A five-year disease-free survival after combined hepatectomy and radiofrequency ablation of large hepatocellular carcinoma adjacent to vena cava

Abstract

<jats:title>Abstract</jats:title><jats:p>Destroying the hepatic tumor located close to the large vessels is a major limiting factor of radiofrequency ablation (RFA) that is difficult to overcome. A long-term disease-free survival after combined hepatectomy and radiofrequency ablation of a large hepatic tumor adjacent to vena cava has not been previously published. We report a patient with a 23-cm large hepatocellular carcinoma occupying the left lateral segments and a 6-cm contralateral intrahepatic metastasis in Couinaud segments VII–VIII adjacent to the retrohepatic IVC, treated with a combination of resection of the larger tumor and intraoperative radiofrequency ablation of the paracaval tumor under intermittent total vascular exclusion of the right hemiliver. After five years of follow up the patient is disease free. This case demonstrates the importance of vascular control for eliminating the heat sink effect of caval blood flow during RFA of liver tumors adjacent to inferior vena cava.</jats:p>

Expanding Local Control Rate in Liver Cancer Surgery – The Value of Radiofrequency Ablation

“…The latter fact ultimately adds unpredictable bias in estimating "new" lesions in any study of percutaneous RFA of liver metastases (Elias et al, 2005). In our study, as in many others IOUS demonstrates significantly higher sensitivity compared with other diagnostic methods for detection of hepatic lesions (Table 3; Julianov, 2008). More than 90% of the missed lesions are < 1cm and frequently had subcapsular location.…”

“…For small HCC the presence or absence of a capsule did not influence the risk of local recurrence. There is an evidence from multivariate meta-analysis that RFA approach (percutaneous or intraoperative) influences significantly the effectiveness of ablation for both primary and metastatic liver malignancies regardless of the size of the tumor ( The possibilities for more precise placement of the electrodes and for obtaining both inflow and outflow vascular control are among the most important factors contributing to the superiority of surgical RFA (Julianov et al, 2008, Julianov, 2009 (Figure 3). The route of application also influences the safety of the RFA.…”

“…However inflow occlusion does not eliminate the "heat sink" when the tumor located near major hepatic vein is treated. In this situation the backflow cooling from the hepatic vein can be simply controlled by finding with IOUS the respective vein confluence to the inferior vena cava, and compressing the vein with the transducer until its lumen disappears on IOUS-screen (Julianov, 2008(Julianov, , 2009. Even the lesions adjacent to the vena cava can be successfully treated if proper vascular control techniques are used during RFA (Julianov et al, 2008; Figure 3).…”

“…Any complication after hepatic RFA require immediate treatment and when necessary interventions (surgical or image-guided) should be regarded as life saving and performed without delay. This approach permits avoiding mortality even in most critical situations (Julianov, 2008) …”