Prognostic factors after cryotherapy for hepatic metastases from colorectal cancer

Prognostic Factors of Radiofrequency Ablation plus Systemic Chemotherapy for Unresectable Colorectal Cancer with Liver Metastasis

INTRODUCTION

Survival outcomes in patients with unresectable colorectal cancer (CRC) liver metastasis treated by radiofrequency ablation (RFA) combined with systemic chemotherapy and correlation with potential prognostic factors were investigated. Material and Methods. A retrospective cohort study was conducted on 61 CRC patients with unresectable liver metastasis who underwent liver tumor-directed percutaneous RFA combined with conventional systemic chemotherapy between October 2013 and September 2018. Survival analyses were conducted using the Kaplan-Meier method, and the log-rank test was used to characterize differences in the median survival time and the 1-year, 3-year, and 5-year overall survival rates of subgroups to identify prognostic factors.

RESULTS

Median overall survival and progression-free survival of all patients were 32 and 14 months, respectively. The cumulative survival rates at 1-, 3-, and 5-years were 93.2%; 44.5%, and 38.2%, respectively. Univariate analysis revealed that pre-RFA serum CEA levels, Eastern Cooperative Oncology Group (ECOG) status, number of liver lesions, the size of the largest lesion, and the total lesion size were prognostic factors. However, multivariate analysis demonstrated that only the number of liver lesions and the size of the largest lesion were independent prognostic factors for survival.

CONCLUSION

RFA plus systemic chemotherapy provides an encouraging survival outcome for patients with unresectable CRC liver metastasis. Multivariate analysis demonstrated that the number and size of liver metastatic lesions are independent prognostic factors for survival.

Cryosurgery for Tumors — A Clinical Overview

Cryosurgery, a method of treating disease by the production of freezing temperatures in the tissue, is a useful technique for the treatment of tumors. When the modern era of cryosurgery began in the mid 1960's, the technique was used only for tumors easily accessible by direct observation or via endoscopy, such as those of the skin, oral cavity, and prostate gland. In general, the technique had limited usefulness in the next two decades. However, with the advent of intraoperative ultrasound as a method of monitoring the process of freezing and with the development of more effective cryosurgical apparatus, the cryosurgical treatment of tumors of the viscera and other deep tissues became practical in the 1990's. This review assesses the present day status of cryosurgery in the management of diverse tumors.

Cryoablation Versus Radiofrequency Ablation for Hepatic Malignancies: A Systematic Review and Literature-Based Analysis

The aim of this study is to summarize and quantify the current evidence on the therapeutic efficacy of cryoablation compared with radiofrequency ablation (RFA) in patients with hepatic malignancies in a meta-analysis.Data were collected by searching PubMed, Scopus, and Cochrane databases for reports published up to May 26, 2015. Studies that reported data on comparisons of therapeutic efficacy of cryoablation and RFA were included. The random effects model was used to estimate the pooled relative risks of events comparing cryoablation to RFA for therapy of hepatic malignancies.Seven articles met the inclusion criteria and were included in the meta-analysis. The meta-analysis showed that there was no statistically significant difference in mortality of at least 6 months (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.68-1.49) and local tumor progression according to both patients (OR = 1.64, 95% CI: 0.57-4.74) and tumors (OR = 1.81, 95% CI: 0.74-4.38) between cryoablation group and RFA group. However, the risk of complications was significantly higher in the cryoablation group than that in the RFA group (OR = 2.93, 95% CI: 1.15-7.46). When considering the specific complications, only thrombocytopenia (OR = 51.13, 95% CI: 2.92-894.21) and renal impairment (OR = 4.19, 95% CI: 1.34-13.11) but not other complications were significantly higher in the cryoablation group.In conclusion, the 2 methods had almost equal mortality and nonsignificant difference in local tumor progression, with higher risk of complications in cryoablation. Further large-scale, well-designed randomized controlled trials are needed to identify the current findings and investigate the long-term effects of cryoablation compared with RFA for therapy of hepatic malignancies.

Non-operative therapies for colorectal liver metastases

Locoregional therapies for colorectal liver metastases complement systemic therapy by providing an opportunity for local control of hepatic spread. The armamentarium for liver-directed therapy includes ablative therapies, embolization, and stereotactic body radiation therapy. At this time, prospective studies comparing these modalities are limited and decision-making relies on a multidisciplinary approach for optimal patient management. Herein, we describe multiple therapeutic non-surgical procedures and an overview of the results of these treatments.

Diagnosis and treatment of coagulopathy following percutaneous cryoablation of liver tumors: experience in 372 patients

Coagulopathy after liver cryoablation was first reported many years ago; the cause is local platelet trapping and destruction within the margin of the cryolesion. However, the prognosis and therapeutic effects of coagulopathy remain unclear. This study retrospectively reviewed clinical data from 372 patients (525 sessions) who underwent liver cryoablation in our hospital during the past 4.5 years. Small tumors (major diameter < 6 cm) were treated with a single complete ablation; massive tumors (major diameter 6-10 cm or >10 cm) were divided into two or three parts that were dealt with in turn. Platelet counts decreased to an average of (46.12 ± 68.13) × 10(9)/L after each session of cryoablation. The decline was most evident in patients with high pretreatment platelet counts, while those with low pretreatment counts had the highest risk of coagulopathy. Change in platelet count was not correlated with the diameter of the tumor. Slight coagulopathy (platelet count (70-100) × 10(9)/L) can resolve without treatment within 1 week and administration of recombinant human interleukin-11 can assist recovery from severe coagulopathy (platelet count < 70 × 10(9)/L).

High-intensity focused ultrasound provides palliation for liver metastasis causing gastric outlet obstruction: case report

Background

Surgery is the standard of care in several oncologic diseases. However, when non-surgical candidates are not suitable for radical treatment, palliation must be achieved at least. High-intensity focused ultrasound uses ultrasound power that can be sharply focused for highly localised application, as it is a completely non-invasive procedure. Its non-invasiveness appears to be of paramount importance in critically ill patients.

Case description

We describe the use of ultrasound-guided high-intensity focused ultrasound for a large liver metastasis from breast cancer causing gastric outlet obstruction in a metastatic disease. The left liver deposit did not allow the stomach to empty due to its large volume, and the patient was unable to eat properly. The tumour was metastatic, resistant to chemotherapy and had a size that contraindicated an ablation percutaneous technique. To improve the patient's quality of life, ultrasound-guided high-intensity focused ultrasound ablation seemed the only and most suitable option. Therefore, a high-intensity focused ultrasound treatment was performed, no complications occurred and the patient's general condition has improved since the early post-procedural period. Three months after treatment, two body mass index points were gained, and the lesion decreased by 72% in volume as detected through multi-detector computed tomography follow-up.

Discussion and conclusion

Quality of life is an unquestionable goal to achieve, and palliation must be achieved while causing as little harm as possible. In this view, debulking surgery and percutaneous ablation technique seemed not appropriate for our patient. Instead, high-intensity focused ultrasound combined several advantages, no lesion size limit and a totally non-invasive treatment. Thus, this technique proved to be a clinically successful procedure, offering better disease control and quality of life. In circumstances where other alternatives clearly seem to fail or are contraindicated, high-intensity focused ultrasound can be used and can provide benefits. We recommend its use and development in several oncologic diseases, not only for therapeutic purposes but also for the improvement of patient's quality of life.

Predictive and prognostic value of circulating nucleosomes and serum biomarkers in patients with metastasized colorectal cancer undergoing Selective Internal Radiation Therapy

Background

Selective Internal Radiation Therapy (SIRT) is a new and effective locoregional anticancer therapy for colorectal cancer patients with liver metastases. Markers for prediction of therapy response and prognosis are needed for the individual management of those patients undergoing SIRT.

Methods

Blood samples were prospectively and consecutively taken from 49 colorectal cancer patients with extensive hepatic metastases before, three, six, 24 and 48 h after SIRT to analyze the concentrations of nucleosomes and further laboratory parameters, and to compare them with the response to therapy regularly determined 3 months after therapy and with overall survival.

Results

Circulating nucleosomes, cytokeratin-19 fragments (CYFRA 21-1), carcinoembryonic antigen (CEA), C-reactive protein (CRP) and various liver markers increased already 24 h after SIRT. Pretherapeutical levels of CYFRA 21-1, CEA, cancer antigen 19-9 (CA 19-9), asparate-aminotransferase (AST) and lactate dehydrogenase (LDH) as well as 24 h values of nucleosomes were significantly higher in patients suffering from disease progression (N = 35) than in non-progressive patients (N = 14). Concerning overall survival, CEA, CA 19-9, CYFRA 21-1, CRP, LDH, AST, choline esterase (CHE), gamma-glutamyl-transferase, alkaline phosphatase, and amylase (all 0 h, 24 h) and nucleosomes (24 h) were found to be prognostic relevant markers in univariate analyses. In multivariate Cox-Regression analysis, the best prognostic model was obtained for the combination of CRP and AST. When 24 h values were additionally included, nucleosomes (24 h) further improved the existing model.

Conclusion

Panels of biochemical markers are helpful to stratify pretherapeutically colorectal cancer patients for SIR-therapy and to early estimate the response to SIR-therapy.

Ablative therapies for colorectal liver metastases: a systematic review

AIM

The standard treatment for colorectal liver metastases (CRLM) is surgical resection. Only 20-30% of patients are deemed suitable for surgery. Recently, much attention has focused on ablative therapies either to treat unresectable CRLM or to extend the margins of resectability. This review aims to assess the long-term outcome and complication rates of various ablative therapies used in the management of CRLM.

METHOD

A literature search was performed of electronic databases including Medline, Cochrane Collaboration Library and the National Library of Medicine's ClinicalTrials.gov. Inclusion criteria were ablation for CRLM with minimum 1 year follow-up and >10 patients, published between January 1994 and January 2010.

RESULTS

In all, 226 potentially relevant studies were identified, of which 75 met the inclusion criteria. Cryotherapy (26 studies) had local recurrence rates of 12-39%, with mean 1-, 3- and 5-year survival rates of 84%, 37% and 17%. The major complication rate ranged from 7% to 66%. Microwave ablation (13 studies) had a local recurrence rate of 5-13%, with a mean 1-, 3- and 5-year survival of 73%, 30% and 16%, and a major complication rate ranging from 3% to 16%. Radiofrequency ablation (36 studies) had a local recurrence rate of 10-31%, with a mean 1-, 3- and 5-year survival of 85%, 36% and 24%, with major complication rate ranging from 0% to 33%.

CONCLUSION

Ablative therapies offer significantly improved survival compared with palliative chemotherapy alone with 5-year survival rates of 17-24%. Complication rates amongst commonly used techniques are low.

The treatment of primary and metastatic hepatic neoplasms using percutaneous cryotherapy

Cryotherapy has been used clinically in the treatment of metastatic liver malignancies since the 1980s. Rapid freezing to sub-zero temperatures promotes ice formation in the extracellular space and the exit of intracellular water. Cellular death is the result of dehydration, protein denaturation, and microcirculatory failure. Cryotherapy probes use nitrogen or argon gas as a coolant and the development of the ice ball can be monitored using ultrasound, computed tomography, or magnetic resonance imaging. Traditionally, cryotherapy has been performed during laparoscopy or laparotomy, using intraoperative ultrasound for image guidance. A decrease in cryoprobe size (from ~24 Fr to ~15 gauge) in conjunction with experience gained in open cryosurgical treatment has allowed the development of minimally invasive percutaneous approaches. In this review, we describe the use of cryotherapy for treatment of primary or secondary liver neoplasms using a percutaneous approach.

Radiofrequency ablation versus resection for liver tumours: an evidence-based approach to retrospective comparative studies

BACKGROUND

Recently randomized controlled trials have been advocated to compare radiofrequency ablation (RFA) and hepatic resection (HR) in resectable tumours and determine whether differences in observed survivals result from the heterogeneity in previous studies between RFA (treating unresectable lesions) and HR (treating lesions deemed resectable). We reviewed the literature that directly compares the treatments and employed an evidence-based approach to examine the data.

MATERIALS AND METHODS

All studies comparing RFA and HR were included. Primary outcomes were the overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. A subgroup analysis was conducted for solitary or small tumors (<4 cm for colorectal metastases (CRM) or <5 cm for hepatocellular carcinoma (HCC)).

RESULTS

Most studies were retrospective. For CRM, HR was markedly superior to RFA in respect of 3- and 5-year OS as well as 5-year DFS including tumours smaller than 4 cm and solitary lesions. For HCC, HR was markedly superior to RFA for 3- and 5-year OS as well as 3-year DFS, and produced a better OS at 3 years for solitary lesions and DFS at 3 years for small tumours.

CONCLUSIONS

Multiple factors determine outcomes following treatment of liver tumours. Small or solitary lesions seem the most appropriate ones to study as this reduces the number of confounding variables, but even in these cases HR confers a better OS and DFS than RFA for both CRM and HCC. If our data are confirmed it will be important to examine other factors influencing the response.

Oligometastases confined one organ from colorectal cancer treated by SBRT

To determine the feasibility and efficacy of stereotactic body radiotherapy (SBRT) for oligometastases from colorectal cancer (CRC). Total of 59 patients with 78 lesions confined to one organ and treated from 2001 to 2006 were involved in this retrospective review. These patients presented with 1-4 metastatic lesions of largest diameter of <7 cm, progressed after chemotherapy, and were amenable to local treatment. The median radiation dose administered was 42 Gy, which was delivered in 3 fractions. Lymph node lesions were most frequent, followed in order by the lung and liver. Five-year overall survival and local control rates were 29 and 19%, respectively. Cumulative gross tumor volume, site of metastasis, and SBRT dose were found to be significantly associated with overall survival. In terms of local control, a cumulative GTV below 23 ml was found to be a significantly favorable prognostic factor. Acute grade 1-2 toxicities occurred in 24 of the 59 patients, and a late grade 4 complication occurred in 2 (3%), and these were relieved by bypass surgery. CRC patients with oligometastases generally fare well after SBRT. In particular, the survival rates of patients with a pelvic LN or a small tumor are promising.

Dose-escalation study of single-fraction stereotactic body radiotherapy for liver malignancies

PURPOSE

We performed a Phase I dose-escalation study to explore the feasibility and safety of treating primary and metastatic liver tumors with single-fraction stereotactic body radiotherapy (SBRT).

METHODS AND MATERIALS

Between February 2004 and February 2008, 26 patients were treated for 40 identifiable lesions. Nineteen patients had hepatic metastases, 5 had intrahepatic cholangiocarcinomas, and 2 had recurrent hepatocellular carcinomas. The prescribed radiation dose was escalated from 18 to 30 Gy at 4-Gy increments with a planned maximum dose of 30 Gy. Cumulative incidence functions accounted for competing risks to estimate local failure (LF) incidence over time under the competing risk of death.

RESULTS

All patients tolerated the single-fraction SBRT well without developing a dose-limiting toxicity. Nine acute Grade 1 toxicities, one acute Grade 2 toxicity, and two late Grade 2 gastrointestinal toxicities were observed. After a median of 17 months follow-up (range, 2-55 months), the cumulative risk of LF at 12 months was 23%. Fifteen patients have died: 11 treated for liver metastases and 4 with primary liver tumors died. The median survival was 28.6 months, and the 2-year actuarial overall survival was 50.4%.

CONCLUSIONS

It is feasible and safe to deliver single-fraction, high-dose SBRT to primary or metastatic liver malignancies measuring ≤5 cm. Moreover, single-fraction SBRT for liver lesions demonstrated promising local tumor control with minimal acute and long-term toxicity. Single-fraction SBRT appears to be a viable nonsurgical option, but further studies are warranted to evaluate both control rates and impact on quality of life.

Thermal ablation for unresectable liver tumours, time to move forward?

Even with the advent of laparoscopic techniques for liver tumours, classic resections still represent a major undertaking for numerous liver lesions. The avoidance of surgery using ablative techniques has been the aim for over 20 years. Large volumes can now be rapidly treated with low morbidity with the many technical developments and modifications of the delivery probes. Despite these advances recurrences rates remain high with all of the presently available techniques. The biological and pathophysiological basis underlying may help explain their limitations and are important in understanding where they may be appropriately applied and ways in which they may be improved in the future.

Experimental application of electrolysis in the treatment of liver and pancreatic tumours: principles, preclinical and clinical observations and future perspectives

BACKGROUND

Electrolytic ablation (EA) is a treatment that destroys tissues through electrochemical changes in the local microenvironment. This review examined studies using EA for the treatment of liver and pancreatic tumours, in order to define the characteristics that could endow the technique with specific advantages compared with other ablative modalities.

METHODS

Literature search of all studies focusing on liver and pancreas EA.

RESULTS

A specific advantage of EA is its safety even when conducted close to major vessels, while a disadvantage is the longer ablation times compared to more frequently employed techniques. Bimodal electric tissue ablation modality combines radiofrequency with EA and produced significant larger ablation zones compared to EA or radiofrequency alone, reducing the time required for ablation. Pancreatic EA has been investigated in experimental studies that confirmed similar advantages to those found with liver ablation, but has never been evaluated on patients. Furthermore, few clinical studies examined the results of liver EA in the short-term but there is no appropriate follow-up to confirm any survival advantage.

CONCLUSIONS

EA is a safe technique with the potential to treat lesions close to major vessels. Specific clinical studies are required to confirm the technique's safety and eventually demonstrate a survival advantage.

Microwave ablation for unresectable hepatic tumours: clinical results using a novel microwave probe and generator

BACKGROUND

Microwave ablation is an in situ method of tumour destruction used to treat patients with unresectable liver tumours. A new microwave generator and probe, designed to deliver high energy into solid tumours quickly has been developed at our institution. We report the results of its use in patients with unresectable liver tumours treated by a single surgeon in a single institution.

METHODS

Thirty-one patients with 89 unresectable liver tumours were recruited into the study and underwent microwave ablation in a single procedure.

RESULTS

There were no post-operative complications. At a median of 24 months post ablation, 15 patients were alive with 7 patients disease free. At a median of 26 months, 8 patients were alive with tumour recurrence but only 1 with local recurrence. The remaining 7 patients with recurrence were found to have new disease at locations remote from the ablation site. Fourteen patients died of disease progression at a median survival of 15 months, with only 1 patient with local and remote tumour recurrence. Of the total numbers of tumours treated (n=89), a local tumour recurrence rate of 2% was observed. Overall median survival was 29 months with 3 year survival of 40%.

DISCUSSION

Microwave tissue ablation using this novel generator and probe has a low local recurrence and complication rate. Overall survival is comparable to alternative ablation modalities and its ability to treat, even large tumours, with a single insertion of the probe makes it an extremely attractive treatment option.

Liver ablation techniques: a review

BACKGROUND

Ablation techniques for unresectable liver carcinomas have evolved immensely since their introduction. Results of studies involving these techniques are restricted to reports of patient case series, which are often not presented in a standardised manner. This review aims to summarise the major studies in ablation technologies and present them in a way that may make comparison between the major modalities easier.

METHODS

All major databases (Medline, Cochrane, Embase and Pubmed) were searched for studies using microwave, radiofrequency or cryoablation to treat unresectable liver tumours. Only studies with at least 30 patients and 3-year follow-up were included. Complication, recurrence and survival rates of all studies are summarised and presented.

RESULTS AND CONCLUSION

It is difficult to compare ablation modalities, as probe design and energy sources have evolved rapidly over the last decade. Ablation offers an invaluable palliative option and in some cases it may offer rates of cure approaching that of surgical resection with lower morbidity and mortality. Perhaps the time has come, therefore, for prospective large-scale randomised control trials to take place comparing ablation modalities to each other and surgical resection.

Intra-arterial hepatic chemotherapy for unresectable colorectal liver metastases: a review of medical devices complications in 3172 patients

Background

Hepatic artery infusion (HAI) is indicated to treat unresectable colorectal hepatic metastases, with recent applications as a neoadjuvant or adjuvant treatment. Traditionally performed with the infusion of fluoropyrimidine-based chemotherapy, it has been now tested with oxaliplatin or irinotecan and associated with systemic chemotherapy.

Methods

To evaluate the impact of medical devices complications we carried out a search of the published studies on HAI in unresectable colorectal liver metastases. Complications were pooled according to the applied medical system: 1) surgical catheter, 2) radiological catheter, and 3) fully implantable pump. The surgical catheter is inserted into the hepatic artery from the gastro-duodenal artery. The radiological catheter is inserted into the hepatic artery through a percutaneous transfemoral or transaxillar access. The fully implantable pump is a totally internal medical device connected to the arterial hepatic catheter during laparotomy.

Results

The selection criteria were met in 47/319 studies. The complications of surgical and radiological medical devices connected to a port were found in 16 and 14 studies respectively. Meanwhile, complications with a fully implantable pump were reported in 17 studies. The total number of complications reported in studies evaluating patients with surgical or radiological catheter were 322 (322/948, 34%) and 261 (261/722, 36.1%) respectively. In studies evaluating patients with a fully implantable pump, the total number of complications was 237 (237/1502, 15.8%). In 18/319 studies the number of cycles was reported. The median number of cycles with surgically and radiologically implanted catheters was 8 and 6 respectively. The fully implantable pump allows a median number of 12 cycles.

Conclusions

The fully implantable pump, maintaining a continuous infusion through the system, allows the lowest risk for thrombosis and infection and the best median number of cycles of loco-regional chemotherapy in HAI.

Bilobar colorectal liver metastases: treatment options

Although prospective, randomized clinical trials never have been conducted, retrospective and comparative studies strongly indicate that hepatic resection is the only available treatment that allows long-term survival in colorectal carcinoma that has metastasized to the liver. Unfortunately, curative resection can be performed in less than 25% of the patients. Ten years ago, hepatic resection was contraindicated in case of multiple or bilobar nodules. Currently, the trend is to be more aggressive and to increase the indications for surgical resection with the development of new strategies using a multidisciplinary approach.

Diagnosis and treatment of metastatic disease to the liver

A number of cancers present with synchronous or metachronous hepatic metastases. Historically, many of these patients were considered unresectable and were treated with either systemic chemotherapy or supportive care. Today, a variety of options exist for the management of hepatic metastases. Newer agents for systemic therapy continue to be introduced and are providing improved progression-free and overall survival and increased resectability of liver metastases. However, complete surgical resection of isolated hepatic metastases remains the optimal management for these patients. Surgical interventions can be offered to patients with hepatic-only metastases. Hepatic artery chemotherapy represents an adjunct for those patients undergoing resection and can improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer generation biologic agents can improve results. New therapeutic modalities to treat lesions that are unresectable include ablative techniques such as radiofrequency ablation (RFA) and cryoablation. This article will examine modalities of diagnosis of hepatic metastases and highlight the data regarding hepatic resection for metastases of several types of primary cancers, the rationale for, and efficacy of, hepatic arterial chemotherapy, in both the postoperative adjuvant setting and in unresectable liver disease, and review the current literature for ablative techniques in the treatment of liver metastases.

Computer-based decision making in medicine: A model for surgery of colorectal liver metastases

AIMS

Seeking the best available treatment for patients with colorectal liver metastases may be complex due to the interpretation of many variables. In this study conjoint analysis is used to develop a decision model to help clinicians selecting patients eligible for surgery of liver metastases.

METHODS

Patient and tumor characteristics decisive for surgery of colorectal liver metastases were selected from literature. A factorial design was used to construct virtual patient cases by balanced combinations of these characteristics. Surgeons experienced in liver surgery (n=25) were asked to give their advised treatment (resection and/or local ablation, or chemotherapy). Different tumor and patient variables were weighted in the analysis for their contribution to treatment choices.

RESULTS

Patient's age, the involvement of lobes and location of metastases in relation to large vessels were most important for treatment decisions. The number of metastases, size of the lesions, presence of resectable extrahepatic disease and time interval from primary tumor to metastases proved of less importance. Based on the analysis a computer-based decision model was designed.

CONCLUSION

Conjoint analysis can be a valuable tool in clinical decision making. The computer-based decision model can assist clinicians in defining which patient should be referred for liver surgery.

Interleukin-1β is the primary initiator of pulmonary inflammation following liver injury in mice

Hepatic injury can lead to systemic and pulmonary inflammation through activation of NF-κB-dependent pathways and production of various proinflammatory cytokines. The exact mechanism remains unknown, although prior research suggests interleukin-1β (IL-1β) plays an integral role. Cultured murine alveolar macrophages were used to identify an optimized IL-1β-specific short interfering RNA (siRNA) sequence, which then was encapsulated in liposomes and administered intraperitoneally to transgenic HLL mice (5′-HIV-LTR-Luciferase). A 35% hepatic mass cryoablation in HLL and IL-1 receptor 1 knockout mice (IL1R1KO) was performed as a model for liver-induced pulmonary inflammation. IL-1β siRNA pretreatment effectively and significantly reduced circulating IL-1β levels at 4 h post-hepatic injury. IL-6 also was suppressed in mice with impaired IL-1 signaling pathways. NF-κB activation in the noninjured liver of HLL reporter mice pretreated with IL-1β siRNA was found to be reduced compared with controls. Pulmonary NF-κB activity in this group also was diminished relative to controls. C-X-C chemokine levels in the lung remained significantly lower in IL-1 pathway-deficient mice. Similarly, lung myeloperoxidase content was unchanged from baseline at 24 h post-liver injury in IL-1β siRNA-treated animals, whereas all other control groups demonstrated marked pulmonary neutrophilic infiltration. In conclusion, liver injury-induced lung inflammation in this model is mediated predominantly by IL-1β. Knockdown of IL-1β expression before hepatic injury led to significant reductions in both cytokine production and NF-κB activation. This translated to reduced pulmonary neutrophil accumulation. Pretreatment with IL-1β siRNA may represent a novel intervention for preventing liver-mediated pulmonary inflammation.

Recurrence and Survival Outcomes after Hepatic Resection with or without Cryotherapy for Liver Metastases from Colorectal Carcinoma

BACKGROUND

Some reports support resection combined with cryotherapy for patients with multiple bilobar colorectal liver metastases (CRLM) that would otherwise be ineligible for curative treatments. This series demonstrates long-term results of 415 patients with CRLM who underwent resection with or without cryotherapy.

METHODS

Between April 1990 and January 2006, 291 patients were treated with resection only and 124 patients with combined resection and cryotherapy. Recurrence and survival outcomes were compared. Kaplan-Meier and Cox-regression analyses were used to identify significant prognostic indicators for survival.

RESULTS

Median length of follow-up was 25 months (range 1-124 months). The 30-day perioperative mortality rate was 3.1%. Overall median survival was 32 months (range 1-124 months), with 1-, 3- and 5-year survival values of 85%, 45% and 29%, respectively. The overall recurrence rates were 66% and 78% for resection and resection/cryotherapy groups, respectively. For the resection group, the median survival was 34 months, with 1-, 3- and 5- year survival values of 88%, 47% and 32%, respectively. The median survival for the resection/cryotherapy group was 29 months, with 1-, 3- and 5-year survival values of 84%, 43% and 24%, respectively (P = 0.206). Five factors were independently associated with an improved survival: absence of extrahepatic disease at diagnosis, well- or moderately-differentiated colorectal cancer, largest lesion size being 4 cm or less, a postoperative CEA of 5 ng/ml or less and absence of liver recurrence.

CONCLUSIONS

Long-term survival results of resection combined with cryotherapy for multiple bilobar CRLM are comparable to that of resection alone in selected patients.

Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma

BACKGROUND

We critically appraised the quantity and quality of current clinical evidence to demonstrate the efficacy and safety of repeat hepatectomy for recurrent colorectal liver metastases (CRLM).

METHODS

Electronic searches for relevant studies published in peer-reviewed medical journals on repeat hepatectomy for recurrent CRLM before January 2007 were performed on six databases. The quality of each included study was independently assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies.

RESULTS

Seventeen studies with more than 20 patients were included for quality appraisal and data extraction. All 17 included articles were observational cases series. The overall perioperative morbidity rate ranged from 7% to 30% and mortality rate varied from 0% to 5%. The overall median survival since the repeat hepatectomy ranged from 23 to 56 months, with 3- and 5-year survival of 24% to 68% and 21% to 49%, respectively. The median disease-free survival ranged from 9 to 52 months, with 3- and 5-year disease-free survival of 16% to 68% and 16% to 48%, respectively.

CONCLUSIONS

The current literature suggests that repeat hepatectomy is associated with a prolonged survival for recurrent CRLM and is justified in selected patients because there is a lack of evidence for effective alternative treatments.

Phase II study on stereotactic body radiotherapy of colorectal metastases

Surgical resection provides long term survival in approximately 30% of patients with colorectal carcinoma (CRC) liver metastases. However, only a limited number of patients with CRC-metastases are amendable for surgery. We have tested the effect of stereotactic body radiotherapy (SBRT) in the treatment of inoperable patients with CRC-metastases. Sixty-four patients with a total number of 141 CRC-metastases in the liver (n = 44), lung (n = 12), lymph nodes (n = 3), suprarenal gland (n = 1) or two organs (n = 4) were treated with SBRT with a central dose of 15 Gy x 3 within 5-8 days. Median follow-up was 4.3 years. After 2 years, actuarial local control was 86% and 63% in tumor and patient based analysis, respectively. Nineteen percent were without local or distant progression after 2 years and overall survival was 67, 38, 22, 13, and 13% after 1, 2, 3, 4 and 5 years, respectively. One patient died due to hepatic failure, one patient was operated for a colonic perforation and two patients were conservatively treated for duodenal ulcerations. Beside these, only moderate toxicities such as nausea, diarrhoea and skin reactions were observed. SBRT in patients with inoperable CRC-metastases resulted in high probability of local control and promising survival rate. One toxic death and few severe reactions were observed. For the majority of patients, the treatment related toxicity was moderate.

Liver-directed therapies for patients with primary liver cancer and hepatic metastases

Liver cancer, whether primary or metastatic, is a major cause of death throughout the world. The surgical management of these diseases varies according to the extent of disease and the overall health of the patient. Surgical resection of hepatic disease remains the only chance for cure. However, a large proportion of patients with liver cancer are unable to undergo a complete surgical resection. These patients are often treated with liver-directed therapies. Although not as effective as surgical resection, these approaches can help to improve the survival of patients. In patients with primary liver cancer, underlying liver disease often prohibits surgical intervention. However, survival advantages have been gained with the application of percutaneous alcohol injection and radiofrequency ablation (RFA). In patients with hepatic metastases, the number of metastases is often what prevents surgical resection. In these patients, RFA, cryoablation, and hepatic artery infusional therapy have all aided in prolonging survival. As chemotherapeutic agents improve and targeted therapies are developed, more patients will be able to undergo surgical management of their liver cancer, primary or metastatic.

Applying Fong's CRS Liver Score in Patients with Colorectal Liver Metastases Treated by Cryotherapy

BACKGROUND

A significant proportion of patients with liver metastases from colorectal cancer have unresectable disease and we have used cytoablative treatment such as cryotherapy in some of these patients. We retrospectively reviewed patients who underwent hepatic cryotherapy for colorectal metastases and studied the effect of the clinical risk score (CRS) reported by Fong et al, which can predict survival following liver resection.

METHODS

A retrospective study was performed on patients who underwent hepatic cryotherapy between 1990 and 2000 in St George Hospital. There were 61 patients in this study and they were stratified into prognostic groups based on five preoperative CRS parameters: primary node positive, disease-free interval from primary to metastases < 12 months, number of hepatic tumours > 1, largest hepatic tumour > 5 cm and carcinoembryonic antigen level > 200 ng/mL. The median follow-up was 25 months.

RESULTS

The median survival was 26 months and the 3-year survival rate was 37%. Median survivals for patients with CRS scores 1 (13%), 2 (25%), 3 (53%), 4 (6%) and 5 (4%) were 37, 25, 30, 21 and 15 months, respectively (R2 = 0.81).

CONCLUSION

The CRS score can be used to predict outcome of hepatic cryotherapy, but the difference in survival between CRS 2, 3 and 4 is modest.

Management of intrahepatic recurrence after curative treatment of colorectal liver metastases

BACKGROUND

Management of intrahepatic recurrence after complete surgical treatment for colorectal liver metastases is not well defined. The aim of this study was to analyse the survival results of patients who had repeat liver resection for intrahepatic recurrence and to evaluate prognostic indicators for survival.

METHODS

Between 1991 and 2005, 55 patients had repeat liver resection for isolated intrahepatic recurrence. The long-term survival results were assessed. Univariable and multivariable analyses were used to identify prognostic indicators for survival after repeat hepatectomy.

RESULTS

The median survival was 53 (range 2-97) months and the 5-year survival rate was 49 per cent. In univariable analysis, size of largest initial liver metastasis, margin of initial liver surgery, carcinoembryonic antigen (CEA) level before and after initial liver surgery, liver disease-free survival, margin of repeat liver surgery, operation type of repeat surgery and CEA level before and after repeat surgery were significant prognostic factors. In multivariable analysis, largest initial liver metastasis 4 cm or less and CEA level 5 ng/ml or less after repeat liver surgery were independently associated with improved survival.

CONCLUSION

Repeat hepatectomy can achieve an acceptable survival in selected patients with isolated intrahepatic recurrence.

Cryoablation of liver tumours -- a review of mechanisms, techniques and clinical outcome

Several techniques exist for in situ destruction or ablation of liver tumours not eligible for resection. Cryoablation, i.e. the use of low temperatures to induce local tissue necrosis, was among the first of the thermal ablative techniques widely used. The procedures have typically been performed by surgeons during laparotomy, but recently minimally invasive cryoablation has been reported feasible. The present review focuses on mechanisms of tissue destruction, techniques of ablation including procedural monitoring, and clinical outcome following cryoablation of liver tumours. Plausible causes of tumour persistence at the site of ablation, i.e. local treatment failure, are discussed. Shortcomings exist in monitoring of the freezing process and may be a main cause. The evidence for the long-term outcome following liver tumour cryoablation needs to be improved. Cryoablation has been challenged by other techniques of tumour ablation such as radiofrequency ablation. Randomised trials against these modern techniques may define the role of cryoablation in the treatment of liver tumours. With improved imaging technology and patient selection, cryoablation of liver tumours may hold promise for selected patients.

Management of involved or close resection margins in 120 patients with colorectal liver metastases: edge cryotherapy can achieve long-term survival

BACKGROUND

The liver resection margin is prognostically significant for patients with colorectal liver metastases. Management plans for patients with suboptimal resection margins have not been adequately addressed. This article reports the long-term results of edge cryotherapy in 120 patients with suboptimal resection margins.

METHODS

A retrospective analysis of prospectively collected clinical data of 120 patients with suboptimal hepatic resection margins was performed. Morbidity, mortality, recurrence, and survival results were analyzed.

RESULTS

The median length follow-up was 30 months (range 1 to 139). The median disease-free interval was 19 months (range 2 to 139). Cryosite, remaining liver, and extrahepatic recurrence rates were 10%, 36%, and 47%, respectively. The median survival was 39 months (range 1 to 139), and 1-, 3-, and 5-year survival rates were 89%, 55%, and 36%, respectively. Cryosite and extrahepatic recurrence were independently associated with a reduced survival outcome.

COMMENTS

Edge cryotherapy to suboptimal liver resection margins can achieve a lower local recurrence rate and a longer survival advantage.

Cryotherapy--a mature ablation technique

This article discusses the use of cryotherapy for the treatment of hepatic tumours, from its early origins to the present day. Results of therapy, preoperative assessment, safety, and the pros and cons of its use are described.

Longterm Results and Prognostic Indicators after Cryotherapy and Hepatic Arterial Chemotherapy With or Without Resection for Colorectal Liver Metastases in 224 Patients: Longterm Survival Can Be Achieved in Patients With Multiple Bilateral Liver Metastases

BACKGROUND

Only a minority of patients are suitable for liver resection for colorectal liver metastases. Cryotherapy was the first widely used ablative technique, achieving a median survival of more than 2 years. Patient selection is important, but the prognostic criteria have been controversial. The combined treatment modality of cryotherapy, resection, and hepatic arterial chemotherapy has been used in treating unresectable liver disease. Many centers would not surgically treat patients with multiple (five or more lesions) bilateral liver metastases. This series reports on longterm results after cryotherapy and hepatic arterial chemotherapy with or without liver resection in 224 patients with colorectal liver metastases, especially in patients with multiple bilateral liver disease, and identifies important prognostic determinants for survival.

STUDY DESIGN

A longterm retrospective analysis was performed of prospectively collected clinical data of 224 patients with colorectal liver metastases who received cryotherapy and hepatic arterial chemotherapy with or without resection. Morbidity, mortality, recurrence, and survival rates were reported and Kaplan-Meier and Cox regression analysis were used to identify prognostic indicators.

RESULTS

Median length of followup was 26 months (range 1 to 130 months). Perioperative mortality rate was 0.4% and morbidity rate was 21%. Cryosite, remaining liver, and extrahepatic recurrence rates were 39%, 62%, and 67%, respectively. Median survival was 31 months (range 1 to 130 months) with 1-, 3-, and 5-year survival rates of 87%, 43%, and 23%, respectively. Ninety-one patients had five or more bilateral lesions. Median and 5-year survival was 31 months (2 to 88 months) and 26%, respectively. Four factors were independently associated with favorable survival outcomes: cryotherapy with resection, complete tumor eradication, low pre- and postoperative CEA levels.

CONCLUSIONS

Cryotherapy and hepatic arterial chemotherapy with or without resection can achieve long survival advantage in patients with unresectable colorectal liver metastases.

Liver resection or cryotherapy for colorectal liver metastases: a prospective case control study

BACKGROUND AND AIMS

While there is promising survival data for cryosurgery of colorectal liver metastases, local recurrence following cryoablation remains a problem. We aimed to compare morbidity and mortality, as well as the recurrence pattern and survival after liver resection and cryotherapy (alone or in combination with resection) for liver metastases.

PATIENTS AND METHODS

Between 1996 and 2002, 168 patients underwent liver resection alone and 55 patients had cryotherapy (25 in combination with liver resection) for colorectal liver metastases. The patient, tumour and operative details were recorded prospectively and the two patient groups were compared regarding morbidity, survival and recurrence.

RESULTS

More patients had a prior liver resection, liver metastases were smaller and less frequently synchronous, morbidity was significantly lower and hepatic recurrence was significantly more frequent in the cryotherapy group. Five-year survival rates following resection and cryotherapy were comparable (23 and 26% respectively), while overall and hepatic recurrence-free survival was inferior following cryotherapy.

CONCLUSION

Cryotherapy is a valuable treatment option for some patients with non-resectable colorectal liver metastases. While survival is comparable to that after resection, higher hepatic recurrence rates following cryotherapy should caution against the use of cryotherapy for resectable disease until the results of randomized controlled trials are available.

Synchronous liver resection and cryotherapy for colorectal metastases: survival analysis

INTRODUCTION

The value of synchronous liver resection and cryotherapy ablation remains controversial for colorectal metastases where complete resection is not possible by conventional liver surgery alone.

OBJECTIVE

To review the long-term survival of patients treated using this approach at our institution.

METHODS

A review was undertaken of data held in the prospectively collected liver surgery database of all patients who underwent synchronous liver resection and cryotherapy. Survival analysis was performed and data recorded on the total number of metastases at initial surgery and the number of lesions treated by cryoablation.

RESULTS

Ninety-three patients with colorectal metastases underwent synchronous liver resection and cryotherapy. Data were available on 86 patients with a median follow-up of 18 months (range 1-83). The median number of metastases at initial surgery was four (range 2-11) and the number of lesions treated by cryotherapy ablation was two (range 1-8). Eighty-four per cent had a hepatic artery catheter inserted at surgery and at least one cycle of post-operative hepatic artery chemotherapy. One-, three- and five-year survival was 85%, 43% and 19% respectively, with a median survival of 33 months (95% confidence interval 19.9-42.1). Site of recurrence was recorded and presented.

CONCLUSIONS

Patients with liver metastases that are not amenable to resection alone can achieve worthwhile median survival with synchronous liver resection and cryotherapy ablation.

Interleukin-1β is prominent in the early pulmonary inflammatory response after hepatic injury

BACKGROUND

Acute lung injury and inflammation can occur after hepatic ischemia/reperfusion or cryoablation. The etiology of this response is uncertain although it involves NF-kappaB-mediated cytokine release from the liver.

METHODS

Inflammation-specific complementary DNA microarrays were utilized to evaluate cytokine upregulation in mouse lung at 4 hours after partial-volume hepatic cryoablation with a recirculating liquid N(2) probe. Hierarchical cluster analysis was performed to identify candidate genes. On the basis of these results, an enzyme-linked immunosorbent assay for interleukin-1beta (IL-1beta) was conducted on serum and pulmonary parenchymal specimens. The time course of IL-1beta transcriptional upregulation in the liver and lungs was evaluated by quantitative reverse transcription/real-time polymerase chain reaction.

RESULTS

Starting with a pool of 35 genes generated from normalization and variation filtration, unsupervised hierarchical clustering clearly distinguished lungs of hepatic cryo-injured mice from controls. Genes from the IL-1-family were prominent in the signature. IL-1beta was demonstrable in serum within 2 hours postinjury (218 +/- 89 pg/mL vs 0 at baseline, P = .01). In the lung, IL-1beta was more than 4-fold greater at 4 hours than at baseline. Real-time polymerase chain reaction showed a transcription peak of IL-1beta at 30 minutes in the liver, whereas expression in the lungs remained low until 60 minutes, then continued to increase through 4 hours.

CONCLUSIONS

Microarray analysis identified cytokines of the IL-1 family as central components of acute lung injury after hepatic cryoablation. IL-1beta levels increased in both serum and lung tissue over 4 hours after liver injury. Expression of IL-1beta peaked early in the injured liver remnant, followed by subsequent increases in the lungs. Targeted intervention against IL-1beta may ameliorate liver-mediated lung injury.

Surgical strategies for colorectal liver metastases

Colorectal cancer remains the second commonest cause of death from cancer in Western society. Nearly half of all patients will develop liver metastases and many will die with disease confined to the liver. The accepted modern definitions of resectability now mean that over twenty per cent of patients are now resectable (with operative mortality of >2%) with curative intent, and nearly one third will be alive, disease free, five years later. The use of additional techniques such as radiofrequency ablation may bring many more patients the possibility of long term survival. The introduction of new chemotherapy regimens, including those based on oxaliplatin may convert one third of non-resectable patients to resectability with curative intent. Therefore, in 2004 nearly one third of patients with disease confined to the liver can now look forward to possibly curative liver surgery.

Surveillance-detected hepatic metastases from colorectal cancer had a survival advantage in seven-year follow-up

PURPOSE

Colorectal cancer is a common cause of cancer-related death. The liver is the most common site of distant metastases and the most amenable to potentially curative surgery. The aim of this study was to determine whether hepatic metastases detected by surveillance following colonic resection were associated with higher resectability rates and to determine whether there was any impact on survival rates.

METHODS

A retrospective study of 211 patients who presented to the liver unit between February 1990 and July 1996 with hepatic metastases following colonic resection for adenocarcinoma was performed. Patients were divided into two groups: Group A (n = 154), hepatic metastases diagnosed by carcinoembryonic antigen or by radiology; and Group B (n = 57), patients with symptomatic presentation.

RESULTS

Potentially curative operations were possible in 51.3 percent (79/154) of Group A patients and 28.1 percent (16/57) of Group B patients (P = 0.0043, chi-squared test). In Groups A and B, 24 percent (37/154) and 43.9 percent (25/57) of patients, respectively, were inoperable. The three-year and five-year survival rates after detection of liver metastases were 26.8 percent (41/153) in Group A and 12.5 percent (7/56) in Group B, and 5.9 percent (9/153) in Group A and 8.9 percent (5/56) in Group B, respectively. Log-rank analysis resulted in P = 0.05, Breslow test in P = 0.01.

CONCLUSION

Our study shows that patients with hepatic metastases from colorectal cancer detected by follow-up were significantly more likely to have a potentially curative operation. Our medium-term survival data show a statistically significant survival benefit in patients with surveillance-detected metastases.

Liver-directed therapies in colorectal cancer

The liver is the most common site of metastatic colorectal cancer (CRC) and the status of this organ is an important determinant of overall survival in patients with advanced disease. Complete resection of hepatic CRC metastases can provide a long-term cure for some patients, but the majority of liver metastases are not amenable to such surgery. Furthermore, most patients after curative resection ultimately suffer from recurrence, and the majority of such failures occur in the liver. Various ablative techniques can achieve local control of tumor after incomplete resection or for palliation. Tumor ablation currently has a secondary therapeutic role, as there is no evidence that it can achieve long-term survival comparable to surgical resection. Regional chemotherapy delivers tumoricidal agents in a selective fashion, minimizing systemic toxicity and damage to normal liver cells. Chemotherapy agents delivered through the hepatic artery can extend time to liver recurrence after curative resection and may prolong survival both in the adjuvant setting and when given to patients with unresectable disease. Molecular-based therapies, such as gene delivery and oncolytic viruses, provide promise for curative outcomes in patients with advanced disease.

Predictors of survival after radiofrequency thermal ablation of colorectal cancer metastases to the liver: a prospective study

PURPOSE

The aim of this study was to determine the predictors of survival at the time of radiofrequency thermal ablation (RFA) in patients with colorectal liver metastasis.

PATIENTS AND METHODS

One hundred thirty-five patients with colorectal liver metastases who were not candidates for resection underwent laparoscopic RFA.

RESULTS

The median Kaplan-Meier survival for all patients was 28.9 months after RFA treatment. Patients with a carcinoembryonic antigen (CEA) less than 200 ng/mL had improved survival compared with those with a CEA more than 200 (34 v 16 months; P = .01). Patients with the dominant lesion less than 3 cm in diameter had a median survival of 38 v 34 months for lesions 3 to 5 cm, and 21 months for lesions greater than 5 cm (P = .03). Survival approached significance for patients with one to three tumors versus more than three tumors (29 v 22 months; P = .09). The presence of extrahepatic disease did not affect survival. Only the largest liver tumor size more than 5 cm was found to be a significant predictor of mortality by Cox proportional hazards model, with a 2.5-fold increased risk of death versus the largest liver tumor size less than 3 cm (P = .05).

CONCLUSION

This study determines which patients do best after RFA. Historical survival with chemotherapy alone is 11 to 14 months, suggesting RFA has a positive impact on overall survival. Limited amounts of extrahepatic disease do not appear to affect survival adversely. RFA is a useful adjunct to chemotherapy in those patients with liver-predominant disease.

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.