Laparoskopische und perkutane Mikrowellenablation maligner Lebertumoren: Anwendbarkeit und Effizienz

Zusammenfassung

Hintergrund: Lokal-ablative Behandlungsformen spielen eine wichtige Rolle in den modernen chirurgischen Therapiealgorithmen. Trotz großer Fortschritte leiden besonders Thermoablationen unter zum Teil inakzeptablen Lokalrezidivraten. Die Mikrowellenablation (MWA) ist eine vergleichsweise neuere Methode, die theroretisch einige Vorteile gegenüber anderen Methoden aufweist. Der vorliegende Bericht beschreibt die erste klinische Serie von Patienten, die im deutschsprachigen Raum mit MWA in einer chirurgischen Klinik behandelt wurden.

Material und Methode: Eine retrospektive Analyse der prospektiv erfassten Daten einer konsekutiven Fallserie eines einzelnen Zentrums wurde vorgenommen. Als MWA-Applikator kam das 915-MHz-System MedWaves™ der Fa. AveCure Inc., San Diego, Kalif./USA, zur Anwendung. Die Indikationen zur Therapie folgten denselben Kriterien wie zu jeder Thermoablation und wurden jeweils in einer interdisziplinären Tumorkonferenz bestätigt.

Ergebnisse: 51 Interventionen an 47 Patienten wurden zur Behandlung von 80 Tumoren vorgenommen. 31 Ablationen wurden perkutan, 20 laparoskopisch vorgenommen. Unter den Indikationen waren mehrheitlich hepatozelluläre Karzinome (HCC) und 14 Metastasen sowie 4 Rezidive eines cholangiozellulären Karzinoms. Die HCC-Diagnosen fanden sich alle in Zirrhose. Nach einem Nachuntersuchungszeitraum von 20 Monaten (Median) lag die Lokalrezidivrate bei 12 % pro Tumor (17 % pro Pat.). In einer univariaten logistischen Regressionsanalyse waren Tumorgröße, Zugangsweg und Risikolokalisation, multivariat dagegen nurmehr die Tumorgröße (p = 0,044) und der Zugangsweg (p = 0,012) signifikante Risikofaktoren für das Auftreten eines Lokalrezidivs.

Schlussfolgerung: Nach steiler Lernkurve war die MWA rasch zu implementieren und mit großem Erfolg in den chirurgischen Alltag einzuführen. Auch ungünstige Tumorlokalisationen können ohne gesteigerte Lokalrezidivraten sicher behandelt werden.

Abstract

Introduction: Local ablative treatments play an important role in current surgical treatment strategies. Radiofrequency ablation (RFA) as one of the most popular examples suffers from partly inacceptable local tumour control. Microwave coagulation therapy (MCT) is a comparatively new type of ablation promising several improvements. This series is to the best of our knowledge the first within the central European area, which reports on the successful clinical implementation of MCT in a surgical department.

Patients and Materials: A novel 915 MHz system (MedWaves™, AveCure Inc., SanDiego, CA/U. S. A.) was used to treat 47 patients with 80 tumour nodules in 51 treatment sessions. Average tumour size was 2.6 ± 0.9 cm. Indications were hepatocellular carcinoma in 29 patients and metastases in 14 as well as 4 cholangiocellular carcinomas. The approach was laparoscopic (20) or percutaneous (31). High-risk conditions defined by unfavourable tumour localisation like invisibility in native transabdominal ultrasound, superficial tumour site or risk of heat sink phenomena were found in 28 cases (53 %).

Results: Local recurrence rate was 17 % on a per-patient and 12 % on a per-tumour basis (n = 9). One patient died because of incurable upper gastrointestinal bleeding during the postoperative hospital stay. No MCT-associated complication occurred. Median follow-up period was 20 months. Local tumour recurrence was significantly different on comparing laparoscopic to percutaneous MCT (p = 0.032, χ² test), as was global recurrence (p = 0.011, χ² test). In a univariate logistic Cox regression, tumour size, access and high-risk localisation were significant prognostic factors for local tumour recurrence, however, in a multivariate reiteration, only the chosen access to MCT (p = 0.012) and tumour size (p = 0.044) remain significant.

Conclusion: MCT seems to be a useful tool, easy to implement in a surgical environment and may eventually prove to be superior to other local ablative treatment modalities. Even unfavourable tumour localisations could be treated safely and efficiently using MCT without increased risk of local tumour recurrence.

Schlüsselwörter

Leberchirurgie - lokale Tumorablation - laparoskopische Chirurgie - hepatozelluläres Karzinom - Lebermetastase - Intervention

Key words

liver surgery - local tumour ablation - laparoscopic surgery - hepatocellular carcinoma - liver metastasis - intervention

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