Aggressive local treatment for recurrent intrahepatic cholangiocarcinoma—Stereotactic radiofrequency ablation as a valuable addition to hepatic resection

Abstract

Background To evaluate the efficacy, safety and overall clinical outcome of local treatment for recurrent intrahepatic cholangiocellular carcinoma after hepatic resection. Methods Between 2007 and 2019 72 consecutive patients underwent hepatic resection for primary intrahepatic cholangiocellular carcinoma. If amenable, recurrent tumors were aggressively treated by HR or stereotactic radiofrequency ablation with local curative intent. Endpoints consisted of morbidity and mortality, locoregional and de novo recurrence, disease free survival, and overall survival. Results After a median follow-up of 28 months, recurrence of intrahepatic cholangiocellular carcinoma was observed in 43 of 72 patients undergoing hepatic resection (60.3%). 16 patients were subsequently treated by hepatic resection (n = 5) and stereotactic radiofrequency ablation (n = 11) with local curative intention. The remaining 27 patients underwent palliative treatment for first recurrence. Overall survival of patients who underwent repeated aggressive liver-directed therapy was comparable to patients without recurrence (p = 0.938) and was better as compared to patients receiving palliative treatment (p = 0.018). The 5-year overall survival rates for patients without recurrence, the repeated liver-directed treatment group and the palliative treatment group were 54.3%, 47.7% and 12.3%, respectively. By adding stereotactic radiofrequency ablation as an alternative treatment option, the rate of curative re-treatment increased from 11.9% to 37.2%. Conclusion Repeated hepatic resection is often precluded due to patient morbidity or anatomical and functional limitations. Due to the application of stereotactic radiofrequency ablation in case of recurrent intrahepatic cholangiocellular carcinoma, the number of patients treated with curative intent can be increased. This leads to favorable clinical outcome as compared to palliative treatment of intrahepatic cholangiocellular carcinoma recurrence.

Role of Percutaneous Ablation in the Management of Intrahepatic Cholangiocarcinoma

“…In comparison to surgical treatment, ablation is cheaper and simpler to perform with a low rate of complications and reduced hospital stay [37]. Compared to palliative treatments with systemic therapies, percutaneous ablation has been shown to lead to favorable clinical outcome in case of recurrent iCCA [27]. From a technical point of view and due to the infiltrative margins of iCCA lesion a minimum of 1 cm is necessary for safety margins.…”

“…Heat is also lost by the cooling effect of flowing blood within adjacent blood vessels which act as a “heat sink” limiting the ablation zone and potentially leaving behind residual unablated cancerous tissue [ 61 , 63 ]. To achieve a complete tumor coverage for larger lesions, including a safety margin of 0.5 to 1 cm, multiple RFA probes can be used to augment the ablation zone size [ 27 , 45 , 64 ].…”

“…Several studies that assessed the efficacy of RFA treatment for patients with recurrent ICC show favorable results with a median overall survival similar to repeated resection, indicating that ablation can be an effective treatment for these patients [ 44 , 69 ] but with tumors less than 3 cm [ 47 ] and repeated resection can be safely combined with RFA with good results [ 40 ]. For large tumors sequential multiple sessions can be used [ 54 ], and stereotactic RFA with the creation of overlapping ablation zones can also be an option to extend survival [ 27 , 70 ]. For small early-stage primary ICC, surgical resection provides a significantly better prognosis than RFA and is still recommended as the first-line treatment, but there is a need for prospective randomized controlled trials to assess this [ 56 ].…”

“…After surgical treatment, median survival approximates 28–30 months [ 22 ], 3-year overall survival is 52–68.6% in complete resection with negative margins [ 23 , 24 ] and 5-year survival rate is 23–42%, while it does not exceed 5% in inoperable cases [ 25 ]. The majority of iCCA cases require extended liver resection [ 26 ] but recurrence rates after resection are high, reaching 60–65% [ 6 ] at a median of 18 months [ 27 ] with risk factors for recurrence being metastases to lymph nodes, vascular invasion, multifocal iCCA, low histologic grading and size of the tumor [ 28 ]. Studies have identified several herbs and formulas that exhibit potential anti-tumor effects against iCCA, including Curcuma wenyujin, Salvia miltiorrhiza, Bufei Yishen formula and Jianpi Huaji formula; these herbs and formulas have been shown to inhibit cancer cell proliferation, induce apoptosis, and regulate immune function [ 29 , 30 ].…”

Navigation and Robotics in Interventional Oncology: Current Status and Future Roadmap

“…Navigation tools for prostate cancer have markedly altered the way prostate cancer is diagnosed and managed via cost-effective and accurate application of imaging information in an office setting for biopsy or focal ablation with fusion or robotic-guided laser, HIFU, IRE, or cryoablation. Robotic systems have been clinically applied to a variety of percutaneous ablative procedures, including a plethora of locations and tumor histologies [ 65 , 66 , 67 ], with excellent results [ 68 , 69 ]. Numerous studies upon navigation-guided or robotic arm-assisted needle positioning during thermal ablation report high rates of feasibility, significant technical ease, and ergonomics, with improved targeting accuracy, reduction in patient radiation dose, and increased procedural performance related to probe placement by a lower number of insertions and readjustments during ablation when compared to manual guidance [ 36 , 37 , 38 , 39 , 40 ].…”