risse O, Kuoch V, Dromain C, Sengel C, Smayra T, El Din M G, Letoublon C, Elias D. Adverse events during radiofrequency treatment of 582 hepatic tumors. AJR. 2003; 181 695-700
- 63 Livraghi T, Lazzaroni S, Meloni F, Solbiati L. Risk of tumour seeding after percutaneous radiofrequency ablation for hepatocellular carcinoma. Br J Surg. 2005; 92 856-858
- 64 Llovet J M, Vilana R, Bru C, Bianchi L, Salmeron J M, Boix L, Ganau S, Sala M, Pages M, Ayuso C, Sole M, Rodes J, Bruix J. Barcelona Clinic Liver Cancer (BCLC) Group . Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology. 2001; 33 1124-1129
- 65 Jaskolka J D, Asch M R, Kachura J R, Ho C S, Ossip M, Wong F, Sherman M, Grant D R, Greig P D, Gallinger S. Needle tract seeding after radiofrequency ablation of hepatic tumors. J Vasc Interv Radiol. 2005; 16 485-491
- 66 Gray B, Van Hazel G, Hope M, Burton M, Moroz P, Anderson J, Gebski V. Randomised trial of SIR-Spheres plus chemotherapy vs. chemotherapy alone for treating patients with liver metastases from primary large bowel cancer. Ann Oncol. 2001; 12 1711-1720
- 67 Van Hazel G, Blackwell A, Anderson J, Price D, Moroz P, Bower G, Cardazi G, Gray B. Randomised phase 2 trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy versus flourouracil/leucovorin chemotherapy alone in advanced colorectal cancer. J Surg Oncol. 2004; 88 78-85
- 68 Jakobs T F, Hoffmann R T, Poepperl G, Schmitz A, Lutz J, Koch W, Tatsch K, Lubienski A, Reiser M F, Helmberger T. Mid-term results in otherwise treatment refractory primary or secondary liver confined tumours treated with selective internal radiation therapy (SIRT) using90Yttrium resin-microspheres. Eur Radiol. 2007; 17 1320-1330
Dr. med. A. Lubienski
Klinik für Radiologie und Nuklearmedizin · Universitätsklinikum Schleswig-Holstein · Campus Lübeck
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Phone: +49/4 51/5 00 21 29
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Email: andreas.lubienski@uk-sh.de