Rapid on-site evaluation may optimize patient selection for radio-frequency-ablation therapy Dr Wolfgang Pokieser Pathologisch-bakteriologisches Institut Wilhelminenspital, Vienna wolfgang.pokieser@wienkav.at

Radio-frequency-ablation therapy (RFA) RFA is generally conducted in the outpatient setting, using conscious sedation anesthesia. In RFA used for liver lesions, neoplastic tissue is ablated by the heat generated from high frequency alternating current (in the range of 470–480 kHz). RFA is done under guidance of ultrasound.

1-3 needles were placed in the nodule (until 7 cm in diameter) 1-3 needles were placed in the nodule (until 7 cm in diameter). Above 60 degrees celsius the liver tissue becomes necrotic.

Indication for RFA in the liver Hepatocellular carcinomas (method of choice for early carcinomas) Colorectal carcinoma metastases (5 year OS 50%) Only 25% of patients with HCC or colorectal carcinoma metastases are suitable for surgery. Fast growing liver tumors might become too big for curative therapy. Berber E et al. J gastrointest Surg 2008

Aim of the study: To evaluate if rapid on-site-evaluation (ROSE ) represents a feasible tool to select patients for radio-frequency-ablation therapy (RFA), especially in cases with fast growing tumours.

Methods: 1. The study comprised 10 patients with fast growing hepatic tumours highly suspicious for malignancy without a previous histological diagnosis. 2. Core needle biopsies were obtained and imprints immediately examined by ROSE. 3. The radiologist was informed of the benign versus malignant cytological appearance. 4. RFA was performed or cancelled. 5. The subsequent histological diagnosis of the core needle biopsy was then compared with the cytology results.

ROSE specimen satisfactory unsatisfactory benign uncertain malignant no RFA RFA patient´s condition + tumor progression no RFA RFA

Rapid on-site evaluation (ROSE) ROSE helps radiologists decide whether to perform RFA or not. References: Algorithm for immediate cytologic diagnosis of hepatic tumors. Pupulim LF et al. AJR 2008 March 190(3):W208-12 Use of fine needle aspiration biopsy in radiofrequency ablation. Moreland WS et al. Acta Cytol 2002 Sept-Oct; 46(5):819-22

Patients (n=10), liver lesions (n=13) sex and age Number of lesions ROSE RFA final histology female 66y 1 benign no male 84y malignant yes colorectal metastases female 61y HCC+CCC male 76y 2 uncertain(2) no(2) liver cell dysplasia male 79y neuroendocrine carcinoma female 47y breast cancer metastases male 70y carcinoid male 50y benign(1) uncertain(1) no(1) yes(1) cirrhosis(2) male 63y uncertain highly suspicious for HCC male 71y yes(2) cirrhosis(1) dysplasia(1)

sex and age Number of lesions ROSE RFA final histology female 66y 1 benign no male 84y malignant yes colorectal metastases female 61y HCC+CCC male 76y 2 uncertain(2) no(2) liver cell dysplasia male 79y neuroendocrine carcinoma female 47y breast cancer metastases male 70y carcinoid male 50y benign(1) uncertain(1) no(1) yes(1) cirrhosis(2) male 63y uncertain highly suspicious for HCC male 71y yes(2) cirrhosis(1) dysplasia(1)

sex and age Number of lesions ROSE RFA final histology female 66y 1 benign no male 84y malignant yes colorectal metastases female 61y HCC+CCC male 76y 2 uncertain(2) no(2) liver cell dysplasia male 79y neuroendocrine carcinoma female 47y breast cancer metastases male 70y carcinoid male 50y benign(1) uncertain(1) no(1) yes(1) cirrhosis(2) male 63y uncertain highly suspicious for HCC male 71y yes(2) cirrhosis(1) dysplasia(1)

sex and age Number of lesions ROSE RFA final histology female 66y 1 benign no male 84y malignant yes colorectal metastases female 61y HCC+CCC male 76y 2 uncertain(2) no(2) liver cell dysplasia male 79y neuroendocrine carcinoma female 47y breast cancer metastases male 70y carcinoid male 50y benign(1) uncertain(1) no(1) yes(1) cirrhosis(2) male 63y uncertain highly suspicious for HCC male 71y yes(2) cirrhosis(1) dysplasia(1)

sex and age Number of lesions ROSE RFA final histology female 66y 1 benign no male 84y malignant yes colorectal metastases female 61y HCC+CCC male 76y 2 uncertain(2) no(2) liver cell dysplasia male 79y neuroendocrine carcinoma female 47y breast cancer metastases male 70y carcinoid male 50y benign(1) uncertain(1) no(1) yes(1) cirrhosis(2) male 63y uncertain highly suspicious for HCC male 71y yes(2) cirrhosis(1) dysplasia(1)

Interpretation of results All malignant (n=5) and all benign (n=2) diagnoses in ROSE revealed malignant diagnoses in final histology. There were 5 uncertain diagnoses. In 12 (92%) of 13 lesions ROSE helped radiologists in their decision 1 ROSE was wrong

Conclusions ROSE is the best way to improve our diagnoses and produce clinically relevant diagnoses. To distinguish morphologicallybetween low grade HCC and reactive liver tissue might be a challenge. This is particularly true in ROSE. In RFA ROSE may be a feasible and time saving alternative to optimize patient selection in fast growing liver tumours.

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