How Effective Are Percutaneous Liver-Directed Therapies in Patients with Non-Colorectal Liver Metastases?

The application of radiofrequency ablation in pancreatic cancer liver-only recurrence after radical pancreatectomy

To evaluate the safety, feasibility, and survival benefit of radiofrequency ablation in liver-only recurrence pancreatic cancer patients after radical pancreatectomy. The data and follow-up of pancreatic cancer patients who suffered liver-only recurrence after radical pancreatectomy from 2015 to 2021 were retrospectively collected. Finally, 19 liver metastases radiofrequency ablation patients were assigned to radiofrequency ablation group, and 41 patients were to systemic treatment group. (1) the baseline, perioperative characteristics, and pathological outcomes were well-balanced. (2) Recurrence pattern showed there were more multiple (> 3) recurrence tumors in systemic treatment patients (multiple one vs. 19, P = 0.005). (3) Median radiofrequency ablation operation time was 30.0 min, median blood loss was 1.0 ml, 4 (21.05%) patients suffered postoperative complications, and 94.74% liver metastases tumors got complete necrosis. The first efficacy evaluation showed a significantly better effect of radiofrequency ablation, complete and partial response rate 72.22% vs. 27.78%, P < 0.001. Overall survival from the initial surgery and after liver recurrence was significantly longer in the radiofrequency ablation group (43.0 vs. 22.0 months, 29.0 vs. 14.0 months, P = 0.003, 0.006, respectively). Progression-free survival after treatment was longer in the radiofrequency ablation group (6.0 vs. 5.0 months, P = 0.029). For liver recurrence tumor ≤ 3, overall survival from the initial surgery and after liver recurrence was significantly longer in radiofrequency ablation patients (43.0 vs. 22.0 months, 29.0 vs. 14.0 months, P = 0.011, 0.013, respectively). Progression-free survival after treatment was longer in the radiofrequency ablation group (7.0 vs. 4.0 months, P = 0.042). Radiofrequency ablation could get a curative purpose for patients with liver-only recurrence after pancreatectomy, improve progression-free survival and overall survival, and with minor surgery damage and risk.

Identifying Optimal Surgical Intervention-Based Chemotherapy for Gastric Cancer Patients With Liver Metastases

Background

This study aimed at evaluating the effects of surgical treatments-based chemotherapy in the treatment of gastric cancer with liver metastases (GCLM). It has not been established whether Liver-directed treatment (LDT) options such as hepatectomy and gastrectomy plus chemotherapy (HGCT), radiofrequency ablation and gastrectomy plus chemotherapy (RFAG), transarterial chemoembolization and gastrectomy plus chemotherapy (TACEG), gastrectomy plus chemotherapy (GCT) enhance the survival of GCLM patients.

Methods

We performed systematic literature searches in PubMed, EMBASE, and Cochrane library from inception to September 2021. We created a network plot to comprehensively analyze the direct and indirect evidence, based on a frequentist method. A contribution plot was used to determine inconsistencies, a forest plot was used to evaluate therapeutic effects, the publication bias was controlled by funnel plot, while the value of surface under the cumulative ranking curves (SUCRA) was calculated to estimate rank probability.

Results

A total of 23 retrospective studies were identified, involving 5472 GCLM patients. For OS and 1-, 2-, 3-year survival rate of all trials, meta-analysis of the direct comparisons showed significant better for HGCT treatments compared with GCT or PCT. In the comparison of the 5 treatments for 1-, 2-, 3-year survival rate, HGCT and RFAG were found to be more effective than GCT and PCT, respectively. By OS and 2-, 3-year survival rate analysis, RFAG was identified as the best option, followed by HGCT, TACEG, GCT and PCT. By 1-year survival rate analysis, HGCT and RFAG were identified as the most effective options.

Conclusion

HGCT and RFAG has remarkable survival benefits for GCLM patients when compared to TACEG, GCT and PCT. HGCT was found to exhibit superior therapeutic effects for GCLM patients for 1-year survival rate while RFAG was found to be a prospective therapeutic alternative for OS and 2-, 3-year survival rate.

Systematic Review Registration

identifier [10.37766/inplasy2020.12.0009].

Addressing hepatic metastases in ovarian cancer: Recent advances in treatment algorithms and the need for a multidisciplinary approach

The lifetime risk for ovarian cancer incidence is 1.39% and the lifetime risk of death is 1.04%. Most ovarian cancer patients are diagnosed at advanced stages (III, IV) because there were no specific symptoms or existing screening tests. Liver metastases have been found in up to 50% of patients dying of advanced ovarian cancer. Recent studies indicate the need for a multidisciplinary approach from initial diagnosis to oncologic surgery and chemotherapy treatment, mandating the involvement of gynecologic oncologists, surgical oncologist, medical oncologists, hepatobiliary surgeons, and interventional radiologists.

Minimally invasive image-guided therapy of primary and metastatic pancreatic cancer

Pancreatic cancer is a challenging malignancy with limited treatment options and poor life expectancy. The only curative option is surgical resection, but only 15%-20% of patients are resectable at presentation because more than 50% of patients has distant metastasis at diagnosis and the rest of them has locally advanced pancreatic cancer (LAPC). The standard of care first line treatment for LAPC patients is chemotherapy with or without radiation therapy. Recent developments in minimally invasive ablative techniques may add to the treatment armamentarium of LAPC. There are increasing number of studies evaluating these novel ablative techniques, including radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation. Most studies which included pancreatic tumor ablation, demonstrated improved overall survival in LAPC patients. However, the exact protocols are yet to set up to which stage of the treatment algorithm ablative techniques can be added and in what kind of treatment combinations. Patients with metastatic pancreatic cancer has dismal prognosis with 5-year survival is only 3%. The most common metastatic site is the liver as 90% of pancreatic cancer patients develop liver metastasis. Chemotherapy is the primary treatment option for patients with metastatic pancreatic cancer. However, when the tumor is not responding to chemotherapy or severe drug toxicity develops, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease progression and improve survival in selected patients. During the last decade new therapeutic options arose with the advancement of minimally invasive technologies to treat pancreatic cancer patients. These new therapies have been a topic of increasing interest due to the severe prognostic implications of locally advanced and metastatic pancreatic cancer and the low comorbid risk of these procedures. This review summarizes new ablative options for patients with LAPC and percutaneous liver-directed therapies for patients with liver-dominant metastatic disease.

Liver Resection as Part of Cytoreductive Surgery for Ovarian Cancer

Objective: The aim of this study was to describe and evaluate the safety of hepatic resections for ovarian cancer liver metastases and the benefit in terms of survival as part of cytoreductive surgery among peritoneal seeding and parenchymal metastases.

Materials and Methods: Data were reviewed retrospectively from patients who underwent liver resection as part of cytoreductive surgery for ovarian cancer at the Instituto Nacional de Enfermedades Neoplásicas, in Lima, Perú, from January 2009 to December 2017.

Results: From January 2009 to December 2017, 1211 patients underwent surgical cytoreduction for ovarian cancer; 39 of these patients had liver resection as part of their surgical treatment, with 9, 17, and 13 patients receiving primary, secondary, and tertiary, resections, respectively. The mean age of the patients was 46, the majority (87%) had stage III/IV ovarian cancer. In addition, 21 patients had parenchymal metastasis resections, and 95% of the patients had Dindo–Clavien I and II grade complications. The 30-day mortality rate was 0.

Conclusions: Liver resection for advanced ovarian cancer is a safe procedure for primary up to quaternary cytoreduction and may confer survival benefits to patients.

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases

BACKGROUND Three patients with stage IV esophagogastric junction cancer (EGJC) underwent extended resection to achieve a graphic/surgical R0 status (no visible remnant of viable tumor in imaging/surgical findings) and adjuvant chemotherapy from the early postoperative period. We also introduced use of our digestive reconstruction technique in these patients. CASE REPORT We used jejunal interposition for digestive reconstruction, which involved end-to-end jejunojejunostomy with a biofragmentable anastomosis ring. The mesojejunal autonomic nerves of the lifted jejunum were preserved. The first adenocarcinoma involved the perilesional lymph nodes (LNs). Graphic/surgical R0 resection was completed by para-aortic LN dissection. The diagnosis (Japanese Classification of Gastric Carcinoma) was stage IV [pM1(LYM)]. Adjuvant chemotherapy began on postoperative day (POD) 11. The second adenocarcinoma was accompanied by a solitary lung metastasis. Intraoperative cytology of ascitic fluid was positive, and cisplatin was intraperitoneally administered. Adjuvant chemotherapy began on POD 10. The solitary lung metastasis was then resected, and graphic/surgical R0 resection was achieved. The diagnosis was stage IV [pM1(PUL) and CY1]. The third adenocarcinoma was accompanied by multiple liver metastases and metastatic regional LNs. The diagnosis was stage IV [H1]. Systemic chemotherapy was repeated. Only a solitary liver metastasis remained and was treated by radiofrequency ablation. Conversion surgery was conducted, achieving graphic/surgical R0 resection. Systemic chemotherapy was continued from POD 10. CONCLUSIONS For patients with stage IV EGJC, extended resection to achieve a graphic/surgical R0 status is still controversial, and systemic chemotherapy is important. The results of the present study suggest that our physiological reconstruction technique does not affect the efficacy of other therapies, such as adjuvant chemotherapy.

Radiofrequency ablation versus hepatic resection for breast cancer liver metastasis: a systematic review and meta-analysis

OBJECTIVE

To evaluate the comparative therapeutic efficacy of radiofrequency ablation (RFA) and hepatic resection (HR) for breast cancer liver metastases (BCLMs).

METHODS

Studies that had examined the outcomes for both RFA and HR for BCLM were identified by searching the electronic databases PubMed, EMBASE, and the Cochrane Library. Pooled analyzes of the overall survival (OS), disease-free survival (DFS), and short-term outcomes of BCLM were performed.

RESULTS

Patients with BCLM gained many more survival benefits from HR than from RFA with regard to the 3-year OS rate (combined odds ratio (OR) 0.41, 95% confidence interval (CI) 0.29-0.59, P<0.001), 5-year OS rate (combined OR 0.38, 95% CI 0.32-0.46, P<0.001), 3-year DFS (combined OR 0.36, 95% CI 0.27-0.49, P<0.001), and 5-year DFS (combined OR 0.51, 95% CI 0.40-0.66, P<0.001). RFA had fewer postoperative complications (combined OR 0.30, 95% CI 0.20-0.44, P<0.001) and shorter hospital stays (combined OR -9.01, 95% CI -13.49-4.54, P<0.001) than HR.

CONCLUSIONS

HR takes precedence over RFA in the treatment of patients with BCLM, considering the better survival rate. RFA gives rise to fewer complications and can be carried out with a shorter hospital stay, compared to HR. RFA should be reserved for patients who are not optimum candidates for resection.

Percutaneous Isolated Hepatic Perfusion as a Treatment for Isolated Hepatic Metastases of Uveal Melanoma: Patient Outcome and Safety in a Multi-centre Study

PURPOSE

Percutaneous isolated hepatic perfusion (PIHP) with Melphalan has been developed as a treatment for patients with isolated hepatic metastases of uveal melanoma. We discuss patient outcome and safety in a retrospective multi-centre study.

MATERIALS AND METHODS

Between 2012 and 2016 18 patients with un-resectable isolated hepatic metastases of uveal melanoma received single or repeated PIHP with Melphalan (n = 35) at seven sites. Progression-free time, overall survival time (OS) and tumour response by means of RECIST 1.1 criteria were evaluated. Peri- and post-procedural adverse events (AE) were registered. Patients' life quality was assessed using four-point scale questionnaires.

RESULTS

Of 18 patients, initial PIHP treatment resulted in partial response (PR) in eight, stable disease (SD) in seven and progressive disease (PD) in three cases. Nine patients underwent second PIHP with PR in eight cases and PD in one case. Six patients were evaluated after third PIHP with PR in five patients and SD in one patient. Two patients received fourth PIHP with PD in both cases. Median OS was 9.6 months (range 1.6-41.0 months). Median progression-free survival time was 12.4 months (range 0.9-41.0 months) with 1-year survival of 44%. Most common post-procedural AE grade 3 and 4 were temporary leukopenia (n = 11) and thrombocytopenia (n = 8). Patients' self-assessments showed good ratings for overall health and quality of life with only slight changes after PIHP, and a high degree of satisfaction with PIHP treatment.

CONCLUSION

PIHP with Melphalan proved to be a relatively safe, minimal-invasive and repeatable treatment for patients with non-resectable hepatic metastases of uveal melanoma.

Preliminary results of ultrasound-guided laser ablation for unresectable metastases to retroperitoneal and hepatic portal lymph nodes

BACKGROUND

Laser ablation with a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is a minimally invasive approach which is able to achieve a precise tissue necrosis. The study was aimed to assess the feasibility and efficiency of laser ablation in the treatment of retroperitoneal and hepatic portal unresectable metastatic lymph nodes.

METHODS

Eight patients including 11 pathologically proven metastatic lymph nodes, 4 in retroperitoneal, 7 in hepatic portal region, were treated by laser ablation. Primary cancers were cholangiocarcinoma (n = 4) and hepatocellular carcinoma (n = 4). Under sonographic guidance, the laser ablation was performed percutaneously. Follow-up contrast computed tomography or magnetic resonance image was performed.

RESULTS

The treatments were completed in single process in all the patients. No severe complications occurred. Follow-up contrast computed tomography or magnetic resonance imaging at 1 and 3 months showed partial responses in 11 lymph nodes. The local response rate at the 6 month follow-up was 75.0 %. The overall response rate was 62.5 %. Abdominal pain scores decreased significantly in all patients. Tumor marker levels decreased in six patients. The Child-Pugh grade did not change.

CONCLUSIONS

The results suggest that sonographically guided laser ablation is technically feasible for the local treatment of unresectable retroperitoneal and hepatic portal lymph nodes from hepatic cancer. Although further study is needed to evaluate its long time efficacy, abdominal pain relief is prominent.