Cryotherapy for liver metastases

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

FUNDING

the trial did not provide information on funding.

AUTHORS' CONCLUSIONS

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

Hepatic artery chemoembolization in patients with ocular melanoma metastatic to the liver: response, survival, and prognostic factors

BACKGROUND

Although hepatic arterial chemoembolization (HACE) has been used for treatment of ocular melanoma metastatic to the liver, the prognostic indicators for survival after HACE have not been studied. We evaluated response rates and survival durations after HACE in such patients and analyzed factors affecting their survival.

METHODS

The medical records of patients with ocular melanoma metastatic to liver who underwent HACE at our institution from 1992 to 2005 were reviewed. The radiologic tumor response rates, and overall survival (OS) and progression-free survival durations were calculated, and patient, tumor, and treatment variables were analyzed to identify factors influencing survival.

RESULTS

One hundred twenty-five patients underwent 265 HACE sessions. Of 105 patients in whom radiologic responses could be evaluated, 12 (11%) had partial responses, 17 (16%) had minor responses, 68 (65%) had stable disease, and 8 (8%) had progressive disease. The median OS and progression-free survival durations were 6.7 and 3.8 months, respectively. Multivariate analysis showed that >75% liver involvement and high lactate dehydrogenase levels were associated with short OS. Patients who had radiologic responses to HACE had a longer median OS duration than did patients who did not (15.8 vs. 6.1 months; P = 0.0005). Patients with >75% liver involvement had a median OS duration of only 2.4 months.

CONCLUSIONS

HACE resulted in radiologic response or disease stabilization in most patients with ocular melanomas metastatic to the liver. The extent of liver involvement, baseline lactate dehydrogenase levels, and response to therapy were found to be significant predictors of OS after HACE.

Hepatic artery chemoembolization for 110 gastrointestinal stromal tumors: response, survival, and prognostic factors

BACKGROUND

The efficacy of hepatic artery chemoembolization (HACE) was evaluated for gastrointestinal stromal tumors (GISTs) metastatic to the liver.

METHODS

Records for patients with metastatic GIST who underwent HACE between January 1993 and March 2005 were reviewed and cross-sectional images were used to determine objective tumor response. Progression-free survival in the liver (PFS-liver) and overall survival (OS) were calculated with the Kaplan-Meier method. Patient, tumor, and treatment variables were analyzed to identify factors influencing survival.

RESULTS

Of the 110 patients identified, the radiologic response to HACE could be evaluated in 85 patients, 12 of whom (14%) demonstrated partial responses, 63 of whom (74%) demonstrated stable disease, and 10 of whom (12%) demonstrated progressive disease. PFS-liver rates were 31.2%, 8.2%, and 5.4% at 1, 2, and 3 years, respectively; the median PFS time was 8.2 months. OS rates were 62% at 1 year, 32% at 2 years, and 20% at 3 years; the median OS time was 17.2 months. Patients who had >5 liver metastases and received only 1 HACE treatment were found to have a shorter PFS compared with patients with fewer metastases or those who received > or =2 HACE sessions. Extensive liver involvement, the presence of extrahepatic metastases, and progression of liver disease after HACE were associated with poor OS. Use of imatinib prolonged OS time.

CONCLUSIONS

HACE produced a durable tumor response or disease stabilization in the majority of patients with GISTs metastatic to liver. Extent of liver disease, presence of extrahepatic disease, number of embolization treatments, and use of imatinib were found to have prognostic influence on PFS, OS, or both.

[Transarterial chemoembolization of liver metastases of colorectal carcinoma using degradable starch microspheres (Spherex): personal investigations and review of the literature]

Since two decades transarterial chemoembolization (TACE) of liver metastases has been investigated in numerous studies. However, no standardized therapeutic procedure exists so far. The present study retrospectively investigated survival, response and side effects after TACE of liver metastases in 21 patients with colorectal cancer and results are compared with previous literature. A total of 68 TACE procedures were performed. A suspension of degradable starch microspheres (DSM, Spherex) and Mitomycin C was applied selectively into hepatic arteries via a transfemoral approach. DSM effect a temporary arterial occlusion. Follow-up studies were performed by contrast enhanced spiral computed tomography (CT). The median survival was 13.8 months. Therapeutic response (according to WHO) was observed only in three patients. The progression free interval was 5.8 months. Patients developed a postembolization-syndrome (abdominal pain, fever, nausea) and increased transaminases in 27-43% of all interventions. A gastric ulcer occurred after four, cholecystitis after two TACE. As already shown in most previous studies, regardless of the used agents, also this investigation underlines the moderate therapeutic effect of TACE on colorectal liver metastases. So far, no significant survival benefit has been shown in the literature and the response rates are rather limited. In general, complications of TACE seem to be rare, but should not to be underestimated. Compared to TACE with long or permanent arterial occlusion, postembolization syndrome seems to be less pronounced using DSM. As TACE is rather a palliative therapeutic approach, DSM therefore might be more suited. Further studies on TACE of liver metastases should focus on to the patients' quality of life.

The enhanced therapeutic efficacy of intra-arterial cis-diamminedichloroplatinum (II) chemotherapy in combination with aortic clamping on metastatic hepatic tumors in the rat

The efficacy of intrahepatic cis-diamminedichloroplatinum (II), cisplatin, administered via the hepatic artery in combination with concomitant clamping of the abdominal aorta beneath the diaphragm against metastatic liver tumors in rats was evaluated. When 2.5 or 5 mg/kg of cisplatin was injected intra-arterially (i.a.) over 5 min, the antitumor activities in the rats with aortic clamping, evaluated by the number of tumor nodules and survival days after treatment, were found to be superior to those in the rats without aortic clamping. Side effects, evaluated in terms of glutamic oxaloacetic transaminase and glutamic pyruvic transaminase levels, changes in body weight, and the number of leukocytes, did not differ significantly among the rats with or without aortic clamping. The blood urea nitrogen levels observed in the rats with aortic clamping were lower than in those without aortic clamping. Immediately after the injection of cisplatin 5 mg/kg i.a., the platinum concentrations in the livers of rats with aortic clamping were approximately 2.1 times higher than in those without aortic clamping, and 1.4 times higher even 60 min after the injection. These increased platinum concentrations in the liver explain the enhanced antitumor activities of the rats given cisplatin with aortic clamping.