Long Term Survival RF Ablation for Primary and Metastatic Liver Tumors

ORIGINAL ARTICLE
Longterm survival outcomes of patients undergoing
treatment with radiofrequency ablation for hepatocellular
carcinoma and metastatic colorectal cancer liver tumors
Iswanto Sucandy1
, Susannah Cheek1
, Benjamin J. Golas2
, Allan Tsung1
, David A. Geller1
&
James W. Marsh1
1
University of Pittsburgh Medical Center/UPMC Liver Cancer Center, Pittsburgh, PA, and 2
NewYork-Presbyterian/Weill Cornell
Medical Center, New York, NY, United States
Abstract
Background: We aim to investigate long-term survival outcomes in patients undergoing radiofrequency
ablation (RFA), based on our longitudinal 5 and 10 year follow-up data.
Methods: All patients who underwent RFA for hepatocellular carcinoma (HCC) and colorectal liver
metastasis (CLM) between 1999 and 2010.
Results: 320 patients were included with oncologic diagnoses of HCC in 122 (38.1%) and CLM in 198
(61.9%). The majority of patients had a single tumor ablation (71% RFA 1 lesion). Minimum 5 year follow-
up information was available in 89% patients, with a median follow-up of 115.3 months. In patients with
HCC, disease eventually recurred in 73 (64%) patients. In patients with CLM, disease recurrence was
ultimately seen in 143 (84.1%) patients. In the HCC group, the 5- and 10-year overall survivals were
38.5% and 23.4%, while in the CLM group, the 5- and 10-year overall survivals were 27.6% and 15%,
respectively.
Conclusions: The use of RFA as a part of treatment strategy for primary and metastatic liver tumors
imparts 10-year overall survivals of >23% and 15%, respectively. This study indicates that long-term
survival is possible with RFA treatment.
Received 21 February 2016; accepted 11 June 2016
Correspondence
Iswanto Sucandy, University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue,
UPMC Monteﬁore, 7-South, Pittsburgh, PA 15213-2582, United States. Tel: +1 412 692 2001. Fax: +1 412
692 2002. E-mail: sucandyi2@upmc.edu
Introduction
For patients with liver metastases from colorectal cancer and
neuroendocrine tumors, complete surgical resection is currently
the only curative option. Colorectal cancer is the third most
common cancer worldwide and it is ranked the second most
frequent cause of cancer associated mortality in the industrial-
ized countries.1
Around 50% of colorectal cancer patients
eventually develop liver metastases.2
Studies have demonstrated
that patients with untreated colorectal liver metastatic lesions
have 31% survival rate at 1 year, 7.9% at 2 years, 2.6% at 3 years
and 0.9% at 4 years.3–5
The addition of chemotherapy regiments
improves median survival from 6-12 months–20 months.4
In
the 1990’s, irinotecan (FOLFIRI) and oxaliplatin (FOLFOX)-
based regiments further improved response rate up to 50%.3,6
Despite improvement in chemotherapy regiments and multi-
modality approach in the last decade, patients with metastatic
colorectal cancer continue to have a poor prognosis with medial
survival of approximately 21 months.3
Therefore, parenchymal
sparing surgical resection with negative margins remains the gold
standard for operable patients with metastatic colorectal cancer
to the liver.
In patients with hepatocellular carcinoma (HCC), liver
transplantation provides the best long term overall survival and
disease-free survival, as it removes both the tumors and the
cirrhotic background liver.7
Due to modern advances in liver
transplantation, recurrence rate for patients with HCC after liver
HPB 2016, 18, 756–763 © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.hpb.2016.06.010 HPB

transplantation is 16%, with a median time from liver trans-
plantation to HCC recurrence of 13 months.8
Liver trans-
plantation for HCC, however, is limited by strict eligibility
criteria, high costs, and a limited availability of donor organs.
The drop out rate for patients with HCC awaiting liver trans-
plantation in contemporary series is 14.5%, which is mainly
secondary to tumor progression or hepatic decompensation.9
While the results with liver resection and hepatic trans-
plantation are encouraging, approximately 70–80% of patients
presenting with HCC and CLM are not resection or transplant
candidates due to extent of their disease, presence of vascular
invasion, or inadequate hepatic reserve. For the majority of pa-
tients with HCC or CLM who are not transplant or resection
candidates, a number of treatment options including systemic
chemotherapy, hepatic-artery directed modalities, isolated he-
patic perfusion, external beam radiation therapy, and ablative
techniques are currently available.
An obvious conundrum is that surgery and liver trans-
plantation afford patients with CLM and HCC the best chance
for a cure, but the vast majority of these patients are not can-
didates. Several local ablative treatments which include trans-
arterial chemoembolization, percutaneous ethanol injection, and
RFA were then developed. RFA particularly have emerged as a
promising adjunct in the treatment of CLM and HCC in the past
decade due to its safety, efficacy, and ability to provide more
consistent results in local tumor control, especially in patients
with limited hepatic reserve.10,11
While there have been several
studies evaluating 5-year survival in small cohorts of patients
undergoing RFA as part of their treatment strategy for HCC or
CLM, there are only limited data on 10-year survival, which is a
time interval that we believe is equivocal with cure.3,12–15
In this
study, we sought to determine whether long-term overall survival
at 10 years is obtainable in patients, who undergo RFA as part of
their treatment for primary and metastatic colorectal hepatic
malignancies.
Materials and methods
After Institutional Review Board approval, a single-institution
review of all patients (n = 320), who underwent RFA as part of
their treatment for hepatocellular carcinoma and colorectal liver
metastasis at the University of Pittsburgh Medical Center be-
tween 1999 and 2010 was performed. Patients who underwent
RFA for treatment of other hepatic lesions were excluded from
the study. Data were retrospectively analyzed from a prospective
institutional hepatic cancer registry. The primary endpoint of the
study are long term 10-year overall survival outcome and tumor
recurrence, following RFA for treatment of HCC and CLM.
Treatment planning for patients with hepatic malignancy is
carried out under the direction of a multidisciplinary liver tumor
board, which is comprised of hepatobiliary surgeons, transplant
surgeons, medical oncologists, hepatologists, and hepatobiliary
radiologists. The diagnosis of HCC was based on the criteria
defined in the practice guidelines of the European Association for
the Study of Liver (EASL) or the American Association for the
Study of Liver Disease (AASLD). Preoperative scans using either
triphasic helical axial computed tomography (CT) or liver
magnetic resonance imaging (MRI) were obtained within 1
month before the ablations to allow for the most accurate
planning. All patients were initially evaluated for resection,
ablation, transplantation, or combination of treatments, based
on their extent of disease, tumor characteristics, degree of
medical comorbidities, and pre-existing liver reserve. All RFA
procedures were performed in the operating room under general
anesthesia. Microwave technology was not used. Laparoscopic,
open, and percutaneous approaches were all utilized and their
applications were at the discretion of the treating surgeon.
Laparoscopic ablation was normally performed via three lapa-
roscopic ports under intraoperative ultrasound guidance to
ensure proper placement of RFA probe. Tissue biopsy was
routinely obtained from the tumors prior to ablation. Patients
were normally admitted to the floor postoperatively.
Table 1 Patient demographics
Variables HCC (n [ 122) CLM (n [ 198)
Age (years) 65.7 (range 33–92) 64.7 (range 33–90)
Gender (Male:Female) 84:38 119:79
Race (n)
a. White 98 (80.3%) 188 (94.9%)
b. Black 18 (14.8%) 7 (3.5%)
c. Others 6 (4.9%) 3 (1.6%)
RFA site (n)
a. Single lesion 110 (90.2%) 117 (59.1%)
b. 2 lesions 10 (8.2%) 40 (20.2%)
c. 3 lesions 2 (1.6%) 41 (20.7%)
RFA approach (n)
a. Laparoscopic 90 (73.8%) 12 (6.1%)
b. Open 30 (24.6%) 182 (91.9%)
c. Percutaneous 2 (1.6%) 4 (2%)
AFP (ng/ml) 36.6 (range 1.7–540) Not applicable
CEA (ng/ml) Not applicable 16.1 (range 0.5–636)
Total bilirubin (mg/dL) 1.1 (range 0.2–4.1) 0.6 (range 0.1–2.4)
Albumin (g/dL) 3.7 (range 2.3–5.3) 4 (range 2.1–4.9)
INR 1.2 (range 0.9–1.9) 1.1 (range 0.8–3.3)
Platelet (1000/mm3
) 119 (range 13–341) 210 (range 72–703)
BUN (mg/dL) 14.9 (range 5–35) 15.4 (range 3–80)
Creatinine (mg/dL) 1 (range 0.5–3.9) 1 (range 0.5–8.4)
Child-pugh classification
a. Child A 102 (83.6%) 196 (99%)
b. Child B 20 (16.4%) 2 (1%)
Average MELD score 10 (range 6–34) 8 (range 6–31)
HPB 757

All patients were evaluated in our liver cancer clinic according
to imaging studies (CT scan or MRI) and tumor biomarkers
[alpha-fetoprotein (AFP) for HCC and carcinoembryonic antigen
(CEA) for CLM] before ablation and at intervals of 1–3 month
post-ablation. Ablation success was defined according to the
appearance of an area equal to or larger than that of the original
tumor, without evidence of contrast enhancement. Disease-free
interval was defined as an interval between the date of RFA
until radiographic documentation of tumor recurrence at the
treated RFA site and/or presence of new tumor elsewhere (intra or
extrahepatic locations). Overall survival was defined as survival
between the date of RFA and the date of death, as determined by
medical record review and confirmed with a query of the Social
Security Death Index. Statistical analysis was performed using
SPSS version 23 for Windows (SPSS, Inc., Chicago, IL, USA).
Comparison between 2 groups was performed using T-test.
Disease-free and overall survival outcomes were analyzed using
the Kaplan–Meier method (log-rank). In all comparisons, a p-
value of .05 was considered statistically significant.
Results
Between 1999 and 2010, 320 patients (laparoscopic: 102, open:
212, percutaneous: 6) underwent RFA for HCC and CLM at the
University of Pittsburgh Liver Cancer Center. The mean overall
age was 65 (range: 33–92) years, predominantly male (63.4%),
and white (89.4%). Oncologic diagnoses included HCC in 122
patients (38.1%) and CLM in 198 patients (61.9%). De-
mographic characteristics of both groups are summarized in
Table 1. RFA alone was performed in 37.8% of all patients, while
62.2% underwent combination of RFA and liver resection. In
patients with HCC, vast majority of the radiofrequency ablations
were performed for a single hepatic lesion (90.2%) via laparo-
scopic approach (73.8%). Only 1.6% of HCC patients underwent
RFA for 3 or more liver lesions. Simultaneous liver resection was
performed in 38.7% of HCC patients, mostly laparoscopically. In
these patients subgroup, nonanatomic wedge liver resection was
the most commonly performed procedure (75%), followed by
anatomic resection of 2 or more segments (20%), and others
(5%). Approximately 10% of HCC patients were found to have
noncirrhotic background liver. In HCC patients with liver
cirrhosis, alcoholism was the most common cause (35%), which
is followed by nonalcoholic steatohepatitis (20%), hepatitis B/C
(30%), cryptogenic (10%), and others (5%).
In patients with CLM, single tumor ablation was performed in
approximately 60% of patients, with most ablations were
accomplished using open approach (91.9%). Simultaneous liver
resections during RFA were performed in 77.2% of patients with
CLM open right hepatic lobectomy (35%), open left hepatic
lobectomy (30%), and open nonanatomical wedge liver re-
sections (30%), others (5%).
Minimum 5 year follow-up information was available in 89%
patients, with a median follow-up of 115.3 months. Of the 114
patients with HCC in whom follow-up information were
obtainable, disease eventually recurred in 73 (64%) patients
[RFA site recurrence = 16.7%, new hepatic lesion(s) = 45.6%,
extrahepatic recurrence = 7.9%]. A median disease free interval
of 13 months was seen in the HCC group. Of the 170 patients
with CLM in whom follow-up information were obtainable,
disease recurrence was ultimately seen in 143 (84.1%) patients
[RFA site recurrence = 7.6%, new hepatic lesion(s) = 58.8%,
extrahepatic recurrence = 44.7%]. A slightly shorter median
disease free interval of 12.2 months was seen in the CLM group
(p-value .05). A detailed breakdown of the tumor recurrence
characteristics for both HCC and CLM is displayed in Table 2.
The 10-year disease free survivals for HCC and CLM groups
were 35.6% and 16.4%, respectively [(p-value = .001) Graph 1].
In patients with HCC, the 5- and 10-year overall survivals were
38.5% and 23.4%, while in patients with CLM, the 5- and 10-
year overall survivals were 27.6% and 15%, respectively [(p-
value = .052) Graph 2].
Discussion
Surgical resection remains the gold standard of curative therapy
in patients with liver cancer, both primary and metastatic. Due to
the fact that significant percentages of these patients are not
resection candidates, alternative treatment modalities play
important roles. Advances in tumor biology and technology have
led to new treatment options for unresectable liver tumors.
National Institute of Health (NIH) guidelines recommend sys-
temic chemotherapy for stage 3 and stage 4 colorectal cancer,
whereas in patients in stage 2, administration of chemotherapy
should be individualized. According to the American Joint
Committee on Cancer, 20% stage 2 and 50% stage 3 patients will
progress to have liver metastasis.16
In addition to regional and
systemic chemotherapy, RFA has been used as an alternative to
liver resection in recent decade with documented safety and ef-
ficacy in primary and metastatic hepatic malignancies. In clinical
practice, patient’s physical status, tumor size, tumor location,
Table 2 HCC and CLM recurrence characteristics after RFA
Clinical findings after RFA HCC
(n [ 122)
CLM
(n [ 198)
No evidence of disease 41 (33.6%) 27 (13.65)
Extrahepatic recurrence 7 (5.7%) 32 (16.2%)
New hepatic lesion (s) 47 (38.5%) 59 (29.85)
RFA site recurrence 14 (11.5%) 8 (4%)
RFA site recurrence + Extrahepatic
lesion (s)
N/A 3 (1.5%)
RFA site recurrence + New hepatic
lesion (s)
3 (2.5%) N/A
RFA site recurrence + New hepatic
lesion (s) + Extrahepatic lesion (s)
2 (1.6%) 2 (1%)
Loss to follow-up 8 (6.6%) 28 (14.1%)
758 HPB

underlying hepatic reserve, and surgeon’s expertise influence
surgical decision on whether to offer RFA, liver resection, or a
combination of both. Despite a randomized trial concluded that
liver resection may provide better survival and lower local
recurrence than RFA for HCC, data from a North American
multicenter study suggested a survival benefit of 2.5 years with
RFA for metastatic colorectal cancer.17,18
While there are docu-
mented 5-year survival rates with RFA, there are only few studies
to date evaluating the long-term efficacy (i.e. 10-year
survival).7,13,14
Radiofrequency ablation (RFA) utilizes a high-frequency
alternating current to generate frictional energy and heat
within tissues. When applied to a tumor, the resultant temper-
ature increase produces protein denaturation, cell death, and
coagulation necrosis. RFA was initially approved for general
tissue ablation by the Food and Drug Administration in 1996 and
for the treatment of unresectable hepatic metastases in 2000.
Since the first-generation RFA electrodes were unipolar and
produced a focused cylinder of ablation, early ablations were
limited to tumors smaller than 2.0 cm. As the technology evolved
to include multiarray electrodes with multiple deploying tines,
ablations fields up to 5 cm can be generated through overlapping
and sequential deployments. RFA can be safely and effectively
performed via percutaneous, laparoscopic, and open techniques.
The decision as to which is the best approach is based on patients
functional status, underlying hepatic reserve, history of prior
abdominal procedures, concurrent abdominal operations (i.e.
liver resections or colorectal resections), and anatomical distri-
bution of tumor burden. Laparoscopic approach in liver ablation
offers several advantages when compared to open or percuta-
neous approaches. Laparoscopic approach affords the ability to
identify and treat lesions located at the dome of the liver,
peripherally in the liver, or in close proximity to other abdominal
organs, while staying minimally invasively. Intraoperative liver
examination by laparoscopic ultrasound is another advantage of
this approach. Lo et al. reported that in 14% of patients, other
liver lesions located in other liver segments were able to be
identified during laparoscopy and subsequently treated.19
This
allows a better oncologic staging and a more complete disease
treatment. In this study, we used the opportunity during lapa-
roscopic RFA to concomitantly performed laparoscopic liver
resection for other liver lesions (found pre-or intraoperatively) in
approximately a third of our HCC patients. Ability to ensure liver
hemostasis via direct visualization of the liver surface is unique to
the surgically delivered RFA. Only less than 2% of patients in our
series underwent percutaneous RFA. We only utilize
Graph 1 Disease free survivals after RFA
HPB 759

percutaneous approach via subcostal or lower intercostal punc-
ture in patients who have undergone multiple prior liver re-
sections or when significant technical challenges are anticipated.
Difficult transabdominal sonographic visualization and absence
of access window limit the use of percutaneous technique.
Radiofrequency ablation technology comes with several limi-
tations and specific risks that should be considered prior to
application. The liver lesions must be visible by ultrasound and
should be away from large blood vessels to avoid the heat sink
effect, which may hinder complete tumor ablation. Residual
unablated tissue is a relatively common occurrence after lapa-
roscopic RFA in patients with HCC lesions larger than 3 cm in
diameter.20,21
Therefore, liver ablation must be cautiously
considered for liver tumors larger than 3 cm, due to the higher
probability of incomplete ablation. Additionally, care must be
taken to avoid thermal injury to the major bile ducts, especially
when RFA is used in close proximity to the hepatic hilum. Tohme
et al. reported that microsatellite disease next to the primary liver
tumor was detected in final pathology (but not on preoperative
imaging) in about 16% of patients after liver resections.7
This
finding suggested that liver resection is superior to the RFA
because it allows for removal of tissues adjacent to the tumor that
might harbor microsatellite disease or venous tumor thrombi.
Even though this theoretically should result in lower frequency of
intrahepatic recurrences, their study did not find any significant
difference in recurrence between the liver resection and RFA
groups.7
In our experience, the majority of patients undergoing RFA
were diagnosed with hepatic lesions which were deemed unre-
sectable secondary to either extent of disease, underlying liver
insufficiency, or presence of significant medical comorbidities. It
is our practice to routinely perform intraoperative ultrasound-
guided core biopsy of all liver lesions prior to RFA. This pro-
vides a diagnosis and allows for accurate 3-dimensional targeting
of lesions in real-time, prior to disruption by larger RFA probes.
The majority of the patients (61.9%) in this study carried a
diagnosis of metastatic colorectal cancer, which is concordant
with the fact that the majority of patients referred to our practice
have metastatic colon cancer. With increasing efficacy of systemic
chemotherapeutic regimens, we are seeing an increasing number
of colorectal cancer patients with extensive bilobar disease, in
whom complete surgical resection is not feasible. In patients with
colorectal metastases, complete surgical resection offers the best
chance for cure and that is the primary goal of every treatment,
whenever possible. Our increasing experience with patients with
extensive unresectable disease has led to the use of RFA as an
Graph 2 Overall survivals after RFA
760 HPB

adjunct to liver resection. A similar approach applies for patients
with metastatic neuroendocrine cancer.
As for HCC in the setting of chronic liver disease, all patients
within Milan criteria are referred for liver transplant evaluation.
Once they are listed for liver transplantation, we utilize RFA as a
bridge therapy while waiting for organ availability. In patients
with disease outside Milan criteria, we employ RFA with aim to
either downstage their disease or as a mean of delaying pro-
gression and prolonging survivals. In our current study, 32
(26.2%) of HCC patients were successfully downstaged using
RFA and subsequently underwent liver transplantation. At the
University of Pittsburgh Liver Cancer Center, approximately 2/3
of patients present with multifocal disease and approximately
half of them underwent RFA as an adjunct to surgical resection to
clear the liver of unresectable lesions. For unresectable advanced
hepatocellular carcinoma, Nexavar®
(Sorafenib) treatment was
offered in about 15% of HCC patients.
Local tumor recurrence is defined as reappearance of
enhancing tissue within and around the ablation zone, which is
secondary to presence of residual viable or unablated tumor in
patients previously considered to have a complete ablation. On
postoperative imaging after ablations, we evaluate the site(s) of
prior RFA for signs of local tumor recurrence, presence of new
intrahepatic lesions, and/or extrahepatic metastasis. A reported
cumulative rate of tumor recurrence after RFA in patients with
HCC is 60–80%.22,23
With a median follow up of nearly 10
years, local RFA site recurrence was found in 15.6% of our
HCC patients. In this study, we initially used an RF 2000®
Radiofrequency Generator for a year, before updating our
generator to the newer version (higher power) of RF 3000®
Radiofrequency Generator (Boston Scientific, Natick, MA,
USA). We did achieve complete roll-off with every ablations.
We did not observe any difference in local failure rates between
ablations performed using the older and the newer RFA gen-
erators. Almost 40% of patients developed new hepatic le-
sion(s) on their post ablation surveillance imaging, while less
than 10% experienced extrahepatic tumor recurrence. Because
HCC most commonly arises in livers with background cirrhosis
or chronic inflammation, a significant number of patients de-
velops new primary liver cancer after successful ablative treat-
ments. Local tumor recurrence maybe caused by incomplete
tumor/tissue ablation, presence of tumor venous invasion, and/
or presence of satellite nodules in the adjacent liver paren-
chyma. Santambrogio et al. reported a 15% rate of local tumor
recurrence/progression within 3 years of the RFA treatments.
Based on a subset analysis, approximately 35% patients
recurred locally within 12 months post ablation.12
It is often
difficult to determine whether the development of a new HCC
lesion is due to local recurrence after ablation versus multi-
centric tumor genesis. HCC recurrence tends to be multi-
centric, away from the ablation area, which is related to the
carcinogenesis potential of hepatocytes affected by chronic
inflammation and cirrhosis.
In patients with CLM, local RFA site recurrence was less than
10%. Almost 40% patients, however, developed extrahepatic
metastasis, which confirms a more systemic nature of the colo-
rectal cancer spread. Common extrahepatic sites included
aortocaval or periportal enlarged nodes, lungs, peritoneum,
abdominal wall, and skeletal bones. Lung metastasis varied from
a single nodule to the more commonly seen multiple bilateral
pulmonary nodules. Due to the colonic mesenteric venous
drainage via the liver, half of patients in our CLM group devel-
oped new intrahepatic tumor(s). Neoadjuvant chemotherapy
was given preoperatively in majority of our CLM patients, nearly
80%. Half of these patients had received chemotherapy prior to
their referral to our liver cancer center. Most commonly used
regiments are Folfox/Folfiri ± Avastin. CLM patients are typically
given two months of neoadjuvant chemotherapy, followed by
liver surgery. Last dose of chemotherapy and/or Avastin must be
at least one month before any liver operation. Postoperatively,
the patients typically receive four more months of chemotherapy.
In terms of postoperative follow-up schedule, all of our patients
are seen in about 2 weeks postoperatively for their initial post-
RFA visit. They are then followed every 3 months with a CT
scan triphasic liver/MRI for one year. If there are no signs of
tumor recurrence, they are then seen every six months for the
next four years. Beyond five years postoperatively without tumor
recurrence, the patients are followed annually. In the subgroup of
patients had RFA local recurrence, approximately 35% of them
underwent another RF reablation. We did not have any patients
who required reablation more than once. Transarterial chemo-
embolization (TACE) with Cisplatin was used in 9 (7.3%) of our
HCC patients who unfortunately developed multifocal bilobar
intrahepatic tumor recurrence after RFA.
Liver function and alpha fetoprotein level strongly influence
survivals in patients with HCC.24
Berber at al reported that pa-
tients with a carcinoembryonic antigen (CEA) less than 200 ng/
mL has an improved overall survival compared with those with a
CEA more than 200.17
Furthermore, patients with dominant
lesion less than 3 cm in diameter had a median survival of 38
versus 34 months for lesions 3–5 cm, and 21 months for lesions
greater than 5 cm (P = .03). Survival approached statistical sig-
nificance for patients with one to three tumors versus more than
three tumors (29 v 22 months, P = .09). Gender, age, colon
versus rectal primary, nodal status at the time of diagnosis,
metachronous versus synchronous, bilobar versus unilobar,
pretreatment chemotherapy and presence of extrahepatic disease
did not affect survival.17
Over the past decade, several studies have assessed the safety
and efficacy of RFA in HCC and CLM for a number of different
primary tumors. Babawale et al. reported 29% overall survival at
5 years after RFA for colorectal liver metastasis, which is com-
parable to our result of 27.6% overall survival at 5 years.15
Sorensen et al. and Solbiate et al., however, reported higher a 5
year overall survival of 44% and 47.8%, respectively.13,15,25
In an
European study of 426 patients who underwent RFA for HCC,
HPB 761

Santambrogio et al. reported 34% overall survival at 5 years.12
The median follow up interval in their study was 37.2 months
(range 2–193 months). When compared with this European
study, our finding of 38.5% five year overall survival in HCC
group compares favorably, especially with our significantly
longer median follow up of 115.3 months.
Even though several publications have described 10 year
experience of using RFA for treatment of colorectal liver
metastasis, hepatocellular carcinoma, and neuroendocrine liver
metastasis, there are only a few studies with actual 10 year follow-
up data.26–28
Most of them are single institution in nature.
Zhang et al. reported their 10 year disease-free and overall sur-
vivals of 15% and 33% in HCC patients, respectively. Patients
enrolled in this study have small 3 cm HCC lesions in a
background of hepatitis B infection, which is common among
the Chinese population. When compared to our HCC patients, a
higher 10 year disease free survival (35.6% versus 15%) but lower
10 year overall survival (23.4% vs 33%) were found. Incidence,
severity, and associated mortality of liver cirrhosis caused by
different hepatitis virus types, as well as dissimilar size of lesions
treated, may explain the difference in survival outcomes. Another
study with 10 year follow up by Solbiati et al. described an overall
10 year survival of 18% after RFA for colorectal liver metastasis.13
A comparable 15% overall survival after RFA in patients with
colorectal liver metastasis at 10 year mark was seen in our study.
Conclusions
This study provides convincing data that long-term survival is
possible with RFA treatment, especially when combined with
hepatic resection for multifocal tumors. This study shows that,
patients who undergo RFA as part of their hepatocellular and
colorectal metastatic treatments exhibit 10-year overall survival
rates of 23% and 15%, respectively. Therefore, selective appli-
cation of this modality has the potential to improve patient
survival in the appropriate setting.
Conflict of interest
None declared.
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