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Commentary |
1 Department of Radiology, Wake Forest University, Baptist Medical Center, WFUSOM, Medical Center Blvd., Winston-Salem, NC 27157.
Received March 23, 2006; accepted after revision March 24, 2006.
Each month the American Journal of Roentgenology will republish
online one of the 100 most-cited articles from its first century. A
corresponding commentary in the print journal by a contemporary radiologist
will provide a current perspective. For a full list of these articles, see
page 3 of the January 2006 issue of the AJR or go to
www.ajronline.org.
Keywords: abdominal imaging • hepatocellular carcinoma • liver cancer • radiofrequency ablation
The AJR's Centennial celebration recognizes "Percutaneous RF Interstitial Thermal Ablation in the Treatment of Hepatic Cancer" [1] as one of the most influential articles published in the AJR's first 100 years. This article helped establish an entirely new field in radiology: percutaneous imaging-guided ablation therapy for liver malignancies. This extremely important article, written by Rossi and colleagues [1] who have established themselves as leaders in the area of percutaneous imaging-guided tumor ablation, was critical in setting the stage for expansion and advances of imaging-guided radiofrequency ablation of tumors. Earlier articles published by these authors gave preliminary results for using radiofrequency ablation in the treatment of inoperable liver tumors [2, 3]. However, this article was particularly important, hence the numerous citations, for several reasons. First, the authors showed the efficacy of this approach by systematically confirming the diagnosis of malignancy in each patient treated. Each treated lesion was a biopsy-proven malignancy. This proof of malignancy validated the effectiveness of the technique in achieving oncologic control. Second, the authors are to be applauded for their careful and meticulous follow-up of patients treated with radiofrequency ablation for liver cancer in their series. This study spanned a 7-year experience using imaging-guided radiofrequency ablation for the treatment of liver tumors. The average patient follow-up was almost 2 years, a period adequate to critically compare this technique with surgical resection, which was previously the gold standard.
Rossi and colleagues [1] carefully evaluated each patient treated with radiofrequency ablation using a battery of studies including postprocedure sonography, multiple imaging-guided biopsies, contrast-enhanced CT, and angiography and in three patients, autopsy evaluation. This comprehensive follow-up was crucial in confirming the efficacy of radiofrequency ablation treatments and was a unique feature of the study. The results of this study were astounding. The authors showed that even with the rudimentary equipment that they used, a 26-W radiofrequency generator, they were able to achieve a median patient survival matching that of patients undergoing surgical resection. They also clearly established the safety of this procedure because neither complications nor evidence of needle track seeding by tumor was seen.
In establishing the safety and efficacy of this technique, Rossi and colleagues [1] addressed an area of significant need. Patients with hepatocellular carcinoma and metastatic colorectal carcinoma have an abysmal prognosis unless the liver tumors can be eradicated. In many of these patients, the tumors are inoperable because of comorbidities such as liver cirrhosis or the distribution of liver tumors combined with the anatomic limitations of hepatic resection. Systemic chemotherapy in these patients, particularly those with colorectal metastases to the liver, offers some palliative support, but the possibility of cure for hepatocellular carcinoma and liver metastases from colorectal carcinoma depends on the total eradication of liver neoplasms. Before this article, eradication of liver tumors in inoperable cases was considered impossible. The authors, very experienced in imaging-guided ablation of tumors using other techniques including ethanol injection and microwave ablation, applied their know-how to the use of radiofrequency ablation.
Before the article by Rossi and colleagues [1] was published, little was known about radiofrequency ablation for the treatment of liver tumors. This article greatly expanded the knowledge and encouraged many later researchers to expand the experience of Rossi et al. and advance the procedure [4-7]. At the time of their study, Rossi et al. used a 26-W radiofrequency generator. Using this low-power generator, they had to perform repeat ablation sessions to adequately destroy the small tumors included in their study. This generator has been eclipsed by newer generators with a capacity of up to 200 W and improved electrode designs [4]. Undoubtedly, the encouraging results from this study spurred industry and medical researchers to continue their quest for better radiofrequency equipment, which has resulted in the ability to treat larger lesions in a shorter amount of time [4].
Rossi and colleagues [1] also discussed some limitations of radiofrequency ablation. Although this technique was effective in eradicating the treated lesions, some problems were detected. Specifically, the authors realized that follow-up surveillance imaging is limited in depicting small volumes of residual tumor. They noted that sonography is inadequate for revealing small volumes of residual tumor. They did show that sonography is useful for guiding percutaneous ablation procedures, and they reiterated the typical findings seen during ablations. More importantly, Rossi et al. recognized that success of treatment for liver metastases is largely limited by the biology of the primary tumor. As previously shown for surgical resection of colorectal metastases to the liver, the authors reported a high rate of recurrence and development of new metastatic disease in these patients. This finding reinforced the idea that local targeted therapy for liver metastases, although possibly improving patient survival, uncommonly results in long-term cure. The frequency of this disease, colorectal metastases to the liver, and the limited effectiveness of localized treatment for metastases have encouraged later authors to experiment with imaging-guided local therapies coupled with systemic treatment to further improve patient prognosis and survival rates [8].
Publication of this article written by Rossi and his team of physicians [1] set in motion changes that have radically altered the scope of involvement for radiologists in treating patients with liver neoplasms. The careful experimental technique and reporting by Rossi et al. set the stage for widespread applications of imaging-guided ablation techniques in the liver and elsewhere. Many of these techniques have now become the standard of care for the treatment of patients with liver neoplasms, small renal tumors, inoperable lung tumors, and bone tumors [9-11]. More importantly, this landmark article helped establish radiofrequency ablation, which has greatly improved the quality of life and survival for thousands of patients who have subsequently undergone imaging-guided radiofrequency ablation of liver neoplasms. We are indebted to the authors of "Percutaneous RF Interstitial Thermal Ablation in the Treatment of Hepatic Cancer" for their innovative technique and their hard work in completing and publishing this innovative clinical series and reporting their findings.
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