© Springer International Publishing Switzerland 2015
Leonard Berliner and Heinz U. Lemke (eds.)An Information Technology Framework for Predictive, Preventive and Personalised MedicineAdvances in Predictive, Preventive and Personalised Medicine810.1007/978-3-319-12166-6_88. Minimally Invasive Therapies for Hepatocellular Cancer: Ablation Technologies
(1)
Kern/UCLA Medical Center, Bakersfield, CA, USA
(2)
University of Arizona College of Medicine, Phoenix, USA
(3)
Brigham and Women’s Hospital, Boston, MA, USA
Abstract
A wide variety of minimally invasive, or locoregional, therapies are now available for the treatment of hepatocellular carcinoma (HCC) along with surgery, systemic chemotherapy, and, occasionally, radiation therapy. These therapies are highly dependent on the strengths and limitations of the supporting technologies. This Chapter will review thermal ablation techniques including: radiofrequency ablation (RFA), interstitial laser thermotherapy (ILT), microwave ablation (MWA), high intensity focused ultrasound (HIFU), and cryotherapy (CRYO), and non-thermal ablations including: alcohol injection (ETOH), irreversible electroporation (IRE), and photodynamic therapy (PDT). Tumor ablation involves a focal destruction of tissue to achieve a therapeutic effect that may be an attempt at local cure of a tumor, or may be for debulking a tumor for symptomatic (i.e. pain) reasons. At this time, RFA has the largest clinical experience and will serve as the prototype for understanding the principles, mechanisms, and methods that have been developed for the treatment of HCC. Ablation is performed with a minimally invasive approach—the effect is delivered interstitially and intratumorally via a device placed percutaneously. Imaging plays a critical role in the targeting of the lesion, the protection of the surrounding anatomy, and, if possible, in the monitoring and control of the ablation process. The parameters used in the selection of thermal ablation device and the outcomes of their usage will eventually be a factored in generating Digital Patient Models (DPMs) to facilitate diagnosis, prognosis, and treatment selection, i.e. Model Guided Therapy (MGT) and Predictive, Preventive and Personalized Medicine (PPPM).
Keywords
Personalized medicineHepatocellular carcinomaLocoregional therapyTreatmentTechnologyRadiofrequency ablation (RFA)Microwave ablation (MWA)Cryotherapy (CRYO)Interstitial laser therapy (ILT)Irreversible electroporation (IRE)Paul Morrison is deceased.
8.1 Introduction
A wide variety of minimally invasive, or locoregional, therapies are now available for the treatment of hepatocellular carcinoma (HCC) along with surgery, systemic chemotherapy, and, occasionally, radiation therapy. These therapies are highly dependent on the strengths and limitations of the supporting technologies. This Chapter will begin with a review of thermal ablation techniques including: radiofrequency ablation (RFA), interstitial laser thermotherapy (ILT), microwave ablation (MWA), high intensity focused ultrasound (HIFU), and cryotherapy (CRYO), and non-thermal ablations including: alcohol injection (ETOH), irreversible electroporation (IRE), and photodynamic therapy (PDT).
The clinical applications that have arisen from these technologies will be reviewed in Chap. 9. At this time, RFA has the largest clinical experience and will serve as the prototype for understanding the principles, mechanisms, and methods that have been developed for the treatment of HCC. The effectiveness of RFA, and of more recent forms of ablation therapy, will be reviewed.
Percutaneous, catheter-directed therapy, or Transarterial Chemoembolization (TACE), will be reviewed in Chap. 10. (Catheter-directed radiation therapy with Yttrium-90 will be discussed in the Chapter on Radiation Therapy, Chap. 11).
8.1.1 Introduction to Tumor Ablation
Tumor ablation involves a focal destruction of tissue to achieve a therapeutic effect. The targeted tissue is focal as well, demonstrable under direct visualization, palpation or via radiologic imaging; multiple foci are individually targeted. The therapeutic effect may be an attempt at local cure of a tumor, or may be for debulking a tumor for symptomatic (i.e. pain) reasons. The term ablation suggests immediacy to the effect, while the results of a tumor ablation may ‘mature’ post-procedurally; the primary direct effects are usually most notable.
Ablation can be practiced in various venues: by a surgeon in the operating room, in an open procedure or under laparoscopy, by an interventional radiologist in a modern hybrid suite or in a simple procedure room. For our purposes here, we discuss image-guided thermal ablation. This suggests an interventional setting in which sonography, computed tomography, fluoroscopy, magnetic resonance imaging, or positron emission tomography could be the imaging modality of choice. In such a setting, the ablation is performed with a minimally invasive approach—the effect is delivered interstitially and intratumorally via a device placed percutaneously. In a percutaneous procedure, imaging plays a critical role in the targeting of the lesion, the protection of the surrounding anatomy and, if possible, in the monitoring and control of the ablation process.
8.1.2 Forms of Ablation
To provide context for ablation one should note that ablation can be divided into thermal and non-thermal ablations. Thermal ablations are those that involve an energy exchange within tissue. This energy exchange can be one in which energy is added to tissue, or one in which energy is removed from tissue; an exchange in which one cooks or freezes tissue, respectively. Types of thermal ablation include: radiofrequency ablation (RFA), interstitial laser thermotherapy (ILT), microwave ablation (MWA), high intensity focused ultrasound (HIFU), and cryotherapy (CRYO). Examples of non-thermal ablations include: alcohol injection (ETOH), irreversible electroporation (IRE), and photodynamic therapy (PDT).
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