Preliminary experience with percutaneous cryotherapy of liver tumours

Survival outcomes and quality of life after percutaneous cryoablation for liver metastasis: A systematic review and meta-analysis

BACKGROUND

Liver metastasis is present in a wide range of malignancies, with colorectal cancer as the most common site. Several minimally invasive treatments have been suggested for managing hepatic metastases, and cryoablation is among them, yet not widely used. In this systematic review, we aimed to assess the effectiveness of percutaneous cryoablation in all types of liver metastases.

METHODS

A systematic search was performed in international databases, including PubMed, Scopus, Embase, and Web of Science, to find relevant studies reporting outcomes for percutaneous cryoablation in liver metastasis patients. In addition to baseline features such as mean age, gender, metastasis origin, and procedure details, procedure outcomes, including overall survival, local recurrence, quality of life (QoL), and complications, were extracted from the studies. Random-effect meta-analysis was performed to calculate the mean difference (MD) and 95% confidence interval for comparison of QoL.

RESULTS

We screened 2131 articles. Fifteen studies on 692 patients were included. Mean overall survival ranged from 14.5-29 months. The rate of local recurrence in the included studies ranged from 9.4% to 78%, and local control progression-free survival ranged from 1 to 31 months. The total QoL decreased one week after the cryoablation procedure (-3.08 [95% Confidence interval: -4.65, -1.50], p-value <0.01) but increased one month (5.69 [3.99, 7.39], p-value <0.01) and three months (3.75 [2.25, 5.24], p-value <0.01) after the procedure.

CONCLUSION

Cryoablation is an effective procedure for the treatment of liver metastases, especially in cases that are poor candidates for liver resection. It could significantly improve QoL with favorable local recurrence.

Transpleurodiaphragmatic cryosurgical ablation for recurrent unresectable colorectal liver metastases

BACKGROUND AND OBJECTIVES

Cryosurgical ablation (CSA) allows the focal destruction of unresectable liver metastases after previous liver resection. The abdominal approach may be difficult for recurrent colorectal cancer metastases located in the upper part of the remaining liver, close to the inferior vena cava (IVC), the hepatic veins, and the diaphragm. A transpleurodiaphragmatic access was assessed for safety and efficacy.

METHODS

Between September 1999 and July 2004, 13 patients with recurrent unresectable colorectal liver metastases underwent transpleurodiaphragmatic CSA via limited right thoracotomy. Seventeen lesions were treated; median diameter was 31 mm (range 13-40 mm). One to three cryoprobes were used, depending on the size and location of metastases.

RESULTS

There was no operative death; three patients developed minor complications (23%). Median hospital stay was 10 days (8-14 days). After a median follow-up of 26 months (range 8-69 months), 9 patients were alive, and 5 were disease-free. Six patients had liver recurrences outside the cryolesion. Median disease free survival was 12 months with 60% 3-year survival after CSA and 58% 5-year survival after first liver surgery.

CONCLUSIONS

Transpleurodiaphragmatic CSA is safe and effective in selected patients with unresectable recurrent liver metastases from colorectal cancer.

In-contiguity and non-anatomical extension of right hepatic trisectionectomy for liver metastases

Background

In some patients undergoing right hepatic trisectionectomy for metastases, extension of the resection beyond the falciform ligament is necessary to achieve tumour clearance. The aim of the present study was to assess the early and long-term outcomes and hepatic function in patients who underwent extensive liver resection beyond right trisectionectomy.

Methods

Thirty-eight patients who had extension of a right trisectionectomy, either in contiguity (IC) or in a non-anatomical (NA) fashion, for liver metastases were included in the study. In-hospital mortality, hepatic function and other morbidity were recorded. Survival outcomes were analysed for the subgroup of patients with colorectal liver metastases. The clinical risk score described by the Memorial Sloan–Kettering Cancer Center was applied to all patients with colorectal liver metastases.

Results

Sixteen patients had IC resection, 15 NA resection, and seven had both IC and NA procedures. There was one in-hospital death. Hepatic dysfunction was seen in 25 patients and two developed liver failure. Disease-free actuarial 3-year survival was 42 per cent for patients with colorectal liver metastases. Survival was significantly better in patients with a clinical risk score of 3 or less.

Conclusion

Extension of right trisectionectomy for liver metastases was associated with a low risk of death and hepatic failure.

Cryotherapy for liver tumors: current status, perspectives, clinical results, and review of literature

Cryotherapy has gained importance as a locally ablative treatment option for patients with non-resectable liver tumors, especially metastases from colorectal cancer. We have used this technique since 1996 for the treatment of 77 patients with malignant liver tumors. Patient data was prospectively recorded and follow-up was until September 2002 or death. Fifty-five patients had colorectal cancer liver metastases, 16 metastases from other primaries and 6 had hepatoma. Forty patients had cryotherapy only and 37 had an additional liver resection. Morbidity and mortality were 22% and 1.3%, respectively. In 68% of patients with colorectal liver metastases and an elevated serum carcinoembryonic antigen-level preoperatively, it returned to the normal range following cryosurgery. For all 77 patients, median survival was 28 months with a 3- and 5-year-survival rate of 39% and 26%, respectively, and median survival was 29 months with a 3- and 5-year-survival rate of 44% and 26%, respectively, for the 55 patients with colorectal liver metastases. Local recurrence at the cryosite was observed in 13 of 65 patients (20%) with initially complete treatment. For cryotherapy to further establish as a treatment for malignant liver tumors in a time where many new local ablative techniques are developing, different goals need to be achieved. The trauma of the procedure and local treatment failure need to be minimized and survival results need to be optimized. Published studies and new possible fields of research regarding these goals are discussed.

Three-dimensional assessment of MRI-guided percutaneous cryotherapy of liver metastases

OBJECTIVE

We report our initial investigation of the use of a 3D method for assessing percutaneous tumor ablations. We hypothesized that these 3D techniques could be used to assess the technical success of ablations and that 3D metrics would be predictive of treatment response.

CONCLUSION

Three-dimensional assessment of percutaneous tumor ablations provides a quantitative evaluation of the technical success of the procedure. Three-dimensional computer-based techniques can both quantify coverage of a tumor and create a virtual ablation margin for percutaneous procedures, akin to a surgical margin. Although results are preliminary, 3D metrics were useful in predicting treatment response.

Systematic reaction to electrolytic treatment of pig livers in vivo

BACKGROUND

Only a minority of secondary liver tumours are amenable to segmental resection and as a result, considerable research has been focused on developing ablative methods to destroy liver metastases. Many of these methods are limited by the development of a systemic inflammatory response mediated by cytokines such as interleukin-8 (IL-8) and tumour necrosis factor alpha (TNF-alpha). The aim of the present study was to determine if a systemic reaction occurred following electrolytic treatment of pig livers in vivo, by measuring biochemical indices of liver function and cytokines such as IL-8 and TNF-alpha.

METHODS

Seventeen white domestic pigs were subjected to varying electrolytic doses ranging from 100 C to 800 C. Blood samples were taken at hourly intervals before, during and after electrolysis. Blood parameters measured included markers of liver enzyme activity; albumin, alkaline phosphatase, gammaglutaryl transferase and aspartate transaminase. Cytokine response to electrolysis was measured using enzyme-linked immunosorbent assays for IL-8 and TNF-alpha.

RESULTS

Aspartate transaminase levels showed a clear and progressive rise post-electrolysis peaking at 2 h post-procedure. IL-8 and TNF-alpha levels showed only very mild variation with no significant response to electrolysis. This lack of association was borne out regardless of the electrolytic dose administered.

CONCLUSION

Electrolysis is not accompanied by a significant systemic inflammatory response, reducing the risk of systemic inflammatory response, acute respiratory distress syndrome and other immune response mediated end-organ damage. Follow-up studies are needed in human trials.

Needle-based ablation of renal parenchyma using microwave, cryoablation, impedance- and temperature-based monopolar and bipolar radiofrequency, and liquid and gel chemoablation: laboratory studies and review of the literature

BACKGROUND AND PURPOSE

Small renal tumors are often serendipitously detected during the screening of patients for renal or other disease entities. Rather than perform a radical or partial nephrectomy for these diminutive lesions, several centers have begun to explore a variety of ablative energy sources that could be applied directly via a percutaneously placed needle-like probe. To evaluate the utility of such treatment for small renal tumors/masses, we compared the feasibility, regularity (consistency in size and shape), and reproducibility of necrosis produced in normal porcine kidneys by different modes of tissue ablation: microwaves, cold impedance-based and temperature-based radiofrequency (RF) energy (monopolar and bipolar), and chemical. Chemoablation was accomplished using ethanol gel, hypertonic saline gel, and acetic acid gel either alone or with simultaneous application of monopolar or bipolar RF energy.

MATERIALS AND METHODS

A total of 107 renal lesions were created laparoscopically in 33 domestic pigs. Microwave thermoablation (N=12) was done using a Targis T3 (Urologix) 10F antenna. Cryoablation (N=16) was done using a single 1.5-mm probe or three 17F microprobes (17F SeedNet system; Galil Medical) (N=10 single probe and N=6 three probes); a double freeze cycle with a passive thaw was employed under ultrasound guidance. Dry RF lesions were created using custom-made 18-gauge single-needle monopolar probe with two or three exposed metal tips (GelTx) (N=12) or a single-needle bipolar probe (N=6) at 50 W of 510 kHz RF energy for 5 minutes. In addition, a multitine RF probe (RITA Medical Systems) was used in one set of studies (N=6). Both impedance- and temperature-based RF were evaluated. Chemoablation was performed with 95% ethanol (4 mL), 24% hypertonic saline (4 mL), and 50% acetic acid (4 mL) as single injections. In addition, chemoablation was tested with monopolar and bipolar RF (wet RF). Tissues were harvested 1 week after ablation for light microscopy.

RESULTS

In 11 of the 15 ablation techniques, there was complete necrosis in all lesions; however, three ethanol gel lesions had skip areas, three hypertonic saline gel lesions showed no necrosis or injury, and one monopolar RF and one bipolar RF lesion showed skip areas. In contrast to impedance-based RF, heat-based RF (RITA) caused complete necrosis without skip areas. All cryolesions resulted in complete tissue necrosis, and cryotherapy was the only modality for which lesion size could be effectively monitored using ultrasound imaging.

CONCLUSIONS

Cryoablation and thermotherapy produce well-delineated, completely necrotic renal lesions. The single-probe monopolar and bipolar RF produce limited areas of tissue necrosis; however, both are enhanced by using hypertonic saline, acetic acid, or ethanol gel. Hypertonic saline gel with RF consistently provided the largest lesions. Ethanol and hypertonic saline gels tested alone failed to produce consistent cellular necrosis at 1 week. In contrast, RITA using the Starburst XL probe produced consistent necrosis, while impedance-based RF left skip areas of viable tissue. Renal cryotherapy under ultrasound surveillance produced hypoechoic lesions, which could be reasonably monitored, while all other modalities yielded hyperechoic lesions the margins of which could not be properly monitored with ultrasound imaging.

The emergent role of focal liver ablation techniques in the treatment of primary and secondary liver tumours

Only 20% of patients with primary or secondary liver tumours are suitable for resection because of extrahepatic disease or the anatomical distribution of their disease. These patients could be treated by ablation of the tumour, thus preserving functioning liver. This study presents a detailed review of established and experimental ablation procedures. The relative merits of each technique will be discussed and clinical data regarding the efficacy of the techniques evaluated. A literature search from 1966 to 2003 was undertaken using Medline, Pubmed and Web of Science databases. Keywords were Hepatocellular carcinoma, liver metastases, percutaneous ethanol injection, cryotherapy, microwave coagulation therapy, radiofrequency ablation, interstitial laser photocoagulation, focused high-intensity ultrasound, hot saline injection, electrolysis and acetic acid injection. Ablative techniques offer a promising therapeutic modality to treat unresectable tumours. Large-scale randomised controlled trials are required before widespread acceptance of these techniques can occur.

Interstitial ablative techniques for hepatic tumours

BACKGROUND

Most patients with liver tumours are not suitable for surgery but interstitial ablative techniques may control disease progression and improve survival rates.

METHODS

A review was undertaken using Medline of all reported studies of cryoablation, radiofrequency ablation, microwave ablation, interstitial laser photocoagulation, high-intensity focused ultrasound and ethanol ablation of primary liver tumours and hepatic metastases.

RESULTS

Although there are no randomized clinical trials, cryoablation, thermal ablation and ethanol ablation have all been shown to be associated with improved palliation in patients with primary and secondary liver cancer. The techniques can be undertaken safely with minimal morbidity and mortality.

CONCLUSION

Although surgical resection remains the first line of treatment for selected patients with primary and secondary liver malignancies, interstitial ablative techniques are promising therapies for patients not suitable for hepatic resection or as an adjunct to liver surgery.

Cryotherapy in the treatment of liver metastases from colorectal cancer

Although hepatic resection remains the treatment of choice for metastatic disease to the liver from colorectal cancer, the procedure is only possible for approximately 10% of patients. Ninety percent of patients with liver metastases ultimately die of liver failure. Thus, attention has turned to other, locoregional techniques that may be used alone or in conjunction with resection to increase the eligibility for some type of surgical, potentially curative treatment. One such option is cryotherapy. This review provides technical, physiologic, and outcome information regarding this technique. Semin Oncol 29:183-191.

Phase I study of percutaneous cryotherapy for colorectal liver metastasis

BACKGROUND

The aim was to determine the safety and feasibility of percutaneous cryotherapy for treating irresectable colorectal liver metastases.

METHODS

Liquid nitrogen cryoprobes were inserted percutaneously into metastases using the Seldinger technique under computed tomographic guidance. Single-probe treatments were performed with either 3.6- or 6.3-mm cryoprobes (ice-ball volumes 18 and 59 cm3 respectively), or dual-probe treatments with two adjacent 6.3-mm probes (ice-ball volume 205 cm3). Treatment involved a single freeze--thaw cycle.

RESULTS

Fifteen patients received 25 single-probe treatments and seven patients received 14 dual-probe treatments. The treatment-related mortality rate was zero and complications occurred after six of 39 treatments. Liver metastasis growth was significantly delayed for 2 months after dual-probe but not single-probe treatment. Metastasis cryotherapy stimulated an immediate rise, followed by a fall, in serum carcinoembryonic antigen (CEA) level, associated with immune upregulation that was significantly greater after dual-probe treatments.

CONCLUSION

Ablation zones that were approximately four times larger than those produced by previously described percutaneous techniques delayed the growth of metastases, reduced serum CEA concentration, and induced detectable inflammatory and T-lymphocyte responses. Percutaneous cryotherapy for treatment of colorectal liver metastases is feasible and may have a place in conjunction with chemotherapy.

Electrolysis and other local ablative treatments for non-resectable colorectal liver metastases

The present paper is a review of the current ablative treatment options for the treatment of colorectal liver metastases. Cryotherapy, microwave coagulation therapy, radiofrequency ablation and laser-induced thermotherapy are discussed. Electrolysis, a novel non-thermal ablative treatment, is described. Potential benefits of electrolysis include the apparent ability to safely and effectively treat lesions abutting major hepatic structures and the lack of a systemic inflammatory reaction following electrolytic ablation. Further studies in animals and humans are needed to confirm this potential and to further refine the methods of electrolytic treatment of colorectal liver metastases.

[Cryosurgery of primary and metastatic cancers of the liver]

Cryosurgery is a method of in situ destruction of tissue by a freezing process. Results of hepatic cryosurgery are now available for more than 2100 patients and allow to assess its place in the treatment of hepatic malignancies. Mechanisms of tissue destruction and indications of cryosurgery are detailed. With a peri-operative mortality rate of 1.5%, the safety of hepatic cryosurgery is now admitted. Cryosurgery has its own morbidity: increase of transaminases levels, platelets drop, myoglobinuria and rarely renal failure or cryoshock. In selected patients, hepatic cryosurgery is feasible with a laparoscopic or percutaneous approach. Long term results do not support cryosurgery as an alternative to liver resection. This technique enlarges possibilities of surgical treatment for patients with primary and metastatic liver cancers.

Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches

Only 10% to 20% of patients with primary and colorectal metastatic liver tumors are candidates for curative surgical resection. Even after curative treatment, tumors recur commonly in the liver. As a less invasive therapy, radiofrequency thermal ablation (RFA) of primary, metastatic, and recurrent liver tumors was performed under percutaneous, laparoscopic, or open intraoperative ultrasound guidance. The safety and local control efficacy of RFA were investigated. RFA was performed mostly in patients with unresectable hepatomas or metastatic liver tumors. Patients with large tumors, major vessel or bile duct invasion, limited extrahepatic metastases, or liver dysfunction were not excluded. An RFA system with a 15-gauge electrode-cannula with four-pronged retractable needles was used. All patients were followed for more than 8 months to assess morbidity and mortality, and to determine tumor recurrence. Sixty RFA operations were performed in 46 patients: 11 patients underwent repeat RFA once or twice. A total of 204 tumors were treated: 70 hepatomas and 134 metastatic tumors. Tumor size ranged from 5 mm to 180 mm (mean 36 mm). RFA was performed in 29 operations for 81 tumors percutaneously, in seven operations for 14 tumors laparoscopically, and in 24 operations for 109 tumors by open surgery. Combined colorectal resection was carried out in five operations and combined hepatic resection was carried out in three operations. There was one death (1.7%) from liver failure, and there were three major complications (5%): one case of bile leakage and two biliary strictures due to thermal injury. There were no intra-abdominal infectious or bleeding complications. The length of hospital stay ranged from 0 to 2, 1 to 3, and 4 to 7 days for percutaneous, laparoscopic, and open surgical RFA, respectively. During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.

Liver tumors and minimally invasive surgery: a feasibility study

Laparoscopic liver resection has not yet been established, although recent reports document that liver resection can be performed safely by the laparoscopic approach. Other interventional procedures like cryoablation have also been introduced in treatment of liver metastases. In this report 11 liver resections performed laparoscopically in eight patients are presented. Six patients had colorectal metastases, one a metastases from a malignant melanoma, and one patient had focal nodular hyperplasia. Two patients received synchronous cryoablation of remaining liver metastases. During follow up, two patients received percutaneous cryoablation of liver recurrences monitored by an open configuration magnetic resonance scanner. All except one of the tumors we attempted to remove had free resection margins (re-resection of new metastasis). No complications occurred except an atelectasis of the left lower pulmonary lobe in one patient. Median postoperative hospital stay was 3 days, and median postoperative opioid-dependent days was 1. The report demonstrates that minimally invasive techniques may safely be combined in hepatic intervention, and that the advantages of minimally invasive surgery, such as reduced hospital stay and less patient discomfort, also applies to liver resections.

MR imaging-guided percutaneous cryotherapy of liver tumors: initial experience

PURPOSE

To describe the cryoablation of liver tumors by using a percutaneous approach and intraprocedural magnetic resonance (MR) imaging monitoring and to assess the feasibility and safety of the procedure.

MATERIALS AND METHODS

Fifteen hepatic tumors (mean diameter, 2.9 cm) in 12 patients were treated (18 total cryoablations). Fourteen were metastases and one was a hemangioma; all were proved at biopsy. By using a 0.5-T open MR imaging system, cryoneedles were placed and lesions ablated by using real-time monitoring. Clinical signs and symptoms were assessed and laboratory tests performed. Intraprocedural depictions of iceballs were compared with contrast material-enhanced MR imaging-based estimates of cryonecrosis that were obtained 24 hours after cryoablation.

RESULTS

MR imaging-guided percutaneous cryotherapy resulted in no serious complications and no clinically important changes in serum liver enzymes or creatinine or myoglobin levels. Intraprocedural MR imaging demonstrated iceballs as sharply marginated regions of signal loss that expanded and engulfed tumors. The maximal iceball size was 4.9 x 2.2 x 2.2 cm with the use of one cryoneedle and 6.0 x 5.6 x 4.9 cm with three cryoneedles. Intraprocedural iceball depictions correlated well with postprocedural cryonecrosis estimates.

CONCLUSION

MR imaging-guided percutaneous cryotherapy of liver tumors is feasible and safe. MR imaging can be used to estimate cryotherapy effects and guide therapy intraprocedurally.

Extension of the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer: long-term results

OBJECTIVE

To evaluate retrospectively the long-term results of an approach consisting of performing surgery in every patient in whom radical removal of all metastatic disease was technically feasible.

SUMMARY BACKGROUND DATA

The indications for surgical resection for liver metastases from colorectal cancer remain controversial. Several clinical risk factors have been reported to influence survival.

METHODS

Between March 1980 and December 1997, 235 patients underwent hepatic resection for metastatic colorectal cancer. Survival rates and disease-free survival as a function of clinical and pathologic determinants were examined retrospectively with univariate and multivariate analyses.

RESULTS

The overall 3-, 5-, 10-, and 15-year survival rates were 51%, 38%, 26%, and 24%, respectively. The stage of the primary tumor, lymph node metastasis, and multiple nodules were significantly associated with a poor prognosis in both univariate and multivariate analyses. Disease-free survival was significantly influenced by lymph node metastasis, a short interval between treatment of the primary and metastatic tumors, and a high preoperative level of carcinoembryonic antigen. The 10-year survival rate of patients with four or more nodules (29%) was better than that of patients with two or three nodules (16%), and similar to that of patients with a solitary lesion (32%).

CONCLUSIONS

Surgical resection is useful for treating liver metastases from colorectal cancer. Although multiple metastases significantly impaired the prognosis, the life expectancy of patients with four or more nodules mandates removal.

Epi-illumination fluorescent light microscopy for the in vivo study of rat hepatic microvascular response to cryothermia

To elucidate the hepatic microvascular response to cryothermia, we studied the liver microcirculation of Sprague-Dawley rats after one and two 4-minute freeze-thaw cycles using intravital fluorescence microscopy. Irrespective of the number of freeze-thaw cycles applied, the nature of hepatic microvascular injury was characterized by complete stasis of sinusoidal blood flow within the central part of the cryolesions and heterogeneous sinusoidal perfusion in a critically perfused border zone located at the periphery of the lesions. Analysis over time (2 hours) revealed a successive shutdown of sinusoidal perfusion within this critically perfused border zone, which was caused by intravascularly lodging cell aggregates, blocking the lumen of individual sinusoids. The aggregates consisted of parenchymal cells and cell fragments, but did not include leukocytes or platelets. Strikingly, microvascular perfusion failure was associated with Ito cell disintegration and marked dilation of sinusoids (15.6 +/- 0.8 microm vs. 8.8 +/- 0.8 microm; P <.05). This excludes sinusoidal constriction as the cause of nutritive perfusion failure, and may indicate dysfunction of Ito cell-regulated vasomotor control by cryothermia. However, because circulating cell aggregates were frequently observed plugging individual microvessels, dilation of sinusoids may just be the result of passive distension caused by outflow blockade. Analysis of hepatic tissue at 8 weeks after cryothermia did not reveal regeneration and microvascular remodeling, but loss of hepatic tissue, which corresponded well with the tissue area presenting with sinusoidal perfusion failure during the initial observation period after cryothermia. The fact that there was no recovery of sinusoidal perfusion over the initial 2-hour observation period, but loss of tissue after 8 weeks, supports the view that cryothermia induces injury not only by direct low-temperature-mediated action, but also through ischemia caused by irreversible deterioration of the microcirculation.