Interventional procedure overview of image-guided percutaneous laser ablation of primary and secondary liver tumours

Arienti V, Pretolani S, Pacella CM et al. (2008) Complications of laser ablation for hepatocellular carcinoma: a multicenter study. Radiology 246: 947–55

HCC

Retrospective and prospective cohort study

n=520

Follow up: 12 months

Major complication rate=1.5% (15/1,004), associated with excess energy and high-risk location. Minor complication rate=6.2% (62/1,004), associated with excess energy, high bilirubin level, and low prothrombin time. Primary effectiveness rates were 60% in all HCCs and 81% in HCCs smaller than 3 cm.

A study from the same population is included (Pacella 2009)

Caspani B, Lerardi AM, Motta F et al. (2010) Small nodular hepatocellular carcinoma treated by laser thermal ablation in high risk locations: preliminary results. European Radiology 20: 2286–92

HCC

Case series

n=49

Follow up: 12 months

Laser ablation can be considered a safe treatment in "critical nodules".

Small case series.

Chai W, Zhao Q, Song H et al. (2019) Treatment response and preliminary efficacy of hepatic tumour laser ablation under the guidance of percutaneous and endoscopic ultrasonography. World Journal of Surgical Oncology 17: 133

Prospective case series

n=92

Follow up: 12 months

Patients in the endoscopic ultrasound guided laser ablation and percutaneous ultrasound guided laser ablation groups shared a similar treatment response and preliminary efficacy in the treatment of hepatic tumours.

Small study, comparing laser ablation under endoscopic ultrasound guidance with conventional ultrasound guidance.

Christophi C, Nikfarjam M, Malcontenti-Wilson C et al. (2004) Long-term survival of patients with unresectable colorectal liver metastases treated by percutaneous interstitial laser thermotherapy. World Journal of Surgery 28: 987–94

CRC liver metastases

Prospective case series

n=80

Follow-up: median 35 months

Median disease-free survival=24.6 months, with a 5-year survival of 3.8%. Poor tumour differentiation and the presence of more than 2 hepatic metastases were associated with lower overall survival (p<0.01). Fourteen patients who had treatment for postoperative hepatic recurrences had the best outcome, with a median overall survival of 36.3 months and a 5-year survival of 17.2%.

Larger or more recent studies are included.

Di Costanzo GG, Francica G, Pacella CM (2014) Laser ablation for small hepatocellular carcinoma: State of the art and future perspectives. World Journal of Hepatology 6: 704–15

HCC

Review

According to internationally endorsed guidelines, percutaneous thermal ablation is the mainstay of treatment in patients with small HCC who are not candidates for surgical resection or transplantation. Laser ablation represents one of currently available loco-ablative techniques. A review of published data suggests that laser ablation is equivalent to the more popular and widespread RFA in both local tumour control and long-term outcome in the percutaneous treatment of early HCC. In addition, the LA technique using multiple thin laser fibres allows improved ablative effectiveness in HCCs greater than 3 cm.

No meta-analysis; all relevant studies are included.

Di Costanzo GG, D'Adamo G, Tortora R et al. (2013) A novel needle guide system to perform percutaneous laser ablation of liver tumors using the multifiber technique. Acta radiologica 54: 876–81

HCC and liver metastases

n=116

Complete tumour ablation was achieved in a single session in 112 (88%) lesions (94% for nodules 3 cm or smaller and 80% for those larger than 3 cm. Of note, complete ablation was achieved in 92% of nodules up to 5 cm.

Larger or more recent studies are included.

Dick EA, Joarder R, de Jode M et al. (2003) MR-guided laser thermal ablation of primary and secondary liver tumours. Clinical Radiology 58: 112–20

Primary and secondary liver tumours

n=35

Follow up: 5.8 months

MR-guided laser ablation produces a better survival in patients with HCC than would be expected in patients who did not have treatment and has a mean survival in patients with metastases at least equal to the longest median survival in patients who did not have treatment.

More recent or larger studies are included.

Eichler K, Zangos S, Gruber-Rouh T et al. (2012) Magnetic resonance-guided laser-induced thermotherapy in patients with oligonodular hepatocellular carcinoma: long-term results over a 15-year period. Journal of clinical gastroenterology 46: 796-801

HCC

Prospective case series

n=113

The mean survival rate from date of diagnosis of the HCC treated with laser ablation, was 4.9 years (95% CI 3.6 to 5.1). The median survival rate was 3.5 years (95% CI 2.7 to 4.2). One-year survival was 95%; 2-year survival 72%, 3-year survival 54%; and 5-year survival 30%.

Larger studies are included.

Eichler K, Mack MG, Straub R et al. (2001) Oligonodular hepatocellular carcinoma (HCC): MR-guided laser-induced thermotherapy (LITT). Radiologe 41: 915–22

HCC

Prospective case series

n=39

Complete necrosis was achieved in 97.5% of tumours with a 5 mm safety margin, resulting in a complete destruction of the tumour without local recurrences. Mean survival was 4.4 years (95% Cl 3.6 to 5.2 years) after the time of diagnoses of the HCC (Kaplan-Meier-method).

More recent or larger studies are included.

Ferrari FS, Stella A, Gambacorta D et al. (2004) Treatment of large hepatocellular carcinoma: comparison between techniques and long term results. La Radiologia medica 108: 356–71

HCC

Randomised controlled trial

n=89

For laser ablation, complete necrosis was 86%. Cumulative survival rates were 86%, 33%, and 12% at 1, 3 and 5 years, respectively.

Combined therapy and laser ablation were most effective.

A more recent study from the same author is included.

Francica G, Petrolati A, Di Stasio E et al. (2012) Influence of ablative margin on local tumor progression and survival in patients with HCC <=4 cm after laser ablation. Acta Radiologica 53: 394–400

HCC

Cohort study

n=116

Follow up: mean 42 months

An ablative margin 7.5 mm or more was useful in preventing local tumour progression but did not affect long-term survival in patients with HCC 4 cm or smaller treated with laser ablation.

Small study, assessing influence of ablative margin.

Francica G, Iodice G, Delle Cave M et al. (2007) Factors predicting complete necrosis rate after ultrasound-guided percutaneous laser thermoablation of small hepatocellular carcinoma tumors in cirrhotic patients: a multivariate analysis. Acta Radiologica 48: 514–19

HCC

Retrospective case series

n=60

The effectiveness of ultrasound-guided laser ablation for HCC tumours 4 cm or less was negatively affected by both operator-related (the beginning of the operator's experience with the technique) and tumour-related factors (non-naive, infiltrating HCC tumours).

Larger or more recent studies are included.

Giorgio A, Tarantino L, de Stefano G et al. (2003) Complications after interventional sonography of focal liver lesions: a 22-year single-center experience.

DOI: 10.7863/jum.2003.22.2.193

Primary and secondary liver tumours

Review

n=13,222 (122 laser ablation)

Major complications after liver tumour ablative procedures included 10 cases of acute liver failure, 2 cases of acute tubular necrosis, 2 cases of self-limiting hemoperitoneum, 2 cases of paralytic ileum, 2 abscesses, and 1 case of cholangitis.

3% of 122 had major complications after laser ablation (self-limiting paralytic ilea [n=2] and acute liver failure treated with medication [n=2 patients with Child-Pugh class C cirrhosis).

Review includes a mix of procedures.

Giorgio A, Tarantino L, de Stefano G et al. (2000) Interstitial laser photocoagulation under ultrasound guidance of liver tumors: results in 104 treated patients. European Journal of Ultrasound 11: 181–8

Primary and secondary liver tumours

Case series

n=104

CT showed complete necrosis in 70 out of 85 HCC nodules in 65 treated patients and in 24 out of 31 patients with metastases. Three patients with Child class C had severe liver failure, 1 was associated with transient paralytic ileum. One of these patients died 2 months after treatment. Two patients with metastasis did not complete treatment because of a complication (1 paralytic ileum, 1 gastric haemorrhage).

More recent or larger studies are included.

Lichun D, Dazhong Z, Wei SS et al. (2017) Clinical observation of laser ablation combined with chemotherapy in postoperative colorectal cancers with liver metastasis. Minerva Chirurgica 72: 18–23

CRC liver metastases

Observational study

n=85

Laser ablation in combination with chemotherapy of colorectal carcinoma liver metastases is effective and well-tolerated.

Study assesses laser ablation in combination with chemotherapy.

Loveman E, Jones J, Clegg AJ et al. (2014) The clinical effectiveness and cost-effectiveness of ablative therapies in the management of liver metastases: systematic review and economic evaluation. Health technology assessment (Winchester, England) 18: vii-283

Liver metastases

2 case series (n=705 and 232, with some patient overlap)

No comparative studies of laser ablation were identified. Two prospective case series, which provide very low-quality evidence, were included from the same institution.

The most common adverse event was non-symptomatic pleural effusion, which occurred 41 (9%) times in 452 treatment sessions. There were 20 (4%) events of small non-symptomatic subscapular haematoma.

Review only includes 2 case series on laser ablation.

Luerken L, Haimerl M, Doppler M et al. (2022) Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. RoFo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin 194: 1075–86

HCC

Review

Laser ablation is a potential alternative in patients with liver cirrhosis and smaller HCCs. Despite the promising results, laser ablation is not mentioned in the current S3 guideline, partly because of the high level of required equipment; but it is rarely used and has been superseded in many centres by microwave ablation or RFA.

The review includes 2 randomised controlled trials on laser ablation, both of which are included in the key evidence.

Luo W, Zhang Y, He G et al. (2017) Effects of radiofrequency ablation versus other ablating techniques on hepatocellular carcinomas: a systematic review and meta-analysis. World Journal of Surgical Oncology 15: 126

HCC

Systematic review

n=30 articles (3 on laser ablation)

Lower complete tumour ablation rates and higher local tumour recurrence rates were observed in the laser ablation group. Higher overall survival was seen in the in RFA group, particularly among larger HCCs (p<0.05).

A tendency of fewer complications was detected in the laser ablation group. Thin needles for laser ablation may improve the ablative effects on tumours with irregular shape or in high-risk locations.

Review only includes 3 randomised controlled trials on laser ablation, all of which are included in the key evidence.

Mack MG, Straub R, Eichler K et al. (2004) Breast cancer metastases in liver: laser-induced interstitial thermotherapy--local tumor control rate and survival data. Radiology 233: 400-9

Breast cancer liver metastases

Case series

n=232

Local recurrence rate at 6-month follow-up =2.3% for metastases up to 2 cm in diameter, 4.3% for metastases 2 cm to 3 cm in diameter, 3.2% for metastases 3 cm to 4 cm in diameter, and 1.9% for metastases larger than 4 cm in diameter. No additional local tumour progression was observed beyond 6 months. Mean survival rate from diagnosis of the metastases treated with laser ablation=4.9 years (95% CI 4.3 to 5.4). Median survival=4.3 years. 1-year survival= 96%, 2-year survival=80%, 3-year survival=63%, 5-year survival=41%. Mean survival after the first laser ablation=4.2 years (95% CI 3.6 to 4.8).

More recent or larger studies are included.

Mack MG, Straub R, Eichler K; et al. (2001) Percutaneous MR imaging-guided laser-induced thermotherapy of hepatic metastases. Abdominal Imaging 26: 369–74

Liver metastases

Case series

n=705

The overall rate of complications and side effects was 7.5%. The rate of clinically relevant complications was 1.3%. Local tumour control rate was 99% after 3 months and 98% after 6 months. In patients with CRC liver metastases, the mean survival was 41.8 months (95% CI 37.3 to 46.4 months). The 1-year survival rate was 93%, the 2-year survival rate was 74%, the 3-year survival rate was 50%, and the 5-year survival was 30%. In patients with liver metastases from breast cancer, the mean survival was 4.3 years (95% CI 3.6 to 5.0).

More recent studies are included.

Majumdar A, Roccarina D, Thorburn D et al. (2017) Management of people with early‐ or very early‐stage hepatocellular carcinoma. Cochrane Database of Systematic Reviews Issue 3. Art. No. CD011650. DOI: 10.1002/ 14651858.CD011650.pub2 Accessed 29 September 2023.

HCC

Systematic review

20 references (18 trials; 2 on laser ablation)

High-quality randomised clinical trials designed to measure clinically important differences in all-cause mortality and following the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials), and CONSORT guidelines, are needed. Future trials on early HCC should follow up people for at least 4 to 5 years because most deaths occur beyond 3 years. They should also include other patient-oriented outcomes such as health related quality of life.

Review only included 2 trials on laser ablation, both of which are included in the key evidence.

Pacella CM, Bizzarri G, Francica G et al. (2006) Analysis of factors predicting survival in patients with hepatocellular carcinoma treated with percutaneous laser ablation. Journal of Hepatology 44: 902–9

HCC

Prospective case series

n=148

Median overall survival=39 months (95% CI 30 to 47) The 1-, 2-, 3-, 4-, and 5-year cumulative survival rates were 89, 75, 52, 43, and 27%, respectively. From multiple regression analysis, the independent predictors of survival were found to be tumour grading (p=0.002; risk ratio [RR] 0.37, 95% CI 0.20 to 0.70), bilirubin levels 2.5mg/dl or lower (p=0.014; RR 1.58, 95% CI 1.09 to 2.28), and the achievement of complete tumour ablation (p=0.020; RR 0.53, 95% CI 0.31 to 0.90). An initial complete tumour ablation was the only factor associated with longer survival in patients with Child-Turcotte-Pugh class A cirrhosis (p=0.012; hazard ratio 0.48, 95% CI 0.23 to 1.03).

Larger or more recent studies are included.

Pacella CM, Valle D, Bizzarri G et al. (2006) Percutaneous laser ablation in patients with isolated unresectable liver metastases from colorectal cancer: Results of a phase II study. Acta Oncologica 45: 77–83

CRC liver metastases

Prospective case series

n=44

After treatment, 61% (46/75) of the tumours were ablated completely. The likelihood of achieving a complete ablation was significantly higher when metastases had a diameter less than 3 cm (p=0.004). Overall survival was 30.0 months in patients with a complete ablation and 20.2 months in those with a partial ablation (p=0.002).

Larger or more recent studies are included.

Pacella CM, Bizzarri G, Francica G et al. (2005) Percutaneous laser ablation in the treatment of hepatocellular carcinoma with small tumors: analysis of factors affecting the achievement of tumor necrosis. Journal of Vascular and Interventional Radiology 16: 1447–57

HCC

Retrospective case series

n=82

Percutaneous laser ablation is a highly effective treatment in HCC with a tumour size of 4.0 cm or smaller. In this setting, 2 variables, tumour size and tumour location, affect the achievement of complete tumour ablation and the number of treatments required to obtain tumour necrosis.

Larger or more recent studies are included.

Pacella CM, Bizzarri G, Magnolfi F et al. (2001) Laser thermal ablation in the treatment of small hepatocellular carcinoma: results in 74 patients. Radiology 221: 712–20

HCC

Case series

n=74

Follow up: mean 25 months

During follow-up 84 tumours (91%) decreased in size. The local recurrence rates ranged from 1.6% to 6.0%. Recurrence rates in other liver segments ranged from 24% to 73%. Cancer-free survival rates ranged from 73% to 24%. Overall survival rates were 99%, 68%, and 15% at 1, 3, and 5 years, respectively. Twenty-one patients (28%) died.

Larger or more recent studies are included.

Pech M, Wieners G, Kryza R et al. (2008) CT-guided brachytherapy (CTGB) versus interstitial laser ablation (ILT) of colorectal liver metastases: an intraindividual matched-pair analysis. Strahlentherapie und Onkologie: Organ der Deutschen Rontgengesellschaft 184: 302–6

CRC liver metastases

Non-randomised comparative study

n=36

Follow up: median 14 months

Only 5 of 18 patients (28%) showed local tumour progression after CT guided brachytherapy, compared with 10 of 18 patients (56%) after laser ablation.

Small, non-randomised study comparing laser ablation with brachytherapy.

Pech M, Wieners G, Freund T et al. (2007) MR-guided interstitial laser thermotherapy of colorectal liver metastases: efficiency, safety and patient survival. European Journal of Medical Research 12: 161–8

CRC liver metastases

Case series

n=66

Follow up: median 8.7 months

The overall median progression free survival was 6.1 months. Median survival was 23 months (95% CI 17 to 29 months). The rate of major complications was 2% (n=2) and peri-procedural mortality (30 days) was 3% (n=2). After 3, 6, 9, and 12 months, local tumour control was 98%, 91%, 76%, and 69%, respectively.

More recent or larger studies were included.

Puls R, Langner S, Rosenberg CH et al (2005) Laser ablation of liver metastases from colorectal cancer with MR thermometry: 5-year survival. Journal of Vascular and Interventional Radiology 16:981–990

CRC liver metastases

Case series

n=87

Technical success=99% Local tumour progression rate was 10% after 6 months. Major complications included large pleural effusion, large subcapsular hematoma, abscess, large pneumothorax, pleuritis with fever, intrahepatic haemorrhage, and biloma. Mean survival from the time of diagnosis of the primary tumour was 50.6 months for all patients who had treatment (95% CI 44.9 to 56.3 months). Median survival time was 54 months and survival rates were 96% at 1 year, 86% at 2 years, 72% at 3 years, 50% at 4 years, and 33% at 5 years. The mean survival time after the first treatment was 31.1 months (95% CI 26.9 to 35.3 months).

More recent or larger studies were included.

Ricke J, Wust P, Stohlmann A et al. (2004) CT-guided interstitial brachytherapy of liver malignancies alone or in combination with thermal ablation: phase I-II results of a novel technique. International Journal of Radiation Oncology, Biology, Physics 58: 1496–505

Primary and secondary liver tumours

Non-randomised comparative study

n=37

Follow up: 6 months

CT-guided brachytherapy using 3D CT data for dosimetry is safe and effective alone or in combination with laser ablation.

Small study, assessing interstitial brachytherapy alone or in combination with laser therapy.

Vogl TJ, Kreutztrager M, Gruber-Rouh T et al. (2014) Neoadjuvant TACE before laser induced thermotherapy (LITT) in the treatment of non-colorectal non-breast cancer liver metastases: feasibility and survival rates. European Journal of Radiology 83: 1804–10

Non-CRC, non-breast liver metastases

Non-randomised comparative study

n=110

Transarterial chemoembolisation with different protocols alone and in combination with laser ablation is a feasible palliative treatment option resulting in a median survival of 21.1 months for unresectable liver metastases of non-colorectal and non-breast cancer origin.

Study focuses on TACE with or without laser ablation.

Vogl TJ, Farshid P, Naguib NNN et al. (2014) Thermal ablation of liver metastases from colorectal cancer: radiofrequency, microwave and laser ablation therapies. La Radiologia Medica 119: 451–61

CRC liver metastases

Review

Reviewed literature showed a local progression rate between 2.8% and 29.7% of RF-ablated liver lesions at 12 to 49 months follow up, 2.7% to 12.5% of microwave ablated lesions at 5 to 19 months follow-up and 5.2% of lesions treated with laser ablation at 6-month follow up. Major complications were observed in 4% to 33% of patients who had treatment with RF ablation, 0% to 19% of patients who had treatment with microwave ablation and 0.1 to 3.5% of lesions treated with laser ablation. The mean of 1-, 3- and 5-year survival rates for RFA, microwave and laser ablated lesions was (93, 45, 31%), (79, 39, 21%) and (94, 62, 29%), respectively. The median survival in these methods was 33.2, 29.5 and 33.7 months, respectively.

No meta-analysis.

All relevant articles have been included.

Vogl TJ, Farshid P, Naguib Nagy NN et al. (2013) Thermal ablation therapies in patients with breast cancer liver metastases: a review. European Radiology 23: 797–804

Breast cancer liver metastases

Review

The reviewed literature showed positive response rates of 63% to 97% in RF-ablated lesions, 98% in laser ablated lesions and 34.5% to 62.5% in microwave ablated lesions. Median survival was 10.9 to 60 months using RFA, 51 to 54 months after laser ablation and 41.8 months using microwave. Five-year survival rates were 27 to 30%, 35% and 29%, respectively. Local tumour progression ranged from 13.5% to 58% using RFA, 2.9% with laser and 9.6% with microwave.

More recent studies are included.

Vogl TJ, Naguib NNN, Nour-Eldin NEA et al. (2011) Repeated chemoembolization followed by laser-induced thermotherapy for liver metastasis of breast cancer. AJR. American Journal of Roentgenology 196: w66–72

Breast cancer liver metastases

Prospective case series

n=161

Transarterial chemoembolisation can be used for sufficient downstaging of liver metastatic lesions of breast cancer to allow laser-induced thermotherapy.

Study assesses use of TACE before laser ablation.

Vogl TJ, Eichler K, Zangos S et al. (2005) Interstitial laser therapy of liver tumors. Medical Laser Application 20: 115–18

Liver metastases

n=1,632

MR-guided laser-induced thermotherapy is a safe method for the treatment of liver tumours and yields a low rate of major and minor complications because of its minimal invasive character.

Other studies published by the same author with more outcomes are included.

Vogl TJ, Straub R, Zangos S et al. (2004) MR-guided laser-induced thermotherapy (LITT) of liver tumours: experimental and clinical data. International Journal of Hyperthermia 20: 713–24

Liver metastases

n=1,259

Local tumour control rate=98.7% at 3 months and 97.3% at 6 months. The mean survival rate=4.4 years (95% CI

4.1 to 4.8 years) and median survival=3.0 years. No statistically significant difference in survival rates was observed in patients with CRC liver metastases compared with other primary tumours. The rate of clinically relevant side effects and complications needing secondary treatment was 2.2%.

Other studies published by the same author are included.

Vogl T, Straub R, Eichler K et al. (2002) Malignant liver tumors treated with MR imaging–guided laser-induced thermotherapy: experience with complications in 899 patients (2,520 lesions). Radiology 225 (no. 2)

Malignant liver tumours

Cohort study

n=899

Major complications included 3 deaths (0.1%) within 30 days, pleural effusion needing thoracentesis in 16 (0.8%) cases, hepatic abscess needing drainage in 15 (0.7%) cases, bile duct injury in 4 (0.2%) cases, segmental infarction in 3 (0.1%) cases, and haemorrhage needing transfusion in 1 (0.05%) case. Minor complications included postprocedural fever in 710 (33%), pleural effusion not needing thoracentesis in 155 (7%), subcapsular hematoma in 69 (3%), subcutaneous haematoma in 24 (1%), pneumothorax in 7 (0.3%), and haemorrhage in 2 (0.1%) cases.

More recent studies are included.

Vogl TJ, Eichler K Straub R et al. (2001) Laser-induced thermotherapy of malignant liver tumors: general principals, equipment(s), procedure(s)--side effects, complications and results. European Journal of Ultrasound 13: 117–27

Primary and secondary liver tumours

Case series

n=676

There were no relevant clinical complications.

Mean survival=35 months

MRI-guided, or ultrasound-guided laser ablation appears to be a safe and effective treatment protocol for liver metastases and oligonodular HCC.

More recent studies are included.

Wietzke-Braun P, Schindler C, Raddatz D et al. (2004) Quality of life and outcome of ultrasound-guided laser interstitial thermo-therapy for non-resectable liver metastases of colorectal cancer. European Journal of Gastroenterology & Hepatology 16: 389-95

CRC liver metastases

Prospective case series

n=45

Follow up: 6 months

Median survival after laser ablation=8.5 months (range 1.5 to 18). In the multivariate analyses, quality-of-life symptoms and functioning scales did not deteriorate in patients alive at 6 months after laser ablation. Univariate analyses outlined a significant increase of the pain subscale before and at 1 week after laser ablation.

Small case series with short term follow up.

Wietzke-Braun P, Ritzel U, Nolte W et al. (2003) Ultrasound-guided laser interstitial thermo therapy for treatment of non-resectable primary and secondary liver tumours--a feasibility study. Ultraschall in der Medizin 24: 107–12

Primary and secondary liver tumours

Case series

n=60

There were no serious adverse events and no deaths within 30 days.

Small feasibility study.

Zangos S, Mack MG, Balzer JO et al. (2004) Neoadjuvant transarterial chemoembolization (TACE) before percutaneous MR-guided laser-induced thermotherapy (LITT): Results in large-sized primary and secondary liver tumors. Medical Laser Application 19: 98–108

Primary and secondary liver tumours

Case series

n=289

The combined treatment protocol (TACE followed by MRI-guided laser ablation) appears to be a safe and effective treatment of large unresectable liver tumours. The combination of TACE and laser ablation results in significant superior survival rates in comparison to the results of TACE alone. HCC showed a better response to the treatment than liver metastases.

The focus of the study is the effect of neoadjuvant TACE before laser ablation.