Evolving techniques in the treatment of liver colorectal metastases: role of laparoscopy, radiofrequency ablation, microwave coagulation, hepatic arterial chemotherapy, indications and contraindications for resection, role of transplantation, and timing of chemotherapy

Cryotherapy for liver metastases

BACKGROUND

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma. Liver metastases are significantly more common than primary liver cancer and long-term survival rates reported for patients after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of patients. Cryotherapy is performed with the use of an image-guided cryoprobe which delivers liquid nitrogen or argon gas to the tumour tissue. The subsequent process of freezing is associated with formation of ice crystals, which directly damage exposed tissue, including cancer cells.

OBJECTIVES

To assess the beneficial and harmful effects of cryotherapy compared with no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, and six other databases up to June 2018.

SELECTION CRITERIA

Randomised clinical trials assessing beneficial and harmful effects of cryotherapy and its comparators for liver metastases, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We extracted information on participant characteristics, interventions, study outcomes, and data on the outcomes important for our review, as well as information on the design and methodology of the trials. Two review authors independently assessed risk of bias in each study. One review author performed data extraction and a second review author checked entries.

MAIN RESULTS

We found no randomised clinical trials comparing cryotherapy versus no intervention or versus systemic treatments; however, we identified one randomised clinical trial comparing cryotherapy with conventional surgery. The trial was conducted in Ukraine. The trial included 123 participants with solitary, or multiple unilobar or bilobar liver metastases; 63 participants received cryotherapy and 60 received conventional surgery. There were 36 women and 87 men. The primary sites for the metastases were colon and rectum (66.6%), stomach (7.3%), breast (6.5%), skin (4.9%), ovaries (4.1%), uterus (3.3%), kidney (3.3%), intestines (1.6%), pancreas (1.6%), and unknown (0.8%). The trial was not reported sufficiently enough to assess the risk of bias of the randomisation process, allocation concealment, or presence of blinding. It was also not possible to assess incomplete outcome data and selective outcome reporting bias. The certainty of evidence was low because of risk of bias and imprecision.The participants were followed for up to 10 years (minimum five months). The trial reported that the mortality at 10 years was 81% (51/63) in the cryotherapy group and 92% (55/60) in the conventional surgery group. The calculated by us relative risk (RR) with 95% Confidence Interval (CI) was: RR 0.88, 95% CI 0.77 to 1.02. We judged the evidence as low-certainty evidence. Regarding adverse events and complications, separately and in total, our calculation showed no evidence of a difference in recurrence of the malignancy in the liver: 86% (54/63) of the participants in the cryotherapy group and 95% (57/60) of the participants in the conventional surgery group developed a new malignancy (RR 0.90, 95% CI 0.80 to 1.01; low-certainty evidence). The frequency of reported complications was similar between the cryotherapy group and the conventional surgery group, except for postoperative pain. Both insignificant and pronounced pain were reported to be more common in the cryotherapy group while intense pain was reported to be more common in the conventional surgery group. However, the authors did not report whether there was any evidence of a difference. There were no intervention-related mortality or bile leakages.We identified no evidence for health-related quality of life, cancer mortality, or time to progression of liver metastases. The study reported tumour response in terms of the carcinoembryonic antigen level in 69% of participants, and reported results in the form of a graph for 30% of participants. The carcinoembryonic antigen level was lower in the cryotherapy group, and decreased to normal values faster in comparison with the control group (P < 0.05).

FUNDING

the trial did not provide information on funding.

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of cryotherapy versus conventional surgery in people with liver metastases is of low certainty. We are uncertain about our estimate and cannot determine whether cryotherapy compared with conventional surgery is beneficial or harmful. We found no evidence for the benefits or harms of cryotherapy compared with no intervention, or versus systemic treatments.

Laparoscopic liver resection: Current role and limitations

Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.

Quality of life following liver transplantation in patients with liver metastases from colorectal carcinoma

PURPOSE

To study quality of life (QoL) in patients with liver metastases from colorectal carcinoma (CRC) following liver transplantation (Ltx).

METHODS

Ten patients participated in a prospective explorative pilot study. Inclusion criteria were nonresectable liver-only metastases determined by CT/MRI-, PET/CT- scans and colonoscopy, and ECOG 0-1. Primary outcome was QoL assessed by the EORTC-C30 questionnaires at baseline, and at 3, 6 and 12 months after Ltx.

RESULTS

The patients' age ranged from 50 to 63 years. Nine of 10 patients were observed for 12 months. One patient did not return the form at 6 months and died shortly after because of recurrence of the malignant disease. Compared to baseline, Ltx resulted in sustained excellent global health status scale (score of 100) in one patient, improved scores in 4 and unchanged scores in 3 patients at 12 months. The majority of the patients also reported good functional scores at follow-ups. Although two patients had marked symptoms both before and after Ltx, the patients in general reported low levels of pain and fatigue before and after surgery.

CONCLUSION

The present study indicates that CRC patients with liver-only metastases who receive Ltx have good QoL and have mostly minor symptoms the first year after Ltx.

Therapeutic effect of microwave ablation combined with injection of 5-fluorouracil in mice bearing CT26 colon carcinoma xenografts

AIM: To evaluate the therapeutic effect of microwave ablation (MA) combined with injection of 5-fluorouracil (5-FU) in mice bearing CT26 colon carcinoma xenografts.

METHODS: Balb/c mice were subcutaneously inoculated with CT26 cells to establish a xenograft mouse model of colon carcinoma. Model mice were divided into four groups: PBS group, MA group, 5-FU group, and MA plus 5-FU group. After treatment, the changes in tumor volume were measured; tumor recurrence, mouse survival and living status were observed; and peripheral serum levels of TNF-α, IL-2, IL-12 and IFN-γ were determined by ELISA.

RESULTS: The life span of mice treated by MA, 5-FU injection, MA plus 5-FU was significantly longer than that of mice treated with PBS (47 d ± 1.7 d, 36 d ± 2.1 d, 56 d ± 2.5 d vs 33 d ± 1.4 d, all P < 0.05). Tumor size significantly decreased in the MA plus 5-FU group compared to the other three groups (all P < 0.05). Peripheral serum levels of TNF-α, IL-2, IL-12, and IFN-γ in the combination therapy group were significantly higher than those in the other three groups (180.3 ± 35.9 vs 62.8 ± 12.7, 96.3 ± 25.1, 136.9 ± 49.4; 72.5 ± 6.8 vs 20.6 ± 7.3, 27.9 ± 10.5, 46.4 ± 9.3; 302.3 ± 69.6 vs 123.4 ± 13.1, 153.8 ± 35.4, 278.9 ± 57.0; 68.4 ± 8.2 vs 29.9 ± 4.3, 36.8 ± 4.6, 59.1 ± 9.0; all P < 0.01).

CONCLUSION: MA combined with 5-FU injection can improve anti-tumor effect by strengthening immunological function and reducing local recurrences as compared to that of either treatment alone.

Making Liver Transection Even Safer: A Novel Use of Microwave Technology

Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment Vresections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.

Radiofrequency ablation of liver tumors: Actual limitations and potential solutions in the future

Over the past decade, radiofrequency ablation (RFA) has evolved into an important therapeutical tool for the treatment of non resectable primary and secondary liver tumors. The clinical benefit of RFA is represented in several clinical studies. They underline the safety and feasibility of this new and modern concept in treating liver tumors. RFA has proven its clinical impact not only in hepatocellular carcinoma (HCC) but also in metastatic disease such as colorectal cancer (CRC). Due to the increasing number of HCC and CRC, RFA might play an even more important role in the future. Therefore, the refinement of RFA technology is as important as the evaluation of data of prospective randomized trials that will help define guidelines for good clinical practice in RFA application in the future. The combination of hepatic resection and RFA extends the feasibility of open surgical procedures in patients with extensive tumors. Adverse effects of RFA such as biliary tract damage, liver failure and local recurrence remain an important task today but overall the long term results of RFA application in treating liver tumors are promising. Incomplete ablation of liver tumors due to insufficient technology of ablation needles, tissue cooling by the neighbouring blood vessels, large tumor masses and ablation of tumors in close vicinity to heat sensitive organs remain difficult tasks for RFA. Future solutions to overcome these limitations of RFA will include refinement of ultrasonographic guidance (accuracy of probe placement), improvements in needle technology (e.g. needles preventing charring) and intraductal cooling techniques.

Update and review of the multidisciplinary management of stage IV colorectal cancer with liver metastases

Background

The management of stage IV colorectal cancer with liver metastases has historically involved a multidisciplinary approach. In the last several decades, there have been great strides made in the therapeutic options available to treat these patients with advancements in medical, surgical, locoregional and adjunctive therapies available to patients with colorectal liver metastases(CLM). As a result, there have been improvements in patient care and survival. Naturally, the management of CLM has become increasingly complex in coordinating the various aspects of care in order to optimize patient outcomes.

Review

A review of historical and up to date literature was undertaken utilizing Medline/PubMed to examine relevant topics of interest in patients with CLM including criterion for resectability, technical/surgical considerations, chemotherapy, adjunctive and locoregional therapies. This review explores the various disciplines and modalities to provide current perspectives on the various options of care for patients with CLM.

Conclusion

Improvements in modern day chemotherapy as allowed clinicians to pursue a more aggressive surgical approach in the management of stage IV colorectal cancer with CLM. Additionally, locoregional and adjunctive therapies has expanded the armamentarium of treatment options available. As a result, the management of patients with CLM requires a comprehensive, multidisciplinary approach utilizing various modalities and a more aggressive approach may now be pursued in patients with stage IV colorectal cancer with CLM to achieve optimal outcomes.

Resection of colorectal liver metastases: is a resection margin of 3 mm enough? : a multicenter analysis of the GAST Study Group

BACKGROUND

A safety margin of > or =10 mm is generally accepted in surgery for colorectal metastases. It is reasonable that modern methods of liver parenchyma dissection may allow for a reduction in this distance.

METHODS

A total of 333 patients were included in a multicenter trial after resection of colorectal liver metastases. Dissection of the liver had been performed with a CUSA, UltraCision, or water-jet dissector. The size of the resection margin was correlated with recurrence risk and survival.

RESULTS

The median hepatic recurrence-free survival reached 35 months for all patients; median recurrence-free survival was 24 months and overall survival was 41 months. Univariate analysis of different groups denoting the extent of resection margin (> or =10 mm, 6-9 mm, 3-5 mm, 1-2 mm, 0 mm (R1)) indicated that a margin of 1-2 mm leads to a significantly reduced median hepatic recurrence-free survival of 20 months (p = 0.004) and recurrence-free survival of 19 months (p = 0.011). Patients with R1 resection had the worst prognosis. Overall survival was not influenced by the size of the resection margin. Surgical margins were significantly reduced in simultaneous resections of four or more liver metastases and in cases in which metastatic infiltration of central liver segments was present. At multivariate analysis, resection margins of 1-2 mm and 0 mm were independent predictors of hepatic recurrence and overall recurrence.

CONCLUSION

The indication for resection of metastases can be safely extended to cases in which tumors sit closer than 1 cm to nonresectable structures.

Herpes simplex virus NV1020 as a novel and promising therapy for hepatic malignancy

BACKGROUND

Patients with hepatic malignancy have a dismal prognosis with standard therapies. NV1020 is an oncolytic herpes simplex virus that has potential to be a safe and effective therapeutic agent for this disease.

OBJECTIVE

We set out to discuss the development of NV1020 as an oncolytic agent and explore the potential role of this particular virus in the setting of human hepatic cancer.

METHODS

The scope of this review includes an overview of preclinical experience with NV1020, as well as an examination of current standard and developing therapies for liver cancer. The primary focus, however, is on the safety and potential clinical efficacy of NV1020 against hepatic malignancy.

RESULTS/CONCLUSION

We have found that NV1020 is a safe, novel therapeutic agent for treatment of refractory hepatic malignancy.

Thermal ablation of hepatic malignancy: useful but still not optimal

The mortality associated with primary and metastatic hepatic malignancies remains high because few patients are candidates for hepatic resection or transplantation. Resection is the most effective treatment for liver tumors but may be contraindicated by factors such as the tumor's location; hepatic transplantation can cure primary hepatocellular carcinoma and underlying cirrhosis, but a donor may not be immediately available. When resection or transplantation is not possible, thermal ablation is a reasonable therapeutic option. Effective destruction of tumors can be achieved with low recurrence rates and minimal complications or risk of death. In patients with primary hepatic malignancy, ablation treatment does not preclude subsequent transplantation. Although radiofrequency ablation is currently the most widely used thermal ablative technique for hepatic malignancy, microwave ablation is gaining popularity and eventually may prove to be more effective.

Radiofrequency ablation of colorectal liver metastases

RFA of liver metastases is promising despite variable results. The differences in reported success rates may be explained by the difference in tumour types/vascularity/aggressiveness, patient selection, operator's expertise and the equipment used. Current limits relate to the small volume of consistent ablation that can be achieved with current equipment. Further technical refinements yielding more reliable ablation with larger surgical margin may reduce local recurrence rate. Although numerous studies have shown effective treatment responses after RFA, the precise impact of RFA on survival of colorectal cancer patients with liver metastases remains unclear. Resection remains the gold standard for patients with liver metastases. In patients with limited number of unresectable lesions and in cases, which are unresectable on the basis of lesional number and localization, RFA is an attractive approach to obtain tumour clearance. Randomised control trials evaluating the value of combined adjuvant systemic chemotherapy are still urgently needed.

Morbidity and mortality of laparoscopic vs. open radiofrequency ablation for hepatic malignancies

AIMS

Surgical radiofrequency ablation (RFA) of hepatic malignancies is associated with superior oncological outcome as compared to percutaneous RFA. The aim of this prospective non-randomized cohort study was to compare morbidity and mortality of laparoscopic (LRFA) vs. open (ORFA) radiofrequency ablation of liver cancer.

METHODS

Between October 1999 and November 2006, RFA was performed in 154 consecutive patients (percutaneous 12, LRFA 93, ORFA 49) for a total of 291 hepatic tumours (HCC 81, colorectal metastases 157, other 53). Seventy-four patients simultaneously underwent additional surgery. Laparoscopic RFA was performed in 45/54 patients with HCC, and in 44/54 patients with cirrhosis. Laparotomy was performed in 14/22 patients who underwent simultaneous colorectal resection, and in 12/22 patients with hepatic resection.

RESULTS

Postoperative complications occurred in 25 patients with subsequent mortality in 2. As compared with LRFA, ORFA was associated with significantly (p<0.01) higher intra-operative blood loss (median 20 (range 0-1700) vs. 10 (0-900) ml), longer duration of surgery (180 (25-440) vs. 75 (30-390) min), more postoperative complications (17 vs. 8), and longer postoperative hospital stay (8 (1-127) vs. 4 (1-51) d). According to the therapy-oriented severity grading system (TOSGS) classification, postoperative complications in the ORFA-group were more severe than those in the LRFA-group (p<0.01). These findings were consistent in patients without simultaneous colorectal and/or hepatic resection and in patients with liver tumours measuring 3cm or less. In univariate analysis the following factors were significantly (p<0.01) related to the presence of postoperative complications: simultaneous colorectal resection, laparotomy, duration of surgery, tumour location in right liver, liver segment 7 (p=0.01), absence of cirrhosis (p=0.02), liver segment 8 (p=0.03), and metastatic liver cancer (p=0.04).

CONCLUSION

LRFA for hepatic malignancies seems preferable above ORFA, provided good patient selection, surgical expertise, and long-term oncological control.

Microwave ablation in a hepatic porcine model: correlation of CT and histopathologic findings

BACKGROUND

Thermal ablative techniques have gained increasing popularity in recent years as safe and effective options for patients with unresectable solid malignancies. Microwave ablation has emerged as a relatively new technique with the promise of larger and faster burns without some of the limitations of radiofrequency ablation (RFA). Here we study a new microwave ablation device in a living porcine model using gross, histologic, and radiographic analysis.

MATERIALS AND METHODS

The size and shape of ablated lesions were assessed using six pigs in a non-survival study. Liver tissue was ablated using 2, 4, and 8 min burns, in both peripheral and central locations, with and without vascular inflow occlusion. To characterize the post-ablation appearance, three additional pigs underwent several 4 min ablations each followed by serial computed tomography (CT) imaging at 7, 14, and 28 days postoperatively.

RESULTS

The 2 and 4 min ablations resulted in lesions that were similar in size, 33.5 cm(3) and 37.5 cm(3), respectively. Ablations lasting 8 min produced lesions that were significantly larger, 92.0 cm(3) on average. Proximity to hepatic vasculature and inflow occlusion did not significantly change lesion size or shape. In follow-up studies, CT imaging showed a gradual reduction in lesion volume over 28 days to 25-50% of the original volume.

DISCUSSION

Microwave ablation with a novel device results in consistently sized and shaped lesions. Importantly, we did not observe any significant heat-sink effect using this device, a major difference from RFA techniques. This system offers a viable alternative for creating fast, large ablation volumes for treatment in liver cancer.