SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm Article

Full Text via DOI: 10.1007/s00464-023-10468-1 Web of Science: 001103756400006

Cited authors

  • Ceppa EP, Collings AT, Abdalla M, Onkendi E, Nelson DW, Ozair A, Miraflor E, Rahman F, Whiteside J, Shah MM, Ayloo S, Dirks R, Kumar SS, Ansari MT, Sucandy I, Ali K, Douglas S, Polanco PM, Vreeland TJ, Buell J, Abou-Setta AM, Awad Z, Kwon CH, Martinie JB, Sbrana F, Pryor A, Slater BJ, Richardson W, Jeyarajah R, Alseidi A

Abstract

  • BackgroundPrimary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies.MethodsA systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations.ResultsThe panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence).ConclusionGiven the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.BackgroundThe multidisciplinary management of both primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) may include liver-directed therapies as part of treatment algorithms; these algorithms focus heavily on control of liver-specific disease as in many cases this serves as a proxy for long-term survival. Hepatectomy is the primary treatment option in patients who can tolerate resection for both HCC and CRLM. Liver-directed therapies include arterial embolization, stereotactic body radiation therapy, and liver ablation. Over the last several decades, microwave ablation (MWA) and radiofrequency ablation (RFA) of liver tumors have been used in high-risk patients unfit for surgical intervention or tumors not amenable to local control with other therapies. As ablation is an evolving technology, outcomes data are primarily reported in liver tumors less than 3 cm in diameter, while data for liver tumors greater than 3 cm are limited for both HCC and CRLM. The authors sought to perform a systematic review of the existing data to assess for meaningful conclusions. Therefore, a multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others regarding the role of liver ablation in the treatment of HCC and CRLM up to 5 cm in diameter.MethodsA systematic review was conducted for six key questions (KQ) regarding the use of either MWA or RFA for solitary HCC or CRLM. Due to the paucity of evidence available, HCC and CRLM less than 5 cm in diameter were combined into two final KQs which were used to develop recommendations. Evidence-based recommendations were formulated using the GRADE methodology by subject matter experts. Additionally, the panel developed recommendations for future research.Interpretation of strong and conditional recommendationsAll guideline recommendations were assigned "conditional" recommendations. These were based on the GRADE approach. The words "the guideline panel suggests" were used for conditional recommendations.Key questions addressed by these guidelinesShould MWA (laparoscopic or open) vs. RFA (laparoscopic or open) be used for HCC or CRLM less than 5 cm ineligible for other therapies?Should laparoscopic MWA vs. percutaneous MWA be used for HCC and/or CRLM less than 5 cm ineligible for other therapies?RecommendationsShould MWA (laparoscopic or open) vs. RFA (laparoscopic or open) be used for HCC or CRLM less than 5 cm ineligible for other therapies?The panel suggests MWA and RFA are both safe and feasible. There was insufficient evidence to recommend one modality over another in terms of oncologic outcomes (conditional recommendation, very low certainty of evidence).Should laparoscopic MWA vs. percutaneous MWA be used for HCC and/or CRLM less than 5 cm ineligible for other therapies?The panel suggests that either ablative approach achieves similar overall outcomes, albeit through distinct patterns. The laparoscopic approach obtained better local control and the percutaneous approach had fewer morbidities while obtaining similar overall 1-year survival (conditional recommendation, very low certainty of evidence).How to use these guidelinesThe aim of these guidelines is to assist surgeons and physicians in making management decisions for patients with HCC or CRLM. Given that the evidence for this guideline was based on very low certainty evidence, these guidelines should be applied with caution. They are also intended to provide education, inform advocacy, and describe future areas for research.The guidelines are not meant to mandate a particular approach or strategy given the lack of evidence and intricacies of the healthcare environment, individual patient needs, comorbidities, and surgeon experience. Specific situations require adjustment of treatment plans to suit the needs and priorities of the individual patient. Finally, since the guidelines take a patient-centered approach, patients can use these guidelines as a source of information and for discussion with their physicians.

Authors

Publication date

  • 2023

International Standard Serial Number (ISSN)

  • 0930-2794

Number of pages

  • 10