Microvascular architecture of hepatic metastases in a mouse model

SAR131675, a VEGRF3 Inhibitor, Modulates the Immune Response and Reduces the Growth of Colorectal Cancer Liver Metastasis

Simple Summary

Colorectal cancer most often metastasizes to the liver, and in most cases, it is unresectable at diagnosis. New treatment options targeting specific cancer characteristics are needed and are currently being explored. Herein we looked at the use of a selective VEGFR-3 tyrosine kinase inhibitor, SAR131675, as an anti-tumor agent in a mouse model of colorectal liver metastasis. We found that SAR131675 dramatically reduced tumor growth and changed the immune response within the tumor and the surrounding liver, suggesting the use of SAR131675 as an adjuvant therapy for colorectal liver metastasis.

Abstract

Most patients with colorectal cancer (CRC) develop metastases, predominantly in the liver (CLM). Targeted therapies are being investigated to improve current CLM treatments. This study tested the effectiveness of SAR131675, a selective VEGFR-3 tyrosine kinase inhibitor, to inhibit CLM in a murine model. Following intrasplenic induction of CLM, mice were treated daily with SAR131675. Tumor growth and immune infiltrates into tumor and liver tissues were assessed at 10-, 16- and 22-days post tumor induction by stereology, IHC and flow cytometry. SAR151675 treatment significantly reduced tumor burden and F4/80⁺ macrophages in the liver tissues. Analysis of immune cell infiltrates in liver showed tissue that at day 22, had the proportion of CD45⁺ leukocytes significantly reduced, particularly myeloid cells. Analysis of myeloid cells (CD11b⁺ CD45⁺) indicated that the proportion of F4/80⁻ Ly6C^low was significantly reduced, including a predominate PD-L1⁺ subset, while CD3⁺ T cells increased, particularly CD8⁺ PD1⁺, reflected by an increase in the CD8⁺:CD4⁺ T cell ratio. In the tumor tissue SAR11675 treatment reduced the predominant population of F4/80⁺ Ly6C^lo and increased CD4⁺ T cells. These results suggest that SAR131675 alters the immune composition within tumor and the surrounding liver in the later stages of development, resulting in a less immunosuppressive environment. This immunomodulation effect may contribute to the suppression of tumor growth.

Mechanisms of vascularization in murine models of primary and metastatic tumor growth

Directed capillary ingrowth has long been considered synonymous with tumor vascularization. However, the vasculature of primary tumors and metastases is not necessarily formed by endothelial cell sprouting; instead, malignant tumors can acquire blood vessels via alternative vascularization mechanisms, such as intussusceptive microvascular growth, vessel co-option, and glomeruloid angiogenesis. Importantly, in response to anti-angiogenic therapies, malignant tumors can switch from one vascularization mechanism to another. In this article, we briefly review the biological features of these mechanisms and discuss on their significance in medical oncology.

Protein MRI contrast agent with unprecedented metal selectivity and sensitivity for liver cancer imaging

With available MRI techniques, primary and metastatic liver cancers that are associated with high mortality rates and poor treatment responses are only diagnosed at late stages, due to the lack of highly sensitive contrast agents without Gd(3+) toxicity. We have developed a protein contrast agent (ProCA32) that exhibits high stability for Gd(3+) and a 10(11)-fold greater selectivity for Gd(3+) over Zn(2+) compared with existing contrast agents. ProCA32, modified from parvalbumin, possesses high relaxivities (r1/r2: 66.8 mmol(-1)⋅s(-1)/89.2 mmol(-1)⋅s(-1) per particle). Using T1- and T2-weighted, as well as T2/T1 ratio imaging, we have achieved, for the first time (to our knowledge), robust MRI detection of early liver metastases as small as ∼0.24 mm in diameter, much smaller than the current detection limit of 10-20 mm. Furthermore, ProCA32 exhibits appropriate in vivo preference for liver sinusoidal spaces and pharmacokinetics for high-quality imaging. ProCA32 will be invaluable for noninvasive early detection of primary and metastatic liver cancers as well as for monitoring treatment and guiding therapeutic interventions, including drug delivery.

Contrast-enhanced high-frequency ultrasound imaging of early stage liver metastasis in a preclinical mouse model

Monitoring angiogenesis is potentially an effective strategy for the early detection of cancer. In this study, early detection was achieved by evaluating blood vessel density in the liver using a three-dimensional contrast-enhanced high-frequency ultrasound (CE-HFUS) system and Sonazoid microbubbles. Three-dimensional CE-HFUS detected an increase in blood vessel density in the liver after intrasplenic injection of breast tumor cells into mice. The results were in agreement with immunohistochemical analysis of blood vessel density. Three-dimensional CE-HFUS using microbubbles is an attractive, novel approach for the early detection of liver metastases through quantification of new, pathological vascular growth (i.e. tumor angiogenesis).

Hyperbaric oxygen therapy reduces the severity of ischaemia, preservation and reperfusion injury in a rat model of liver transplantation

BACKGROUND

  Approaches to increase organ availability for orthotopic liver transplantation (OLT) often result in the procurement of marginal livers that are more susceptible to ischaemia, preservation and reperfusion injury (IPRI).

METHODS

  The effects of post-OLT hyperbaric oxygen (HBO) therapy on IPRI in a syngeneic rat OLT model were examined at various time-points. The effects of IPRI and HBO on hepatocyte necrosis, apoptosis, proliferation, and sinusoidal morphology and ultrastructure were assessed.

RESULTS

  Post-OLT HBO therapy significantly reduced the severity of IPRI; both apoptosis [at 12 h: 6.4 ± 0.4% in controls vs. 1.6 ± 0.7% in the HBO treatment group (p < 0.001); at 48 h: 2.4 ± 0.2% in controls vs. 0.4 ± 0.1% in the HBO treatment group (p < 0.001)] and necrosis [at 12 h: 18.7 ± 1.8% in controls vs. 2.4 ± 0.4% in the HBO treatment group (p < 0.001); at 48 h: 8.5 ± 1.3% in controls vs. 3.4 ± 0.9% in the HBO treatment group (P= 0.019)] were decreased. Serum alanine transaminase was reduced [at 12 h: 1068 ± 920 IU/l in controls vs. 370 ± 63 IU/l in the HBO treatment group (P= 0.030); at 48 h: 573 ± 261 IU/l in controls vs. 160 ± 10 IU/l in the HBO treatment group (P= 0.029)]. Treatment with HBO also promoted liver regeneration [proliferation at 12 h: 4.5 ± 0.1% in controls vs. 1.0 ± 0.3% in the HBO treatment group (p < 0.001); at 48 h: 8.6 ± 0.7% in controls vs. 2.9 ± 0.2% in the HBO treatment group (p < 0.01)] and improved sinusoidal diameter and microvascular density index.

CONCLUSIONS

  Hyperbaric oxygen therapy has persistent positive effects post-OLT that may potentially transfer into clinical practice.

Lymphatic patterns of colorectal liver metastases

BACKGROUND

Hematogenous spread is considered the predominant pathway for development of colorectal liver metastases (CRLM) and subsequent further tumor dissemination portal nodal involvement is also frequently observed in such cases, suggesting that lymphatics may have a role in the spread of CRLM. The role of lymphatics in the development of liver metastases is, however, controversial. The lymphatic patterns of CRLM were determined using a well established murine model.

METHODS

CRLM were induced using a well established murine intrasplenic colorectal cancer model. Tumors were assessed at varying stages of development, and lymphatic patterns were determined in tumors and liver by immunohistochemistry staining for podoplanin and LYVE-1. Blood vessels were characterized using the vascular marker CD-34. Assessment was undertaken using digital microscopy and image analysis.

RESULTS

Peri- and intratumoral lymphatic vessels were identified by podoplanin staining in all metastases and significantly increased with tumor growth. LYVE-1 staining was also noted but was variable. There was a concurrent significant increase in portal lymphatic staining within the normal liver with increasing growth of CRLM.

CONCLUSION

There is increased expression of lymphatics within CRLM and normal liver with increasing tumor growth. Lymphatic development is likely to play a significant role in the intrahepatic and periportal dissemination of CRLM.

Changes in the renin angiotensin system during the development of colorectal cancer liver metastases

BACKGROUND

Blockade of the renin angiotensin system (RAS) via angiotensin I converting enzyme (ACE) inhibition reduces growth of colorectal cancer (CRC) liver metastases in a mouse model. In this work we defined the expression of the various components of the RAS in both tumor and liver during the progression of this disease.

METHODS

Immunohistochemistry and quantitative RT-PCR was used to examine RAS expression in a mouse CRC liver metastases model. CRC metastases and liver tissue was assessed separately at key stages of CRC liver metastases development in untreated (control) mice and in mice treated with the ACE inhibitor captopril (750 mg/kg/day). Non-tumor induced (sham) mice indicated the effect of tumors on normal liver RAS. The statistical significance of multiple comparisons was determined using one-way analysis of variance followed by Bonferroni adjustment with SAS/STAT software.

RESULTS

Reduced volume of CRC liver metastases with captopril treatment was evident. Local RAS of CRC metastases differed from the surrounding liver, with lower angiotensin II type 1 receptor (AT1R) expression but increased ANG-(1-7) receptor (MasR) compared to the liver. The AT1R localised to cancer and stromal infiltrating cells, while other RAS receptors were detected in cancer cells only. Tumor induction led to an initial increase in AT1R and ACE expression while captopril treatment significantly increased ACE expression in the final stages of tumor growth. Conversely, captopril treatment decreased expression of AT1R and angiotensinogen.

CONCLUSIONS

These results demonstrate significant changes in RAS expression in the tumor-bearing captopril treated liver and in CRC metastases. The data suggests the existence of a tumor-specific RAS that can be independently targeted by RAS blockade.

Development of arterial blood supply in experimental liver metastases

In this study, we present a mechanism for the development of arterial blood supply in experimental liver metastases. To analyze the arterialization process of experimental liver metastases, we elucidated a few key questions regarding the blood supply of hepatic lobules in mice. The microvasculature of the mouse liver is characterized by numerous arterioportal anastomoses and arterial terminations at the base of the lobules. These terminations supply one hepatic microcirculatory subunit per lobule, which we call an arterial hepatic microcirculatory subunit (aHMS). The process of arterialization can be divided into the following steps: 1) distortion of the aHMS by metastasis; 2) initial fusion of the sinusoids of the aHMS at the tumor parenchyma interface; 3) fusion of the sinusoids located at the base of the aHMSs, which leads to the disruption of the vascular sphincter (burst pipe); 4) incorporation of the dilated artery and the fused sinusoids into the tumor; and 5) further development of the tumor vasculature (arterial tree) by proliferation, remodeling, and continuous incorporation of fused sinusoids at the tumor-parenchyma interface. This process leads to the inevitable arterialization of liver metastases above the 2000- to 2500-mum size, regardless of the origin and growth pattern of the tumor.

Vascular targeting agent Oxi4503 inhibits tumor growth in a colorectal liver metastases model

BACKGROUND AND AIM

Oxi4503 is a potent vascular targeting agent belonging to the family of combretastatins. These agents produce an acute reduction in tumor blood flow leading to tumor necrosis. Despite evidence of its efficacy in certain malignancies, the effect on colorectal liver metastases remains largely unknown. This study investigates the effect of Oxi4503 on colorectal liver metastases in a murine model.

METHODS

The effect of a single dose of Oxi4503 on established tumors in a murine model of colorectal liver metastases was assessed following administration of 1-50 mg/kg Oxi4503. In addition, the effects of continuous, daily and intermittent dosing (1-5 mg/kg) on tumor necrosis and growth were studied by quantitative histological and stereological analysis. The effect of multiple dosing on long-term survival was also assessed using the Kaplan-Meier analysis. The microvascular effects of therapy were studied by scanning electron microscopy of microvascular resin casts.

RESULTS

A single dose of 5 or 50 mg/kg of Oxi4503 produced significant tumor necrosis compared to the controls. Subcutaneous continuous dosing infusion with Oxi4503 at 1 mg/kg/day reduced tumor growth compared to the controls, but was associated with marked systemic toxicity. Daily administration over 21 days was associated with significant mortality. Intermittent dosing of Oxi4503 (two doses, 3 days apart) produced the greatest reduction in tumor growth with minimal toxicity and conferred a significant survival advantage. Microvascular casts demonstrated significant disruption of tumor vessels.

CONCLUSIONS

A single dose of Oxi4503 produced significant necrosis and microvascular injury in colorectal liver metastases. Intermittent dosing with Oxi4503 produced the maximum reduction in tumor growth, minimal toxicity, and a significant improvement in survival. Oxi4503 is a potential anticancer agent. Further research into its mechanism of action and its synergistic use with other therapies is warranted.

Changes of Intratumoral Microvessels and Blood Perfusion during Establishment of Hepatic Metastases in Mice

PURPOSE

To prospectively evaluate the stepwise changes that occur in intratumoral microvessels and microcirculation during the establishment of murine colonic hepatic metastases by using in vivo fluorescent microscopy and to compare the changes with tumor angiogenesis evaluated with an immunohistochemical study.

MATERIALS AND METHODS

This study was approved by the institutional animal care and use committee. Twenty-five mice with hepatic metastases created with injection of murine colonic adenocarcinoma (colon 26) tumor cells into the spleen were examined with in vivo microscopy and immunohistochemical study for CD34, intracellular adhesion molecule (ICAM-1), and alpha smooth muscle actin (alpha-SMA). The tumor size, microcirculation in tumors, intratumoral microvessel density (MVD), afferent MVD, and CD34-positive MVD were evaluated. The data among the tumors that showed different hemodynamic or immunohistochemical patterns were compared with the Kruskal-Wallis test and the Student t test.

RESULTS

Four stepwise patterns were observed according to the changes in morphology, hemodynamics, and immunohistochemical characteristics of intratumoral microvessels during the establishment of hepatic metastases, as follows: metastases without definite intratumoral blood perfusion or any intratumoral microvessels (mean diameter, approximately 180 microm), metastases with portal perfusion and intratumoral ICAM-1-positive residual hepatic sinusoids (mean diameter, approximately 290 microm), metastases with mixed portal and arterial perfusion and increased CD34-positive microvessels and alpha-SMA-positive arterioles (mean diameter, approximately 520 microm), and metastases with exclusively arterial perfusion and increased CD34-positive microvessels and alpha-SMA-positive arterioles (mean diameter, >2000 microm). The differences among the mean sizes of the tumors that showed these four patterns were statistically significant (P < .01).

CONCLUSION

Stepwise changes of intratumoral microcirculation were revealed from direct diffusion, to portal perfusion, to mixed portal and arterial perfusion, and finally to arterial perfusion in accordance with stepwise tumor neovascularization during the growth of murine colonic hepatic metastases.

Effect of ACE inhibitors and angiotensin II receptor antagonists in a mouse model of colorectal cancer liver metastases

BACKGROUND AND AIMS

Angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II type I receptor (AT1R) antagonists are commonly used as a treatment for hypertension. Recent experimental and population studies have suggested that these agents may exert an inhibitory effect on malignancy, possibly through anti-angiogenic pathways. The aim of this study was to investigate the effect of an ACE-I (captopril) and an AT1R antagonist (irbesartan) in colorectal cancer liver metastases.

METHODS

The effect of captopril and irbesartan on tumor growth was investigated in a mouse model using quantitative stereological and histological analysis. Tumor microcirculation was assessed by microvascular resin casting. A survival study was also carried out.

RESULTS

Both captopril and irbesartan markedly decreased tumor growth when compared to control (P = 0.003 and P = 0.004, respectively). However, there was no significant difference in survival or tumor necrosis for either of the drugs. Tumor microvasculature exhibited a reduction in central microvascular density, with constriction and tapering of vessels.

CONCLUSION

Captopril and irbesartan caused a marked reduction in volume of colorectal cancer liver metastases and caused changes in tumor microvasculature. However, there was no difference in percentage tumor necrosis or improvements in survival. Further investigation is needed to identify the mode of action of these agents.

Right portal vein embolization before right hepatectomy for unilobar colorectal liver metastases reduces the intrahepatic recurrence rate

AIM

To assess the effect of portal vein embolization (PVE) on intrahepatic recurrence rate after right hepatectomy for unilobar colorectal liver metastases (CLM).

SUMMARY AND BACKGROUND

Recent research suggests that CLM could spread retrogradely through the portal vein. PVE may reduce tumor shedding by the occlusion of distal portal branches. However, no study reported the clinical effect of PVE on intrahepatic recurrence after CLM resection.

PATIENTS AND METHODS

Between 1995 and 2003, 44 patients requiring a right hepatectomy for unilobar CLM were operated in our institution. Right hepatectomy was performed after PVE in 23 patients (group A) and without PVE in 21 (group B). Surgical outcome and site of recurrence were analyzed.

RESULTS

The postoperative mortality was nil. Overall morbidity and transitory liver failure rates were similar in groups A and B (43.4% and 17.3% vs. 33.3% and 14.2%, respectively). The 3- and 5-year overall survival rates did not differ in group A and B patients (61.2% and 43.7% vs. 49.7% and 35.5%, respectively; P = 0.862). The disease-free survival rate was similar in both groups. Thirty patients (68.2%) developed recurrences. Recurrences were intrahepatic in 22 patients (50%) and extrahepatic in 27 (61.3%). Intrahepatic recurrence rate was significantly lower in group A compared with group B (26.0% vs. 76.1% respectively; P < 0.001). PVE, number of CLM, and administration of neoadjuvant chemotherapy were independent prognostic factors for intrahepatic recurrences.

CONCLUSION

This study showed that PVE reduces intrahepatic recurrence rate after right hepatectomy for unilobar CLM.

Altered growth patterns of colorectal liver metastases after thermal ablation

BACKGROUND

Thermal ablation by radiofrequency or laser is used increasingly for the treatment of colorectal liver metastases. Recurrence after thermal ablation is common and occurs both locally and at distant sites. One possible cause of this recurrence may be a result of growth stimulation of micrometastases in the remaining liver. This study examined the impact of thermal ablation on growth patterns of hepatic micrometastases.

METHODS

Colorectal liver metastases were induced in male CBA-strain mice via an intrasplenic injection of a murine-derived cancer cell line. Subtotal thermal ablation of the left posterior lobe of the liver (30% of total liver volume) was performed by neodymium yttrium-aluminum-garnet laser 7 days after induction of metastases. The distribution, number, cross-sectional diameter, volume, and proliferation rate of established neoplasms were compared with controls at 21 days after tumor induction. The effect of thermal ablation of 7% of the total liver volume by laser on the expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor 2 (FGF-2), transforming growth factor beta, and cellular proliferation (Ki-67 antigen) adjacent to the ablated site was assessed by immunohistochemistry in separate groups of animals at specific time points after therapy.

RESULTS

Thermal ablation did not alter the overall volume, number, size, and proliferation rate of neoplasms 21 days after laser ablation. There were no extrahepatic metastases after therapy. The number of neoplasms in the regenerated posterior lobe was equivalent to control despite subtotal ablation (29 +/- 2 vs 27 +/- 2; P = NS). A greater amount of metastases occupied the regenerated thermal-ablated lobe compared with controls (55% +/- 4% vs 29% +/- 3%; P < .04). Thermal ablation stimulated liver proliferation adjacent to the treatment site at 12 hours compared with untreated controls. Stimulation peaked at 72 hours (20% +/- 1% vs 1% +/- 1%; P < .001) and persisted to 21 days after therapy. FGF-2 and VEGF expression increased in liver tissue adjacent to the ablation site compared with baseline, peaking at 12 hours (112% +/- 2% vs 102% +/- 1%; P < .001) and 72 hours (114% +/- 2% vs 101% +/- 1%; P < .001), respectively.

CONCLUSIONS

Thermal ablation promotes the progression of micrometastases to form macroscopically detectable neoplasms in treated regenerating liver. This effect may relate to an increased expression of VEGF and FGF-2 adjacent to the treatment site.

IMPACT OF BLOOD FLOW OCCLUSION ON LIVER NECROSIS FOLLOWING THERMAL ABLATION

BACKGROUND

Laser, radiofrequency and microwave are common techniques for local destruction of liver tumours by thermal ablation. The main limitation of thermal ablation treatment is the volume of necrosis that can be achieved. Blood flow occlusion is commonly advocated as an adjunct to thermal ablation to increase the volume of tissue necrosis based on macroscopic and histological assessment of immediate or direct thermal injury. This study examines the impact of blood flow occlusion on direct and indirect laser induced thermal liver injury in a murine model using histochemical methods to assess tissue vitality.

METHODS

Thermal ablation produced by neodymium yttrium-aluminium-garnet laser (wavelength 1064 nm) was applied to the liver of inbred male CBA strain mice at 2 W for 50 s (100 J). Treatment was performed with and without temporary portal vein and hepatic artery blood flow occlusion. Animals were killed upon completion of the procedure to assess direct thermal injury or at 24, 48 and 72 h to assess the progression of tissue damage. The maximum diameter of necrosis was assessed by vital staining for nicotinamide adenine dinucleotide (NADH) diaphorase. Microvascular changes were assessed by laser Doppler flowmetry, confocal in vivo microscopy and scanning electron microscopy.

RESULTS

The direct thermal injury (mean SE) assessed by NADH diaphorase staining was significantly greater following thermal ablation treatment without blood flow occlusion than with blood flow occlusion (3.3 (0.4) mm vs 2.9 (0.3) mm; P = 0.005). Tissue disruption, cracking and vacuolization was more pronounced adjacent to the fibre insertion site in the group treated with thermal ablation combined with blood flow occlusion. There was an equivalent increase in the extent of injury following therapy in both groups that reached a peak at 48 h. The maximum diameter of necrosis in the thermal ablation alone group at 48 h was significantly greater than the thermal ablation combined with blood flow occlusion group (5.8 (0.4) mm vs 5.3 (0.3) mm; P = 0.011). The patterns of microvascular injury were similar in both groups, varying in extent.

CONCLUSION

Temporary blood flow inflow occlusion appears to decrease the extent of initial injury measured by vital staining techniques and does not alter the time sequence of progressive tissue injury following thermal ablation therapy.

Effect of thalidomide on colorectal cancer liver metastases in CBA mice

BACKGROUND AND AIMS

Thalidomide has undergone resurgence in the treatment of specific malignancies. One of the possible actions of thalidomide may be an antiangiogenic effect. This study investigates the effects of thalidomide on tumor growth and long-term survival in a murine model of colorectal liver metastases.

METHODS

Liver metastases were produced in male CBA mice by intrasplenic injection of a dimethyl hydrazine induced MoCR colon cancer murine cell line. Thalidomide was administered daily at doses ranging from 50 to 300 mg/kg by intraperitoneal injection. Tumor growth was assessed using quantitative stereological analysis. The effect on long-term survival was determined at the maximum tolerated dose using Kaplan-Meier analysis. The microvascular effects of thalidomide were assessed by laser Doppler flowmetry (LDF) and microvascular resin casting. Immunohistochemistry was used to determine vascular endothelial growth factor (VGEF) and basic fibroblast growth factor (bFGF) expression.

RESULTS

Thalidomide, (50-300 mg/kg) caused no significant reduction in tumor growth by day 21 following induction of liver metastases and caused systemic toxicity at a dose of 300 mg/kg. At a dose of 200 mg/kg given beyond 35 days, thalidomide significantly reduced tumor growth compared to control, (P = 0.029). No significant impact on survival was however observed (P = 0.93). LDF and microvascular resin casting showed no differences in blood flow or tumor microvascular architecture. VGEF and FGF were expressed in tumors, but remained unaltered by thalidomide administration compared to matched controls.

CONCLUSIONS

Thalidomide caused a significant reduction in the volume of colorectal liver metastases during the late phase of tumor growth. There was however no improvement in survival. Tumor growth reduction in this model did not appear to be due to microvascular changes or altered expression of VGEF or basic FGF. Further investigation into potential mechanisms of action of thalidomide and its synergistic use with other therapies is required.

Focal hyperthermia produces progressive tumor necrosis independent of the initial thermal effects

Focal hyperthermia, produced using laser, radio frequency, and microwave, is used to treat liver tumors. The exact mechanisms of tissue destruction using focal hyperthermia are, however, unknown. Clinical and experimental studies suggest a progression of injury after cessation of the initial heat stimulus. This study investigates the mechanisms and time sequence of progressive tissue necrosis induced using focal hyperthermia in a murine model of colorectal liver metastases. Focal hyperthermia produced using a neodymium-yttrium aluminum garnet (Nd-YAG) laser source was applied to the normal liver and colorectal cancer liver metastases in inbred male CBA strain mice. The extent of direct lethal thermal injury was assessed histochemically using vital stain for nicotinamide adenine dinucleotide (NADH) diaphorase immediately after laser application. Tissue injury at subsequent time points was assessed using both NADH diaphorase staining and routine histology to determine the temporal relationship between tissue necrosis and time. Thermal injury occurring immediately after the application of 100 joules of energy was greater in the tumor tissue than in the normal liver (mean [standard error of the mean (SEM)]), measuring 23.5 (3.4) and 16.3 (2.6) mm(3), respectively (P=0.046), despite similar tissue temperature profiles. There was a significant increase in tissue necrosis after initial injury that was greater in the normal liver than in the tumor tissue. In the normal liver, the peak volume of necrosis was 137.4 (9.8) mm(3) and occurred at 3 days, whereas in the tumor tissue the peak was 49.0 (3.5) mm(3) at 4.5 days (P < 0.001). Focal hyperthermia produces tissue necrosis that occurs in two phases. The first phase is caused by the direct lethal thermal injury followed by a second phase involving a progression of necrosis beyond the initial thermal effects. The normal liver and the tumor tissue responded differently to focal hyperthermia. In the tumor tissue, the direct injury is more pronounced, whereas the progression of injury is more rapid and extensive in the normal liver.

Progressive microvascular injury in liver and colorectal liver metastases following laser induced focal hyperthermia therapy

BACKGROUND AND OBJECTIVES

Focal hyperthermia by laser or radiofrequency is currently the preferred method for local ablation of liver tumors. The underlying mechanism of action of focal hyperthermia, in particular the relationship between the microvascular and tissue effect is uncertain and was investigated in a murine model.

STUDY DESIGN/MATERIALS AND METHODS

Focal hyperthermia produced by a Neodymium-Yttrium-Aluminium-Garnet laser (wavelength 1,064 nm) was applied to the normal liver and colorectal cancer liver metastases in inbred male CBA strain mice at 2 W for 50 seconds (100 J). Tissue injury was assessed at 0, 24, 48, 72, 120, and 168 hours following therapy by measurements of necrosis in tissue sections stained for nicotinamide adenine dinucleotide (NADH) diaphorase activity. Characteristics of microvascular injury were assessed at the various time points by scanning electron microscopy (SEM) of vascular resin casts, Laser Doppler flowmetry, and confocal in vivo microscopy.

RESULTS

Focal hyperthermia produced progressive tissue and vascular injury. There was an initial reduction in blood flow and increased vascular permeability in the microcirculation of both tumor and liver tissue immediately following heat application as assessed by laser Doppler flowmetry and confocal in vivo microscopy, respectively. SEM of vascular casts showed heterogeneous regions of microvascular injury immediately following heat application. The extent of initial vascular disruption or occlusion on SEM of vascular resin casts (mean+/-SE) was significantly less than the tissue necrosis in liver (1.9+/-0.1 mm vs. 3.0 mm+/-0.2 mm P<0.001), but was equivalent to the tissue injury in tumor tissue (3.5 mm+/-0.2 mm vs. 3.6 mm+/-0.1 mm P = 0.907). This was followed by a progressive increase in both microvascular and tissue injury in liver and tumor that peaked by 72 hours following treatment. The peak microvascular injury and tissue damage in liver (6.6 mm+/-0.2 and 6.3 mm+/-0.2 mm, respectively) was significantly greater than the extent of microvascular and tissue damage in tumors (4.8 mm+/-0.2 mm and 4.5 mm+/-0.2 mm, respectively) (P<0.001). The progression of microvascular injury in liver and tumor at times preceded the tissue injury.

CONCLUSION

Focal hyperthermia produces both progressive microvascular and tissue damage in liver and colorectal liver metastases. An increase in tissue injury following focal hyperthermia may be a direct result of progressive microvascular damage. Tumor vessels appear more susceptible to direct focal hyperthermia destruction than liver sinusoids. The liver sinusoids are however more susceptible to progressive damage or occlusion following the initial laser thermal stimulus.

Scanning electron microscopy study of the blood supply of human colorectal liver metastases

AIMS

The failure of hepatic artery directed treatment of colorectal liver metastases may reflect a major portal venous contribution to tumour blood supply. This study provides ultrastructural details of the blood supply of colorectal liver metastases and their association with the portal vein and hepatic artery.

METHODS

Resected liver specimens from six patients with colorectal liver metastases were examined by histology and scanning electron microscopy (SEM), following vascular resin casting.

RESULTS

Nine metastatic colorectal adenocarcinomas were identified. The main feature of all tumours on SEM was direct communication between hepatic sinusoids and tumour vessels. A direct portal venous connection with tumour vessels was observed in a single specimen, whilst a direct arteriole connection was not identified.

CONCLUSIONS

It appears that both the hepatic artery and portal vein contribute to the blood supply of colorectal liver metastases through sinusoidal connections with tumour specific blood vessels. SEM provides useful additional information on the morphological features of tumour vasculature.

Interstitial laser hyperthermia and the biological characteristics of tumor: study in a murine model of colorectal liver metastases

BACKGROUND DATA

Percutaneously applied interstitial laser hyperthermia (ILH) is a minimally invasive therapy that is currently used in the treatment of liver metastases. Despite its documented efficacy, theoretical considerations and evidence based on animal studies suggest the potential for stimulating tumor growth, especially following surgery. This study investigates the influence of ILH on tumor behaviour in an animal model of colorectal liver metastases.

MATERIALS AND METHODS

A model of colorectal cancer liver metastases in male inbred CBA mice was used. Laser hyperthermia was applied to tumor tissue using a bare optical quartz from a Medilas fibertom 4100 Nd:YAG surgical laser generator. Liver injury by ILH was initially produced in three experimental groups of animals at different time points in the development of metastases. ILH was applied (i) to normal liver 10 days prior to tumor induction, (ii) immediately prior to tumor induction, and (iii) 15 days after tumor induction to achieve approximately 8% liver destruction. Animals were killed 21 days after tumor induction, and the effects of ILH on overall tumor development were compared with controls using stereological assessment of tumor volume and by histology. In a separate experimental group, the effects of ILH on fully established tumors were examined. Suitable tumors were selected 21 days after induction and partially destroyed by ILH at a standard energy setting. Animals were then killed 15 days later, and the growth rate of the residual viable tumors was compared to control tumors having undergone sham procedures.

RESULTS

No significant stimulation of tumor growth was evident in any of the experimental groups following ILH, irrespective of the time of application. Incomplete tumor destruction also had no influence on subsequent tumor growth.

CONCLUSION

ILH does not influence the biological characteristics of tumors during any stage of the metastatic process.

Interstitial laser hyperthermia for colorectal liver metastases: the effect of thermal sensitization and the use of a cylindrical diffuser tip on tumor necrosis

OBJECTIVE

Our aim in this study was to investigate the characteristics of a diffuser-tipped optical fiber in producing tumor necrosis, compared to a standard bare-tipped fiber. The potential synergistic effect between thermal sensitization by metronidazole and interstitial laser hyperthermia (ILH)-induced tumor necrosis is also evaluated.

BACKGROUND DATA

ILH is a minimally invasive technique for the treatment of colorectal liver metastases. One of the major limitations is the size of tissue necrosis achieved by a single optical fiber. Use of cylindrical diffuser-tipped fibers and thermal sensitization of tumor cells by metronidazole may increase the size of tumor necrosis achieved by a single optical fiber.

MATERIALS AND METHODS

A model of colorectal cancer liver metastases in male inbred CBA mice was used. Laser hyperthermia was applied to tumor tissue using either a bare optical quartz fiber or a cylindrical diffuser-tipped fiber from a Medilas fibertom 4100 Nd:YAG surgical laser generator. Six hundred joules of energy was applied at two power settings, 5 and 10 watts, using bare- and diffuser-tipped fibers, respectively. The extent of necrosis was assessed by histological techniques. A similar study with three experimental groups was treated with 300 J of applied energy. Extent of immediate tumor necrosis was compared to that seen 24 h after ILH treatment. The third group, which had been treated with intraperitoneal metronidazole prior to ILH, was also assessed for tumor necrosis after 24 h and results compared with both the previous groups.

RESULTS

ILH delivered using a cylindrical diffuser-tipped fiber resulted in a significantly larger diameter of tumor necrosis when compared to a bare-tipped fiber, for a given amount of applied energy. The differences were more significant at higher power settings. Six hundred joules of energy applied by ILH using a bare-tipped fiber at 5 and 10 watts produced 6.7 +/- 1.1 mm and 5.9 +/- 0.6 mm diameter of tumor necrosis, respectively. At equivalent settings, the diffuser-tipped fiber produced 7.7 +/- 1.0 mm and 8.1 +/- 0.6 mm diameter of tumor necrosis (p = 0.02 and p < 0.001). Using a diffuser-tipped fiber and an applied energy of 300 J delivered at 5 watts power, mean diameter of tumor necrosis immediately after treatment was 6.7 +/- 1.1 mm and after 24 h 7.9 +/- 1.3 mm (p = 0.006). Mean diameter of tumor necrosis 24 h after ILH in animals treated with metronidazole was 8.3 +/- 1.9 mm (p = 0.11).

CONCLUSION

Diffuser-tipped optical fiber appears to significantly increase the diameter of ILH-induced tumor necrosis compared to the bare fiber. In contrast to the bare fiber, it enables the application of laser energy using higher power settings without compromising the diameter of tumor necrosis achieved. In animals treated with metronidazole, a trend towards increased tumor destruction at the tumor-host interface was seen on histolopathology. In addition, a trend towards increased diameter of tumor necrosis was also seen; however, statistical significance was not achieved.

Effect of blood flow occlusion on laser hyperthermia for liver metastases

BACKGROUND

Interstitial laser hyperthermia (ILH) is an in situ ablative technique for the treatment of colorectal liver metastases. A significant factor limiting tumor destruction is hepatic blood flow. Modulation of hepatic blood flow may increase the size of tumor necrosis achieved. Our aim was to investigate the effect of blood flow occlusion on ILH-induced necrosis in both tumor and normal liver tissue.

MATERIALS AND METHODS

A model of colorectal liver metastases in male inbred CBA mice was used. ILH was applied to normal liver and tumor tissue using a bare optical quartz fiber from an SYL500 Nd:YAG surgical laser generator, with and without hepatic blood flow occlusion, and the extent of necrosis was studied. Tumor blood flow was assessed by laser Doppler flowmetry and scanning electron microscopy.

RESULTS

Hepatic blood flow occlusion resulted in a significant reduction in blood flow in normal liver tissue (37.9% +/- 5.8, P < 0.001) and in the periphery of the tumor (17.5% +/- 7.8, P < 0.001). It did not affect the blood flow in the center of the tumor (13.4% +/- 4.3, P = 0.07). ILH of normal liver tissue, at low power (2 W), with hepatic blood flow occlusion, resulted in a significant increase in the diameter of necrosis. This effect was not seen when higher power (5 W) was used in normal liver. No significant effect was noted within tumor tissue at either power setting.

CONCLUSION

The overall effect of hepatic blood flow occlusion in ILH-induced tissue necrosis appears to be negligible in tumor tissue. Its main applicability appears to be at the tumor-host interface, where a decrease in blood flow may lead to higher temperatures and therefore to a greater degree of tumor cell destruction.

Changes in the microvascular architecture of colorectal liver metastases following the administration of SMANCS/lipiodol

BACKGROUND

Liver metastases are the major cause of death for patients with colorectal cancer. Surgical resection is at present the only curative option. Styrene maleic acid neocarzinostatin [SMANCS/Lipiodol (S/L)] targets the unique vascular architecture of tumor blood vessels, which are hyperpermeable and lack a well-developed lymphatic system. Here we report changes in the microvascular architecture of liver metastases by scanning electron microscopy (SEM) following the administration of S/L.

MATERIALS AND METHODS

Liver metastases were induced by the intrasplenic injection of dimethylhydrazine induced colon cancer cells in mice. In this model tumor angiogenesis occurs at day 10, while exponential tumor growth occurs at day 16. Changes in the tumor microvasculature were observed at 3 weeks following treatment with S/L at these time points by SEM of corrosion casts.

RESULTS

Tumors treated with S/L at day 10 appear similar to day 10 controls. Tumor vessels, 50 +/- 18 microm in diameter, are easily identified from hepatic vessels. Within the hepatic sinusoids are avascular spaces, 144 +/- 60 microm in diameter, which correspond to tumor cell aggregates at the initial stages of growth. Similarly, day 16 treated tumors appear comparable to day 16 controls. These vessels are narrower (84 +/- 32 microm vs. 150 +/- 70 microm) than their control counterparts. This is in contrast to vessels (216 +/- 36 microm in diameter) of a complex nature at 3 weeks.

CONCLUSIONS

S/L exerts a marked and immediate effect on the tumor microvessels at both the angiogenic and the exponential phases of tumor growth. This agent is effective at the microvascular level during inhibition of metastatic growth.

Effect of interstitial laser hyperthermia in a murine model of colorectal liver metastases

Interstitial laser hyperthermia (ILH) is an in situ ablative technique used for the treatment of colorectal liver metastases. At present, few data exist concerning the optimum power settings required to maximize tissue necrosis. The aim of this study was to establish the dose-response relationship between the laser power setting and the extent of tissue necrosis produced in liver and tumor tissue, as well as the pattern of necrosis in a murine model of liver metastases. An intrasplenic induction model of liver metastases in 4- to 6-week-old male inbred CBA mice was used. Laser hyperthermia was applied to liver and tumor tissue using a bare optical quartz fiber from a Laserex SLY500 Nd:YAG surgical laser generator. Two-watt and 5-watt power settings were used at specific time intervals. The livers were then excised, fixed in formalin, and the extent and degree of necrosis were measured. Results were expressed as mean +/- standard deviation and were normally distributed. Analysis of variance was performed, and the least significant difference was used for post hoc tests. A P value of less than 0.05 was considered significant. Interstitial laser hyperthermia at 5 watts of power produced larger diameters of necrosis than did 2 watts for specific exposure times in normal liver tissue. However, when the total energy applied was compared, there was no significant difference in the diameters of tissue necrosis produced by the two power settings. The diameter of tissue necrosis in the normal liver increased from 2 mm at 10 joules to 8 mm at 600 joules of energy. Within tumor tissue, ILH at 2 and 5 watts produced similar diameters of necrosis for specific exposure times. When amounts of total energy applied were compared, ILH at the lower power setting (2 watts) produced a significantly larger diameter of necrosis than the higher power setting (5 watts). The diameter of necrosis achieved in tumor tissue was significantly larger than that in normal liver tissue at both power settings, for an equivalent amount of applied energy. The difference was more pronounced when ILH was performed at the lower power setting. The maximum diameter of necrosis achieved was 6.8 +/- 0.7 mm in normal liver tissue and 7.7 +/- 0.8 mm in tumor tissue. Charring of the fiber tip was delayed when the lower power setting was used, occurring after 20 seconds of exposure, compared to 5 seconds at the higher power setting. Similarly, cavitation occurred initially at 50 seconds at 5 watts of power and was delayed until 90 seconds of exposure at 2 watts of power. Histopathologic findings revealed an elliptical area of homogeneous necrosis, with a central acellular coagulum surrounded by intact but non-viable tissue. ILH is capable of producing highly reproducible, uniform, and complete tissue necrosis. The diameter of necrosis is related to the total energy applied. At low-power settings at any given amount of applied energy, a significantly larger diameter of tissue necrosis was achieved in tumor tissue compared to normal liver tissue.

Interstitial laser thermotherapy in the treatment of colorectal liver metastases

Metastatic liver disease is the commonest cause of death in patients with colorectal cancer. A small proportion of these patients (10%) may be treated by surgical resection with five year survival approaching 35-40%. Alternative treatment modalities for localised hepatic disease include in situ ablative techniques that have the advantages of percutaneous application and minimal morbidity. These include Interstitial Laser Thermotherapy (ILT), Radio Frequency Ablation, Percutaneous Microwave therapy, and Focussed Ultrasound Therapy. This article focuses specifically on the development and utilisation of ILT in the treatment of colorectal liver metastases. It provides a review of the pathophysiological factors involved, present status of clinical studies, and future directions. ILT is a safe technique for the treatment of colorectal liver metastases. It may be delivered by minimally invasive techniques to lesions considered unresectable by present criteria. Limitations include the extent and completeness of tumour necrosis achieved as well as imaging techniques. Clinical problems include a lack of controlled studies. Assessment of long-term survival in prospective randomised trials is needed to assess the efficacy of this procedure.