Combination of intraoperative radiofrequency ablation and surgical resection for treatment of cholangiocarcinoma: feasibility and long-term survival

Abstract

PURPOSE Most patients with intrahepatic cholangiocarcinoma (ICC) are not eligible for surgical resection due to advanced stage. We aimed to evaluate the feasibility, local tumor control, and long-term survival of intraoperative radiofrequency ablation (IORFA) with surgical resection to treat unresectable intrahepatic cholangiocarcinoma (ICC). METHODS From 2009 to 2016, 20 consecutive patients (12 primary ICC, 8 recurrent ICC) underwent curative IORFA with hepatic resection for surgically unresectable ICC. Patients were not qualified to undergo surgical resection due to multiple lesions causing postoperative hepatic insufficiency and undesirable tumor locations for surgical resection or percutaneous RFA. Of the 51 treated tumors (mean, 2.6±0.9 tumors/patient), 24 were treated by IORFA and 27 were surgically removed. The technical success and effectiveness, overall survival, progression-free survival (PFS), and complications were assessed retrospectively. The overall survival and PFS rates were estimated by the Kaplan-Meier method. RESULTS The technical success and effectiveness of IORFA were 100%. The overall survival rates at 6 months, 1, 3, and 5 years were 95%, 79%, 27%, and 14%, respectively. The median overall survival time was 22.0±3.45 months. The PFS rates at 6 months, 1, 3, and 5 years were 70%, 33%, 13%, and 13%, respectively. The median PFS was 9.0±1.68 months. The prognosis was significantly worse for patients with recurrent ICC than for patients with primary ICC. One patient (5%) had major complications due to IORFA such as liver abscess and biliary stricture. CONCLUSION IORFA with surgical resection can be a feasible option for ICC cases that are not amenable to treatment with surgical resection alone. This strategy provides acceptable local tumor control and overall survival.

Figure 1. a–e

A 71-year-old man presented with intrahepatic cholangiocarcinoma (ICC). Gadoxetic acid-enhanced image (a) during hepatobiliary phase using a T1 VIBE sequence shows an 8.2 cm, soft tissue mass (arrows) in the hepatic segments IV, V, and VIII. A 2.1 cm, hypointense daughter nodule (arrowheads) is also found in segment VII. Extended right hemihepatectomy was planned, but central bisegmentectomy with intraoperative radiofrequency ablation (IORFA) was performed because of high risk of hepatic insufficiency for isolated resection. During IORFA, Sonazoid-enhanced US image (b) shows a clearly delineated nodule (arrow) in the liver that had a correlation with an ill-defined isoechoic nodule (arrowheads) on gray-scale ultrasound. Intraoperative ultrasound image obtained 12 minutes after the RFA shows successful ablation with sufficient margin (white arrows). Contrast-enhanced axial CT image (c) in portal phase obtained 1 month after the central bisegmentectomy with IORFA shows surgical removal of the main mass and complete ablation of the daughter nodule (arrow). CT image (d) obtained 10 months after IORFA shows reduced RFA zone (arrow) without a viable portion. CT image (e) 7 years following IORFA shows no suspicious enhancement within the extremely reduced ablated zone (arrows). The patient has been doing well for 96 months without tumor recurrence or distant metastasis.

Figure 2. a–d

A 40-year-old woman presented with recurrent ICC. Gadoxetic acid-enhanced axial T1-weighted image (a) during hepatic biliary phase shows a 7 cm, lobulated mass (arrows) with hypointense rim in left hepatic lobe, which was histologically confirmed cholangiocarcinoma. The patient underwent hemihepatectomy of the left hepatic lobe. After 17 months, contrast-enhanced axial CT image (b) in portal phase shows three recurrent tumors in the hepatic segment VI (arrow), segment VII (arrowheads), and segment V (not shown). CT image (c) obtained 1 month after second operation shows complete ablation (arrow) and surgical resection. CT image (d) 1 year after IORFA shows reduced RFA zone (arrow) without tumor recurrence. Progression-free survival and overall survival periods of the patient were 10 months and 18 months, respectively. The patient had no intrahepatic recurrence, but died due to distant metastasis in the lungs and bones.

Figure 3. a, b

Graphs show progression-free survival (a) and overall survival (b) after IORFA of all 20 patients.

Figure 4

Graph shows overall survival curves of primary and recurrent ICC, respectively.