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16 april 2018: Bron: Journal of Hepatology, 13 april 2018

In een recent bijgewerkt studierapport wordt een uitgebreid overzicht gegeven van de waarde van zogeheten percutane ablatietechnieken van primaire leverkanker - HCC = hepatocellulair carcinoom. En wat de voordelen zijn en beperkingen en wanneer het beste welke ablatietechniek ingezet kan worden of combinaties daarvan. Eventueel in combinatie met chemotherapie of gedeeltelijke leveroperatie.

Onder die zogeheten percutane ablatietechnieken worden o.a. verstaan RFA - Radio Frequency Ablation, Microwave albation, Cryotherapie c.q. Ultra Sound, IRE - Irevesible electroporation (Nanoknife) of combinaties daarvan eventueel gecombineerd met radio embolisatie (Yttrium-90) of Trans Arteriële Chemo Embolisatie (TACE, PEI).  (Tekst loopt verder onder grafiek)

Large image of Fig. 1.

In de conclusie van dit studierapport schrijven de auteurs dat percutane behandelingen professioneel en veilig kunnen worden toegepast bij de behandeling van primaire leverkanker (HCC). En geldt dit ook voor levertumoren vanuit andere vormen van kanker wanneer er sprake is van geïsoleerde levertumoren. Maar ook schrijven de onderzoekers dat alleen RFA nog altijd eventuele lokale recidieven of recidieven op afstand niet in alle gevallen kunnen voorkomen. 

Inmiddels zijn er verschillende nieuwe ablatie-technieken bijgekomen, evenals nieuwe combinaties van behandelingen om de prognose van de leverkankerpatiënten te verbeteren; De onderzoekers stellen wel dat de resultaten met die nieuwe technieken onderzocht moet worden in gerandomiseerde gecontroleerde studies. Maar ook schrijven zij dat bij levertumoren langdurend placebo gecontroleerd onderzoek niet de meest geëigende manier is van onderzoek omdat levertumoren de neiging hebben snel te groeien als er geen behandeling aanslaat. 

De onderzoekers uit Milaan stellen oook dat elk academisch ziekenhuis dat primaire leverkanker behandeld en/of levertumoren vanuit andere vormen van kanker in principe alle genoemde ablatietechnieken in huis zou moeten hebben zodat er altijd gekozen kan worden tussen de verschillende vormen of combinaties ervan.

Zij schrijven bv.: Over het algemeen moet de kwestie van leverresectie, percutane ablatie en levertransplantatie niet worden gezien als een reden van onenigheid tussen de oncologen / radiologen / chirurgen van welke ablatie de beste zou zijn, maar eerder als een puzzel voor een multidisciplinair team om op te lossen. Dat zal uiteindelijk leiden tot behandelingsvoorstellen voor een veilige curatieve behandeling voor een groot aantal patiënten met primaire leverkanker of levertumoren vanuit andere vormen van kanker.

Bovendien schrijven de onderzoekers gaat de behandeling van grotere tumoren, soms met metastasen of poortaderstrombose, vanuit een in principe curatieve aanpak over in een grijs gebied tussen curatieve en palliatieve percutane behandelingen. Samenwerking en onderling overleg is het beste en dit studierapport kan daaraan bijdragen hopen de onderzoekers.

Het volledige studierapport: Percutaneous treatment of hepatocellular carcinoma: State of the art and innovations is gratis in te zien met m.i. uitstekende beschrijvingen van de verschillende ablatietechnieken en de voor- en nadelen van elk van die ablatietechnieken.

Hier het abstract van de studie met referentielijst.

Percutaneous treatments are the cornerstone of hepatocellular carcinoma treatment. This is an excellent review of when each treatment option can be applied and is most effective. It includes the background data for each treatment and different methods of use.

Journal of hepatology: 

DOI: https://doi.org/10.1016/j.jhep.2017.10.004

Percutaneous treatment of hepatocellular carcinoma: State of the art and innovations

Jean-Charles Nault'Correspondence information about the author Jean-Charles Nault,

Olivier Sutter

Pierre Nahon

Nathalie Ganne-Carrié

Olivier Séror'

Summary

Percutaneous treatment of hepatocellular carcinoma (HCC) encompasses a vast range of techniques, including monopolar radiofrequency ablation (RFA), multibipolar RFA, microwave ablation, cryoablation and irreversible electroporation. RFA is considered one of the main curative treatments for HCC of less than 5 cm developing on cirrhotic liver, together with surgical resection and liver transplantation. However, controversies exist concerning the respective roles of ablation and liver resection for HCC of less than 3 to 5 cm on cirrhotic liver. In line with the therapeutic algorithm of early HCC, percutaneous ablation could also be used as a bridge to liver transplantation or in a sequence of upfront percutaneous treatment, followed by transplantation if the patient relapses. Moreover, several innovations in ablation methods may help to efficiently treat early HCC, initially considered as “non-ablatable”, and might, in some cases, extend ablation criteria beyond early HCC, enabling treatment of more patients with a curative approach.

Conclusion

Percutaneous treatments are approaching the age of maturity for the treatment of HCC. Monopolar RFA is still impaired by local and distant tumour recurrence, and several new ablation techniques, as well as new combinations of treatments, have been proposed to improve prognosis; however, they need to be rigorously studied in randomised controlled trials vs. the treatment of reference. However, randomised controlled trials are difficult to perform in such a rapidly moving field. For ablative techniques, completeness of tumour control appears to be the most relevant primary endpoint of efficacy, with the rate of local recurrence and overall recurrence as secondary endpoints. We are no longer simply dealing with one technique of percutaneous ablation (monopolar RFA), but we now have a wide choice of techniques (monopolar RFA, multibipolar RFA, IRE, MWA, cryoablation, etc.) that increase the armamentarium available to curatively treat the maximum number of patients with HCC within Milan criteria. Consequently, a large range of percutaneous ablative technologies needs to be available in each centre dealing with HCC. This increased ability to safely ablate a larger number of patients will avoid the drift from curative to palliative treatment observed in a percentage of patients with HCC within Milan criteria. Moreover, we are also observing a changing paradigm in the role of ablation in the complex discussion of curative treatment. Overall, the question of liver resection, percutaneous ablation and liver transplantation should not be seen as a cause for disagreement, but rather, as a puzzle for a multidisciplinary tumour board, that will lead to propositions for safe curative treatment for a large number of patients while preserving the number of grafts used. Moreover, treatment of larger tumours, sometimes with metastases or portal vein thrombosis, pushes the concept of curative ablation into a grey zone between curative and palliative percutaneous treatment. Finally, hepatobiliary surgeons are implementing training in liver surgery in order to propagate worldwide surgical techniques for safely treating patients with HCC. The same principle should be applied to percutaneous interventional radiology, to train young interventional radiologists, and to test and disseminate new ablation techniques at centres throughout the world.

Conflict of interest

O Seror received personal fees and non-financial support from Angiodynamics, Olympus, and Bayer Schering Pharma and received personal fees from GE as a consultant. N Ganne and P Nahon received personal fees from Bayer Schering Pharma. JC Nault and O Sutter has no conflict of interest to declare.

Please refer to the accompanying ICMJE disclosure forms for further details.

Authors’ contributions

Writing and approval of this review (JCN, OSu, PN, NGC, OSe).

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This author was the recipient of the EASL Young Investigators’ Award 2017.

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