Local recurrence rates after radiofrequency ablation or resection of colorectal liver metastases. Analysis of the European Organisation for Research and Treatment of Cancer #40004 and #40983

The relationship between applied energy and ablation zone volume in patients with hepatocellular carcinoma and colorectal liver metastasis

Objectives

To study the ratio of ablation zone volume to applied energy in computed tomography (CT)-guided radiofrequency ablation (RFA) and microwave ablation (MWA) in patients with hepatocellular carcinoma (HCC) in a cirrhotic liver and in patients with colorectal liver metastasis (CRLM).

Methods

In total, 90 liver tumors, 45 HCCs in a cirrhotic liver and 45 CRLMs were treated with RFA or with one of two MWA devices (MWA_A and MWA_B), resulting in 15 procedures for each tumor type, per device. Device settings were recorded and the applied energy was calculated. Ablation volumes were segmented on the contrast-enhanced CT scans obtained 1 week after the procedure. The ratio of ablation zone volume in milliliters to applied energy in kilojoules was determined for each procedure and compared between HCC (R_HCC) and CRLM (R_CRLM), stratified according to ablation device.

Results

With RFA, R_HCC and R_CRLM were 0.22 mL/kJ (0.14–0.45 mL/kJ) and 0.15 mL/kJ (0.14–0.22 mL/kJ; p = 0.110), respectively. With MWA_A, R_HCC was 0.81 (0.61–1.07 mL/kJ) and R_CRLM was 0.43 (0.35–0.61 mL/kJ; p = 0.001). With MWA_B, R_HCC was 0.67 (0.41–0.85 mL/kJ) and R_CRLM was 0.43 (0.35–0.61 mL/kJ; p = 0.040).

Conclusions

With RFA, there was no significant difference in energy deposition ratio between tumor types. With both MWA devices, the ratios were higher for HCCs. Tailoring microwave ablation device protocols to tumor type might prevent incomplete ablations.

Key Points

• HCCs and CRLMs respond differently to microwave ablation

• For MWA, CRLMs required more energy to achieve a similar ablation volume

• Tailoring ablation protocols to tumor type might prevent incomplete ablations

The impact of primary tumour location in patients undergoing hepatic resection for colorectal liver metastasis

BACKGROUND

Primary tumour location has long been debated as a prognostic factor in colorectal cancer patients with liver metastases (CRLM) undergoing liver resection. This retrospective study was conducted to clarify the prognostic value of tumour location after radical hepatectomy for CRLM and its underlying causes.

METHODS

We retrospectively analysed clinical data from 420 patients with CRLM whom underwent liver resection between January 2002 and December 2015. Right-sided (RS) tumours include tumours located in the cecum, ascending colon, and transverse colon, and left-sided (LS) tumours include those located in the splenic flexure, descending colon, sigmoid colon, and rectum.

RESULTS

Both overall survival (OS) and disease-free survival (DFS) were similar between patients with RS and LS primary tumours (5-year OS: 46.5% vs 38.3%, P = 0.699; 5-year DFS: 29.1% vs 22.4%, P = 0.536). Specifically, RAS mutation rate was significantly higher in patients with RS tumours (P = 0.007). Subgroup analysis showed that the RAS mutation on the LS and RS tumours have different prognostic impact for CRLM patients on long-term survival after hepatic resection (RS, OS: P = 0.437, DFS: P = 0.471; LS, OS: P < 0.001, DFS: P = 0.002). The multivariable analysis showed that RAS mutant is an independent factor influencing OS in patients with LS primary tumour only.

CONCLUSIONS

The site of the primary tumour has no significant impact on the long-term survival in patients with CRLM undergoing radical surgery. However, prognostic value of RAS status differs depending on the site of the primary tumour.

Two-Stage Hepatectomy vs One-Stage Major Hepatectomy with Contralateral Resection or Ablation for Advanced Bilobar Colorectal Liver Metastases

BACKGROUND

Both 2-stage hepatectomy (TSH) and 1-stage hepatectomy (OSH) represent feasible strategies for resection of advanced bilobar colorectal liver metastases (CLM). However, the influence of the surgical approach on postoperative outcomes and overall survival (OS) is unknown. To define the optimal surgical approach for advanced bilobar CLM requiring right hemihepatectomy, we compared short-term and long-term outcomes after TSH and OSH with contralateral resection or radiofrequency ablation (RFA).

STUDY DESIGN

We retrospectively reviewed 227 patients with bilobar CLM, who underwent right or extended right hepatectomy with treatment of synchronous CLM in segments I, II, and/or III, between 1998 and 2015. Postoperative outcomes and OS were compared between patients who underwent TSH and those who underwent OSH.

RESULTS

Of the 227 patients, 126 (56%) underwent at least the first stage of TSH, and 101 (44%) underwent OSH, 29 (13%) without RFA and 72 (32%) with RFA. Two-stage hepatectomy was associated with a lower incidence of postoperative major complications (14% vs 26%, p = 0.03) and postoperative hepatic insufficiency (6% vs 20%, p = 0.001) than OSH. The 5-year OS rate was higher for patients assigned to TSH than for those who underwent OSH (35% vs 24%, p = 0.016). Patients who completed both stages of TSH had a higher 5-year OS rate than patients who underwent OSH without RFA (50% vs 20%, p = 0.023) or OSH with RFA (50% vs 24%, p < 0.0001).

CONCLUSIONS

In patients with advanced bilobar CLM, TSH is associated with fewer complications than OSH. Both TSH in intention-to-treat analysis and completed TSH in as-treated analysis were associated with better OS than OSH.

Liver resection surgery versus thermal ablation for colorectal LiVer MetAstases (LAVA): study protocol for a randomised controlled trial

Background

Although surgical resection has been considered the only curative option for colorectal liver metastases (CLM), thermal ablation has recently been suggested as an alternative curative treatment. A prospective randomised trial is required to define the efficacy of resection vs ablation for the treatment of colorectal liver metastases.

Methods

Design and setting: This is a multicentre, open, randomised controlled non-inferiority trial design with internal pilot and will be performed in tertiary liver centres in UK and The Netherlands.

Participants: Eligible patients will be those with colorectal liver metastases at high surgical risk because of their age, co-morbidities or tumour burden and who would be suitable for liver resection or thermal ablation.

Intervention: Thermal ablation as per local policy.

Control: Surgical liver resection performed as per centre protocol.

Co-interventions: Further chemotherapy will be offered to patients as per current practice.

Outcomes

Pilot study: Same as main study and in addition patients and clinicians’ acceptability of the trial to assist in optimisation of recruitment.

Primary outcome: Disease-free survival (DFS) at two years post randomisation.

Secondary outcomes: Overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, DFS measured from end of intervention.

Follow-up: 24 months from randomisation; five-year follow-up for overall survival.

Sample size: 330 patients to demonstrate non-inferiority of thermal ablation.

Discussion

This trial will determine the effectiveness and cost-effectiveness of thermal ablation vs surgical resection for high-risk people with colorectal liver metastases, and guide the optimal treatment for these patients.

Trial registration

ISRCTN Registry, ISRCTN52040363. Registered on 9 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2499-5) contains supplementary material, which is available to authorized users.

[Oligometastasized stage IV colorectal cancer : Surgical resection and local ablative procedures]

BACKGROUND

By the intensified combination of systemic, surgical and local ablative therapies a significant improvement in therapy results for metastasized colorectal cancer has been achieved in the last decade. Downstaging with subsequent resection is nowadays a standard for oligometastasized primarily unresectable colorectal cancer.

MATERIAL AND METHODS

The value of combining resection and local ablation is unclear; therefore, this article gives an overview of the available literature dealing with the combination of surgery and local ablative methods for oligometastasized stage IV colorectal cancer.

RESULTS

The best results were obtained following surgical resection alone. Whereas nowadays cryoablation is of minor importance, the most successful results are achieved following local ablative methods by radiofrequency and microwave ablation. In the future irreversible electroporation will be the most promising local ablative method. A combination of surgical resection and local ablation appears to be rational in patients if an R0 resection can be achieved.

CONCLUSION

Surgical resection of colorectal liver metastases is the gold standard for oncological therapy whenever possible. The rational combination of non-curative surgical resection and local ablation should be considered in the context of a multimodal therapeutic strategy, particularly in patients with primarily resectable disease.

Comparison of Stereotactic Body Radiation Therapy and Radiofrequency Ablation in the Treatment of Intrahepatic Metastases

PURPOSE

Stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) are widely used therapies for the treatment of intrahepatic metastases; however, direct comparisons are lacking. We sought to compare outcomes for these 2 modalities.

METHODS AND MATERIALS

From 2000 to 2015, 161 patients with 282 pathologically diagnosed unresectable liver metastases were treated with RFA (n = 112) or SBRT (n = 170) at a single institution. The primary outcome was freedom from local progression (FFLP). The effect of treatment and covariates on FFLP was modeled using a mixed-effects Cox model with application of inverse probability treatment weighting to adjust for potential imbalances in treatment modality.

RESULTS

The median follow-up period was 24.6 months. Patients receiving SBRT had larger tumors than those treated with RFA (median, 2.7 cm vs 1.8 cm; P < .01). On univariate analysis, tumor size was associated with worse FFLP for RFA (hazard ratio [HR]; 1.57; 95% confidence interval [CI], 1.15-2.14; P < .01) but not for SBRT (HR, 1.38; 95% CI, 0.76-2.51; P = .3). The 2-year FFLP rate was 88.2% compared with 73.9%, favoring SBRT (P = .06). For tumors ≥2 cm in diameter, SBRT was associated with improved FFLP (HR, 0.28; 95% CI, 0.09-0.93; P < .01). On multivariate analysis, treatment with SBRT (HR, 0.21; 95% CI, 0.07-0.62; P = .005) and smaller tumor size (HR, 0.65; 95% CI, 0.47-0.91; P = .01) were associated with improved FFLP. The 2-year overall survival rate was 51.1%, with no difference between groups (P = .8). Grade ≥3 treatment-related toxicity was rare, with no difference between SBRT (n = 4) and RFA (n = 3).

CONCLUSIONS

Treatment with SBRT or RFA is well tolerated and provides excellent and similar local control for intrahepatic metastases <2 cm in size. For tumors ≥2 cm in size, treatment with SBRT is associated with improved FFLP and may be the preferable treatment.

Surgical Treatment of Metastatic Colorectal Cancer

Surgical treatment of metastatic colorectal cancer offers a chance for cure or prolonged survival, particularly for those with more favorable prognostic factors and limited tumor burden. The treatment plan requires multidisciplinary evaluation because multiple therapy options exist. Advanced surgical techniques, adjuncts to resection, and modern chemotherapy all contribute to best outcomes for patients with hepatic metastases. Although cure is less common for patients with metastasis to lung or peritoneum, surgical resection for the former and cytoreduction and intraperitoneal chemotherapy for the latter may help to achieve cancer control in selected patients.

Ultrasound-ultrasound image overlay fusion improves real-time control of radiofrequency ablation margin in the treatment of hepatocellular carcinoma

OBJECTIVES

To assess the clinical feasibility of US-US image overlay fusion with evaluation of the ablative margin in radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).

METHODS

Fifty-three patients with 68 HCCs measuring 0.9-4.0 cm who underwent RFA guided by US-US overlay image fusion were included in this retrospective study. By an overlay of pre-/postoperative US, the tumor image could be projected onto the ablative hyperechoic zone. Therefore, the ablative margin three-dimensionally could be shown during the RFA procedure. US-US image overlay was compared to dynamic CT a few days after RFA for assessment of early treatment response. Accuracy of graded response was calculated, and the performance of US-US image overlay fusion was compared with that of CT using a Kappa agreement test.

RESULTS

Technically effective ablation was achieved in a single session, and 59 HCCs (86.8 %) succeeded in obtaining a 5-mm margin on CT. The response with US-US image overlay correctly predicted early CT evaluation with an accuracy of 92.6 % (63/68) (k = 0.67; 95 % CI: 0.39-0.95).

CONCLUSION

US-US image overlay fusion can be proposed as a feasible guidance in RFA with a safety margin and predicts early response of treatment assessment with high accuracy.

KEY POINTS

• US-US image overlay fusion visualizes the ablative margin during RFA procedure. • Visualizing the margin during the procedure can prompt immediate complementary treatment. • US image fusion correlates with the results of early evaluation CT.

Survival prediction in patients with resectable colorectal liver metastases: Clinical risk scores and tumor response to chemotherapy

Clinical risk scores and response to pre-operative chemotherapy are prognostic factors of colorectal liver metastases. The aim of the present study was to evaluate the effectiveness of combining these factors to predict patient survival and to select patients for curative therapy. The study included 189 patients who underwent hepatectomy following neo-adjuvant chemotherapy, for initially resectable colorectal liver metastases, between January 2005 and December 2015. Patients were stratified into four sub-groups: A1-2, low clinical risk scores with/without a response to pre-operative chemotherapy; and B1-2, high clinical risk scores with or without a response to pre-operative chemotherapy. Treatment and survival data were analysed. Survival was significantly longer in patients with low clinical risk scores and a response to pre-operative chemotherapy; these factors were confirmed as independent prognostic factors by multivariate analysis. Combining clinical risk score and chemotherapy response classification, patient survival was significantly longer for groups A1-2/B1 compared with for group B2, in which only 10.2% of patients were alive after 5 years. Of those with no response to first-line chemotherapy, survival was significantly longer in patients who responded to second-line chemotherapy. A combined clinical risk score and chemotherapy response classification may aid in identifying suitable candidates for potentially curative therapy.

[Liver metastases of colorectal cancer]

Liver metastases are the most common cause of death in colorectal cancer patients. Nowadays, complete resection is considered to be the only curative treatment but only approximately 25% of patients are suitable candidates for surgery; therefore, many different interventional oncology techniques have been developed in recent years for the treatment of secondary liver metastases. The aim of interventional oncological procedures is either to provide a potentially curative treatment option for locally limited metastases with local ablative techniques, to enable nonresectable tumors to become accessible to surgical or local ablative techniques using transarterial procedures or to achieve improved survival in a palliative setting. These interventional therapies include transarterial approaches, such as chemoembolization and radioembolization as well as a multitude of different ablative techniques, such as radiofrequency and microwave ablation as well as irreversible electroporation (IRE). This article describes the indications for the various procedures and the clinical results of each of these techniques are reviewed based on the currently available literature.

Targeting STAT3 to Suppress Systemic Pro-Oncogenic Effects from Hepatic Radiofrequency Ablation

Purpose To (a) identify key expressed genes in the periablational rim after radiofrequency ablation (RFA) and their role in driving the stimulation of distant tumor growth and (b) use adjuvant drug therapies to block key identified mediator(s) to suppress off-target tumorigenic effects of hepatic RFA. Materials and Methods This institutional animal care and use committee-approved study was performed in C57BL6 mice (n = 20) and F344 rats (n = 124). First, gene expression analysis was performed in mice after hepatic RFA or sham procedure; mice were sacrificed 24 hours to 7 days after treatment. Data were analyzed for differentially expressed genes (greater than twofold change) and their functional annotations. Next, animals were allocated to hepatic RFA or sham treatment with or without STAT3 (signal transducer and activator of transcription 3) inhibitor S3I-201 for periablational phosphorylated STAT3 immunohistochemistry analysis at 24 hours. Finally, animals with subcutaneous R3230 adenocarcinoma tumors were allocated to RFA or sham treatment with or without a STAT3 inhibitor (S3I-201 or micellar curcumin, eight arms). Outcomes included distant tumor growth, proliferation (Ki-67 percentage), and microvascular density. Results At 24 hours, 217 genes had altered expression (107 upregulated and 110 downregulated), decreasing to 55 genes (27 upregulated and 28 downregulated) and 18 genes (four upregulated, 14 downregulated) at 72 hours and 7 days, respectively. At 24 hours, STAT3 occurred in four of seven activated pathways associated with pro-oncogenic genes at network analysis. Immunohistochemistry analysis confirmed elevated periablational phosphorylated STAT3 24 hours after RFA, which was suppressed with S3I-201 (percentage of positive cells per field: 31.7% ± 3.4 vs 3.8% ± 1.7; P < .001). Combined RFA plus S3I-201 reduced systemic distant tumor growth at 7 days (end diameter: 11.8 mm ± 0.5 with RFA plus S3I-201, 19.8 mm ± 0.7 with RFA alone, and 15 mm ± 0.7 with sham procedure; P < .001). STAT3 inhibition with micellar curcumin also suppressed postablation stimulation of distant tumor growth, proliferation, and microvascular density (P < .01). Conclusion Gene expression analysis identified multiple pathways upregulated in the periablational rim after hepatic RFA, of which STAT3 was active in four of seven. Postablation STAT3 activation is linked to increased distant tumor stimulation and can be suppressed with adjuvant STAT3 inhibitors. ^© RSNA, 2017.

局部治疗手段在结直肠癌肝转移治疗中的价值

结直肠癌肝转移患者全身治疗是标准治疗, 应该作为每一种治疗策略的初始, 但局部治疗也发挥着重要价值. 手术完全切除肝转移灶仍是目前能治愈结直肠癌和胃肠道神经内分泌肿瘤肝转移的最佳方法. 射频消融主要应用于那些不可切除或术后复发的局限性病灶, 但受转移灶大小、数量和解剖位置的制约. 立体定向放射治疗作为一种非手术的局部治疗是安全、有效的. 微波消融、冷冻消融、高能聚焦超声刀、经皮穿刺瘤内注射无水乙醇、肝动脉栓塞或肝动脉化疗栓塞、肝动脉灌注化疗等也是重要的局部治疗手段, 在患者的综合治疗中发挥重要作用. 本文就以上内容作一综述.

Local tumor progression patterns after radiofrequency ablation of colorectal cancer liver metastases

PURPOSE

We aimed to evaluate patterns of local tumor progression (LTP) after radiofrequency ablation (RF ablation) of colorectal cancer liver metastases (CRCLM) and to highlight the percentage of LTP not attributable to lesion size or RF ablation procedure-related factors (heat sink or insufficient ablation margin).

METHODS

CRCLM treated by RF ablation at a single tertiary care center from 2004-2012, with a minimum of six months of postprocedure follow-up, were included in this retrospective study. LTP morphology was classified as focal nodular (<90° of ablation margin), circumferential (>270°), or crescentic (90°-270°). Initial metastasis size, minimum ablation margin size, morphology of LTP, presence of a heat sink, and time to progression were recorded independently by two radiologists.

RESULTS

Thirty-two of 127 RF ablation treated metastases (25%) with a mean size of 23 mm (standard deviation 12 mm) exhibited LTP. Fifteen of 32 LTPs (47%) were classified as focal nodular, with seven having no procedure-related factor to explain recurrence. Ten of 32 LTPs (31%) were circumferential, with four having no procedure-related factor to explain recurrence. Seven of 32 LTPs (22%) were crescentic, with two having no procedure-related factor to explain recurrence. Of the 13 lesions without any obvious procedure-related reason for LTP, six (46%) were <3 cm in size.

CONCLUSION

Although LTP in RF ablation treated CRCLM can often be explained by procedure-related factors or size of the lesion, in this study up to six (5%) of the CRCLM we treated showed LTP without any reasonable cause.

Radiofrequency Ablation versus Liver Resection for Colorectal Cancer Liver Metastasis: An Updated Systematic Review and Meta-analysis

Background:

Controversial results about the therapeutic value of radiofrequency ablation (RFA) and liver resection (LR) in the treatment of colorectal cancer liver metastasis (CRCLM) have been reported. Thus, we performed the present meta-analysis to summarize the related clinical evidences.

Methods:

A systematic literature search was conducted using PubMed (Medline), EMBASE, Cochrane Library, and Web of Science, for all years up to April 2016. Pooled analyses of the overall survival (OS), progression-free survival (PFS), and morbidity rates were performed.

Results:

A total of 14 studies were finally enrolled in the meta-analysis. Patients treated by LR gained a longer OS and PFS than those of patients treated by RFA. Patients in the RFA group had lower morbidity rates than those of patients in the LR group. Publication bias analysis revealed that there was no significant publication bias in the meta-analysis.

Conclusions:

Patients with CRCLM gained much more survival benefits from LR than that from RFA. RFA rendered lower rates of morbidities. More well-designed randomized controlled trails comparing the therapeutic value of LR and RFA are warranted.

Long-term outcomes of radiofrequency ablation combined with hepatectomy compared with hepatectomy alone for colorectal liver metastases

Background

Combining radiofrequency ablation (RFA) with hepatectomy may enable treatment with curative intent for patients with colorectal liver metastasis (CRLM). However, the oncological outcomes in comparison with resection alone remain to be clarified.

Methods

Patients who underwent a first hepatectomy between 2001 and 2012 for CRLM were enrolled. Short- and long-term outcomes of patients who underwent hepatectomy plus RFA were compared with those of patients who had hepatectomy alone using propensity score matching.

Results

Of a total of 553 patients, hepatectomy + RFA and hepatectomy alone were performed in 37 and 516 respectively. Before matching, patients in the hepatectomy + RFA group were characterized primarily by a larger tumour burden. After matching of 31 patients who underwent hepatectomy + RFA with 93 who had hepatectomy alone, background characteristics were well balanced. In the matched cohort, overall and disease-free survival in the hepatectomy + RFA group were no different from those among patients who had hepatectomy alone (5-year overall survival rate 57 versus 61 per cent, P = 0·649; 5-year disease-free survival rate 19 versus 17 per cent, P = 0·865). Local recurrence at the ablated site was observed in four of 31 patients (13 per cent). Although overall local recurrence (ablated site and/or cut surface) was more frequent in the hepatectomy + RFA group (9 of 31 (29 per cent) versus 11 of 93 (12 per cent); P = 0·032), there was no difference in intrahepatic disease-free survival between the two groups (P = 0·705).

Conclusion

Hepatectomy + RFA achieved outcomes comparable to hepatectomy alone. Combining RFA with hepatectomy should be considered as an option to achieve cure.

Chemosaturation Percutaneous Hepatic Perfusion: A Systematic Review

The Hepatic CHEMOSAT® Delivery System is an innovative medical device for the treatment of patients with unresectable primary liver tumors or unresectable hepatic metastases from solid organ malignancies. This system is used to perform chemosaturation percutaneous hepatic perfusion (CS-PHP), a procedure in which a high dose of the chemotherapeutic agent melphalan is delivered directly to the liver while limiting systemic exposure. In a clinical trial program, CS-PHP with melphalan significantly improved hepatic progression-free survival in patients with unresectable hepatic metastases from ocular or cutaneous melanoma. Clinically meaningful hepatic responses were also observed in patients with hepatocellular carcinoma or neuroendocrine tumors. Furthermore, the results of published studies and case reports demonstrated that CS-PHP with melphalan resulted in favorable tumor response rates in a range of tumor histologies (ocular or cutaneous melanoma, colorectal cancer, and hepatobiliary tumors). Analyses of the safety profile of CS-PHP revealed that the most common adverse effects were hematologic events (thrombocytopenia, anemia, and neutropenia), which were clinically manageable. Taken together, these findings indicate that CS-PHP is a promising locoregional therapy for patients with primary and secondary liver tumors and has a acceptable safety profile.

FUNDING

Delcath Systems Inc., New York, NY, USA.

Radiofrequency Ablation Combined with Hepatic Arterial Chemoembolization Using Degradable Starch Microsphere Mixed with Mitomycin C for the Treatment of Liver Metastasis from Colorectal Cancer: A Prospective Multicenter Study

PURPOSE

This phase II prospective study investigates possible benefits of radiofrequency ablation (RFA) combined with hepatic arterial chemoembolization using degradable starch microsphere (DSM) mixed with mitomycin C (MMC) in non-surgical candidates with colorectal liver metastases.

MATERIALS AND METHODS

This study, approved by the respective institutional review board, included non-surgical candidates with 3 or fewer liver tumors of 3 cm or smaller, or a single lesion 5 cm or smaller. Percutaneous RFA was performed immediately after chemoembolization using DSM-MMC. Primary and secondary endpoints were the local tumor control rate, safety, and 2-year recurrence-free and overall survival rates.

RESULTS

This study examined 25 patients (22 males, 3 females) with 38 tumors of mean maximum diameter of 2.2 ± 0.9 cm (standard deviation) (range 1.0-4.2 cm). Their mean age was 70.2 ± 8.2 years (range 55-82 years). Local tumor progression developed in 3 tumors (7.9%, 3/38) of 3 patients (12%, 3/25) during the mean follow-up of 34.9 ± 9.2 months (range 18.3-50.1 months). The 2-year local tumor control rates were 92.0% [95% confidence interval (CI), 81.4-100%] on a patient basis and 94.6% (95% CI, 87.3-100%) on a tumor basis. The respective 2-year overall and recurrence-free survival rates were 88.0% (95% CI, 75.3-98.5%) and 63.3% (95% CI, 44.2-82.5%), with median survival time of 48.4 months. Fever was the only adverse event requiring treatments in 2 patients (8%).

CONCLUSIONS

This combination therapy is safe, exhibiting strong anticancer effects on colorectal liver metastasis, which might contribute to patient survival.

CXCR4-CXCL12-CXCR7, TLR2-TLR4, and PD-1/PD-L1 in colorectal cancer liver metastases from neoadjuvant-treated patients

A neoadjuvant clinical trial was previously conducted in patients with resectable colorectal cancer liver metastases (CRLM). At a median follow up of 28 months, 20/33 patients were dead of disease, 8 were alive with disease and 5 were alive with no evidence of disease. To shed further insight into biological features accounting for different outcomes, the expression of CXCR4-CXCL12-CXCR7, TLR2-TLR4, and the programmed death receptor-1 (PD-1)/programmed death-1 ligand (PD-L1) was evaluated in excised liver metastases. Expression profiles were assessed through qPCR in metastatic and unaffected liver tissue of 33 CRLM neoadjuvant-treated patients. CXCR4 and CXCR7, TLR2/TLR4, and PD-1/PD-L1 mRNA were significantly overexpressed in metastatic compared to unaffected liver tissues. CXCR4 protein was negative/low in 10/31, and high in 21/31, CXCR7 was negative/low in 16/31 and high in 15/31, CXCL12 was negative/low in 14/31 and high in 17/31 CRLM. PD-1 was negative in 19/30 and positive in 11/30, PD-L1 was negative/low in 24/30 and high in 6/30 CRLM. Stromal PD-L1 expression, affected the progression-free survival (PFS) in the CRLM population. Patients overexpressing CXCR4 experienced a worse PFS and cancer specific survival (CSS) (p = 0.001 and p = 0.0008); in these patients, KRAS mutation identified a subgroup with a significantly worse CSS (p < 0.01). Thus, CXCR4 and PD-L1 expression discriminate patients with the worse PFS within the CRLM evaluated patients. Within the CXCR4 high expressing patients carrying Mut-KRAS in CRLM identifies the worst prognostic group. Thus, CXCR4 targeting plus anti-PD-1 therapy should be explored to improve the prognosis of Mut-KRAS-high CXCR4-CRLMs.

Colorectal Liver Metastases: A Critical Review of State of the Art

BACKGROUND

Over 50% of patients with colorectal cancer will develop liver metastases. Only a minority of patients present with technically resectable disease. Around 40% of those undergoing surgical resection are alive five years after their diagnosis compared with less than 1% for those with disseminated disease treated with systemic chemotherapy. Surgical resection remains the only possibility for long-term survival for these patients and great efforts have been made to increase the rates of resection whilst improving long-term outcomes.

SUMMARY

This review considers current technical and oncological criteria for resection, as well as targeted approaches to stratify underlying tumor biology in order to better predict long-term benefit. The role of neoadjuvant and perioperative systemic chemotherapy is critically reviewed, with suggestions for patient stratification in order to identify those who are likely to derive the greatest benefit. The key role of multidisciplinary assessment and decision making for these complex patients is also discussed.

KEY MESSAGES

Surgery remains the optimal treatment for colorectal liver metastases (CRLM). Despite the curative intent of surgical resection, the majority of patients develop recurrence. Surgical strategies should therefore be adopted to maximize the potential for repeat resections in the event of recurrence. Although a number of preoperative prognostic markers have been identified, none are absolute contraindications to resection. In order to reduce postoperative recurrence, neo-adjuvant chemotherapy is now the standard of care in a number of countries. The evidence base for this approach is contentious, and the potential benefit of such a strategy is likely to be greatest in patients with high oncological risk disease. Multidisciplinary care is essential to ensure the optimal management of these complex patients. In addition, all patients with CRLM should be discussed with specialist hepatobiliary surgeons.

Local Ablation for Solid Tumor Liver Metastases: Techniques and Treatment Efficacy

BACKGROUND

Treatment options for liver metastases from solid tumors, such as colon cancer, breast cancer, neuroendocrine tumors, and sarcomas, have expanded in recent years and now include nonresection methods.

METHODS

The literature focused on the treatment of liver metastases was reviewed for technique, perioperative, and long-term outcomes specifically related to local ablation techniques for liver metastases.

RESULTS

Ablation modalities have become popular as therapies for patients who are not appropriate candidates for surgical resection. Use of these techniques, alone or in combination with other liver-directed therapies (and often systemic therapy), has extended the rate of survival for patients with liver metastases and, at times, offers nearly equivalent disease-free survival rates to surgical resection.

CONCLUSIONS

Although surgical resection remains the optimal treatment for liver metastasis, local options, including microwave ablation and radiofrequency ablation, can offer similar long-term local control in appropriately selected patients.

US-US Fusion Imaging in Radiofrequency Ablation for Liver Metastases

OBJECTIVE

Radiofrequency ablation (RFA) induces gas bubbles in ablation zones, and the ablative margin cannot be evaluated accurately on ultrasound (US) during and immediately after RFA. This study assessed the usefulness of US-US fusion imaging to visualize the ablative margin of RFA for liver metastasis.

METHODS

RFA guided by US-US fusion imaging was performed on 12 targeted tumors in 10 patients. Secondary hepatic malignancies included patients with colorectal cancer (n = 4), breast cancer (n = 2), lung cancer (n = 1), gastrointestinal stromal tumor (n = 1), pancreatic neuroendocrine tumor (n = 1), and adrenocortical carcinoma (n = 1). The maximal diameter of the tumors ranged from 0.8 to 4.0 cm (mean ± SD 1.6 ± 0.9 cm).

RESULTS

The mean number of electrode insertions was 1.6 per session (range 1-3). Technically, effective ablation was achieved in a single session in all patients, and safety ablative margins were confirmed on contrast-enhanced CT for early assessment of tumor response. There were no serious adverse events or procedure-related complications. During the follow-up period (median 220 days, range 31-417 days), none of the patients showed local tumor progression.

CONCLUSION

US-US fusion imaging could show the tumor images before ablation and the ablative area on US in real time. The image overlay of US-US fusion imaging made it possible to evaluate the ablative margin three dimensionally according to the US probe action. Therefore, US-US fusion imaging can contribute to RFA therapy with a safety margin, that is, the so-called precise RFA.

Impact of Systemic Therapy and Recurrence Pattern on Survival Outcome after Radiofrequency Ablation for Colorectal Liver Metastases

Background: Most patients undergoing radiofrequency ablation (RFA) of colorectal liver metastasases (CLM) develop disease recurrence, but little is known about the effect of recurrence patterns and/or systemic therapy on outcome. In this study, we examined the recurrence patterns and survival after systemic therapy plus RFA in patients with unresectable CLM without extrahepatic disease. The aims were to analyze the effect of recurrence patterns on survival and to assess the relative benefit contributed by systemic therapy and local ablation to disease control and patient outcome. Methods: From January 2002 to December 2012, 113 patients underwent RFA of liver-limited CLM after systemic therapy. Univariate and multivariate analyses for associations between clinical and/or treatment-related variables, recurrence-free survival (RFS), recurrence patterns, and overall survival (OS) were carried out. Results: Of 113 patients, 105 (92.8%) had disease recurrence (median RFS: 6.1 months). Lower post-recurrence OS was observed after early (≤6 months) than after late recurrence (8.5 versus 24.0 months, p < 0.001). Recurrence sites were RFA-sites only (4.8%), liver-only (57.1%), lung-only (10.5%), or multiple (27.6%); the corresponding post-recurrence OS was 21, 19, 39, and 7 months (p < 0.001), respectively. Response to pre-RFA systemic therapy was the strongest predictor for OS (hazard ratio [HR] 5.28), RFS (HR 3.30), early (odds ratio [OR] 6.34) and multiple-site recurrence (OR 3.83) (p < 0.01), respectively; only responders achieved 5-year OS and RFS (29% and 12% versus 0% and 0% for non-responders, p < 0.001, respectively). Conclusions: Survival after RFA for liver-limited CLM is strongly linked to the timing and pattern of non-local disease recurrence. Local ablation efficacy is necessary but not sufficient to obtain long-term disease control. Effective pre-RFA systemic therapy does favourably affect the incidence, timing and patterns of recurrence and long-term survival and appears essential for the tailoring of RFA application to maximize patient benefit.

Parenchymal-sparing hepatectomies (PSH) for bilobar colorectal liver metastases are associated with a lower morbidity and similar oncological results: a propensity score matching analysis

OBJECTIVE

The aim of this study is to evaluate whether a parenchymal-sparing strategy provides similar results in terms of morbidity, mortality, and oncological outcome of non-PSH hepatectomies in a propensity score matched population (PSMP) in case of multiple (>3) bilobar colorectal liver metastases (CLM).

BACKGROUND

The surgical treatment of bilobar liver metastasis is challenging due to the necessity to achieve complete resection margins and a sufficient future remnant liver. Two approaches are adaptable as follows: parenchymal-sparing hepatectomies (PSH) and extended hepatectomies (NON-PSH).

METHODS

A total of 3036 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched in a 1:1 propensity score analysis in order to compare PSH versus NON-PSH resections.

RESULTS

PSH was associated with a lower number of complications (≥1) (25% vs. 34%, p = 0.04) and a lower grade of Dindo-Clavien III and IV (10 vs. 16%, p = 0.03). Liver failure was less present in PSH (2 vs. 7%, p = 0.006), with a shorter ICU stay (0 day vs. 1 day, p = 0.004). No differences were demonstrated in overall and disease-free survival.

CONCLUSION

In conclusion, PSH resection for bilobar multiple CLMs represents a valid alternative to NON-PSH resection in selected patients with a reduced morbidity and comparable oncological results.

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases

BACKGROUND

The feasibility of parenchymal-sparing hepatectomy has yet to be assessed based on the tumor location, which affects the choice of treatment in patients with colorectal liver metastases.

METHODS

Sixty-three patients underwent first curative hepatectomy for deep-placed colorectal liver metastases whose center was located >30 mm from the liver surface. Operative outcomes were compared among patients who underwent parenchymal-sparing hepatectomy or major hepatectomy (≥3 segments).

RESULTS

Parenchymal-sparing hepatectomy and major hepatectomy were performed for deep-placed colorectal liver metastases in 40 (63%) and 23 (37%) patients, respectively. Resection time was longer in the parenchymal-sparing hepatectomy than in the major hepatectomy group (57 vs 39 minutes) (P = .02) and cut-surface area was wider (120 vs 86 cm²) (P < .01). Resected volume was smaller in the parenchymal-sparing hepatectomy than in the major hepatectomy group (251 vs 560 g) (P < .01). No differences were found between the 2 groups for total operation time (306 vs 328 minutes), amount of blood loss (516 vs 400 mL), rate of major complications (10% vs 13%), and positive operative margins (5% vs 4%). Overall, recurrence-free, and liver recurrence-free survivals did not differ between the 2 groups. Direct major hepatectomy without portal venous embolization could not have been performed in 40% of the parenchymal-sparing hepatectomy group (16/40) because of the small liver remnant volume.

CONCLUSION

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.

ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common malignancies in Western countries. Over the last 20 years, and the last decade in particular, the clinical outcome for patients with metastatic CRC (mCRC) has improved greatly due not only to an increase in the number of patients being referred for and undergoing surgical resection of their localised metastatic disease but also to a more strategic approach to the delivery of systemic therapy and an expansion in the use of ablative techniques. This reflects the increase in the number of patients that are being managed within a multidisciplinary team environment and specialist cancer centres, and the emergence over the same time period not only of improved imaging techniques but also prognostic and predictive molecular markers. Treatment decisions for patients with mCRC must be evidence-based. Thus, these ESMO consensus guidelines have been developed based on the current available evidence to provide a series of evidence-based recommendations to assist in the treatment and management of patients with mCRC in this rapidly evolving treatment setting.

Minimal vascular flows cause strong heat sink effects in hepatic radiofrequency ablation ex vivo

BACKGROUND

The present paper aims to assess the lower threshold of vascular flow rate on the heat sink effect in bipolar radiofrequency ablation (RFA) ex vivo.

METHODS

Glass tubes (vessels) of 3.4 mm inner diameter were introduced in parallel to bipolar RFA applicators into porcine liver ex vivo. Vessels were perfused with flow rates of 0 to 1,500 ml/min. RFA (30 W power, 15 kJ energy input) was carried out at room temperature and 37°C. Heat sink effects were assessed in RFA cross sections by the decrease in ablation radius, area and by a high-resolution sector planimetry.

RESULTS

Flow rates of 1 ml/min already caused a significant cooling effect (P ≤ 0.001). The heat sink effect reached a maximum at 10 ml/min (18.4 mm/s) and remained stable for flow rates up to 1,500 ml/min.

CONCLUSIONS

Minimal vascular flows of ≥1 ml/min cause a significant heat sink effect in hepatic RFA ex vivo. A lower limit for volumetric flow rate was not found. The maximum of the heat sink effect was reached at a flow rate of 10 ml/min and remained stable for flow rates up to 1,500 ml/min. Hepatic inflow occlusion should be considered in RFA close to hepatic vessels.

Colorectal liver metastatic disease: efficacy of irreversible electroporation--a single-arm phase II clinical trial (COLDFIRE-2 trial)

Background

Irreversible electroporation (IRE) is a novel image-guided tumor ablation technique that has shown promise for the ablation of lesions in proximity to vital structures such as blood vessels and bile ducts. The primary aim of the COLDFIRE-2 trial is to investigate the efficacy of IRE for unresectable, centrally located colorectal liver metastases (CRLM). Secondary outcomes are safety, technical success, and the accuracy of contrast-enhanced (ce)CT and ¹⁸F-FDG PET-CT in the detection of local tumor progression (LTP).

Methods/design

In this single-arm, multicenter phase II clinical trial, twenty-nine patients with ¹⁸F-FDG PET-avid CRLM ≤ 3,5 cm will be prospectively included to undergo IRE of the respective lesion. All lesions must be unresectable and unsuitable for thermal ablation due to vicinity of vital structures. Technical success is based on ceMRI one day post-IRE. All complications related to the IRE procedure are registered. Follow-up consists of ¹⁸F-FDG PET-CT and 4-phase liver CT at 3-monthly intervals during the first year of follow-up. Treatment efficacy is defined as the percentage of tumors successfully eradicated 12 months after the initial IRE procedure based on clinical follow-up using both imaging modalities, tumor marker and (if available) histopathology. To determine the accuracy of ¹⁸F-FDG PET-CT and ceCT, both imaging modalities will be individually scored by two reviewers that are blinded for the final oncologic outcome.

Discussion

To date, patients with a central CRLM unsuitable for resection or thermal ablation have no curative treatment option and are given palliative chemotherapy. For these patients, IRE may prove a life-saving treatment option. The results of the proposed trial may represent an important step towards the implementation of IRE for central liver tumors in the clinical setting.

Trial registration

Trial registration number: NCT02082782.

Radiofrequency ablation of unresectable colorectal liver metastases: trends in management and outcome during a decade at a single center

Background

Radiofrequency ablation (RFA) is widely used for treatment of colorectal liver metastases (CRLM).

Purpose

To evaluate the effect of increased experience in RFA of CRLM on morbidity and survival, and the trends in patient management and outcomes during the last decade.

Material and Methods

Hospital records of the initial 52 consecutive patients who underwent RFA (56 procedures/70 lesions) were retrospectively reviewed. The patients were divided into two groups according to time period of treatment, period I (2001–2006: n = 26) and period II (2007–2011: n = 26).

Results

Concomitant liver resection was performed in 15 patients in each period. Operative morbidity decreased from 47% to 19% (P = 0.047). Most complications were found in patients who underwent a concomitant liver resection and not related to the ablation per se. Local recurrence rate decreased from 19.4% to 12.9% (P = 0.526). At least one risk factor for recurrence was found in patients with local recurrence (n = 11): subcapsular localization (n = 4), tumor size >3 cm and subcapsular localization (n = 2), and perivascular localization (portal veins/hepatic veins) (n = 5). Median overall survival was 32 months in period I and 49 months in period II, whereas estimated 5-year survival was 19% and 36%, respectively (P = 0.09). Adjuvant chemotherapy was given to four patients (15.4%) in period I and 13 patients (50%) in period II (P = 0.017).

Conclusion

RFA alone or in combination with liver resection is a potentially curative treatment to selected patients with CRLM. Over time, the morbidity and survival have improved in RFA of CRLM. Although a possible effect of a learning curve should be taken into consideration in the appraisal of this improvement, it is more likely to be attributable to optimization of indication, development in surgical techniques, and increased use of perioperative chemotherapy.

Stereotactic body radiotherapy for liver metastases

The role for local ablative therapies in the management paradigm of oligometastatic liver disease is increasing. The evidence base supporting the use of stereotactic body radiotherapy for liver metastases has expanded rapidly over the past decade, showing high rates of local control with low associated toxicity. This review summarises the evidence base to date, discussing optimal patient selection, challenges involved with treatment delivery and optimal dose and fractionation. The reported toxicity associated with liver stereotactic body radiotherapy is presented, together with possible pitfalls in interpreting the response to treatment using standard imaging modalities. Finally, potential avenues for future research in this area are highlighted.

Cost–utility analysis of operative versus non-operative treatment for colorectal liver metastases

Background

Surgical resection of colorectal liver metastases (CRLMs) is the standard of care when possible, although this strategy has not been compared with non-operative interventions in controlled trials. Although survival outcomes are clear, the cost-effectiveness of surgery is not. This study aimed to estimate the cost-effectiveness of resection for CRLMs compared with non-operative treatment (palliative care including chemotherapy).

Methods

Operative and non-operative cohorts were identified from a prospectively maintained database. Patients in the operative cohort had a minimum of 10 years of follow-up. A model-based cost–utility analysis was conducted to quantify the mean cost and quality-adjusted life-years (QALYs) over a lifetime time horizon. The analysis was conducted from a healthcare provider perspective (UK National Health Service) in a secondary care (hospital) setting.

Results

Median survival was 41 and 21 months in the operative and non-operative cohorts respectively (P &lt; 0·001). The operative strategy dominated non-operative treatments, being less costly (€22 200 versus €32 800) and more effective (4·017 versus 1·111 QALYs gained). The results of extensive sensitivity analysis showed that the operative strategy dominated non-operative treatment in every scenario.

Conclusion

Operative treatment of CRLMs yields greater survival than non-operative treatment, and is both more effective and less costly.

Recurrence patterns after resection of liver metastases from colorectal cancer

Recurrence of metastatic disease after resection of liver metastases from colorectal cancer remains a major problem as 70-80 % of patients will have a recurrence, most commonly in the liver or lung. To predict patterns of recurrence and outcome may guide follow-up and further treatment, as patients with recurrence might be candidates for repeated surgery or ablation therapy. A summary of studies shows that after hepatectomy 20-43 % will have a recurrence only in the remaining liver without extrahepatic disease, whereas 15-37 % will have a recurrence only to the lung. Early recurrence is associated with poorer outcome compared to late recurrence. Site of first recurrence after resection of liver metastases is predicted by several baseline variables; synchronous disease, primary tumor site, hepatic tumor size, CEA level, number of hepatic lesions, and RAS mutation status. Pattern of recurrence is a predictor for survival after hepatectomy, with liver-only and lung-only recurrences having the best survival. In the majority of patients with isolated hepatic or lung recurrence, repeated metastasectomy is possible resulting in a 40 % 5-year survival rate. Perioperative chemotherapy reduces the risk of liver recurrence after hepatectomy of colorectal cancer liver metastases.

Treatment of colorectal liver metastases in Germany: a ten-year population-based analysis of 5772 cases of primary colorectal adenocarcinoma

BACKGROUND

Purpose of this study was to analyse the surgical management and long-term clinical outcome of patients diagnosed with colorectal liver metastases (CLM) over a period of 10 years using data from a German tumour registry.

METHODS

Retrospective analysis of 5772 patients diagnosed with colorectal adenocarcinoma between 2002 and 2007. Follow-up was continued until 2012.

RESULTS

1426 patients (24.7%) had CLM; 1019 patients (71%) had synchronous, 407 patients (29%) developed metachronous CLM. Hepatic resection was performed in 374 of the 1426 CLM patients (26%). A significant increase in liver resection rate from 16.6% for the 2002 cohort to 32% in later cohorts was observed. In centers specialized in liver surgery, CLM resection rates reached 46.6%. However, up to 52% of patients diagnosed with three or less CLM did not undergo liver surgery, although, if resected, patients with 1 CLM show a similar long-time survival as CRC patients who do not develop any CLM. Univariate and multivariate analyses adjusted for age, sex, year of resection, time of CLM diagnosis and number of CLM revealed a significant survival benefit for CLM resection (HR =0.355; CI 0.305-0.414). Furthermore, significant impact on OS was seen for age at diagnosis, perioperative chemotherapy and number of CLM.

CONCLUSIONS

We here present the first long-term, population-based analysis of the surgical management of CLM in Germany. Significant increase in hepatic resection rates, translating to a significant benefit in OS, was seen over years. However, we still see a striking potential for further improvements in interdisciplinary CLM management.

Liver-directed therapies in metastatic colorectal cancer

Colorectal cancer (CRC) is a major health concern in the United States (US) with over 140,000 new cases diagnosed in 2012. The most common site for CRC metastases is the liver. Hepatic resection is the treatment of choice for colorectal liver metastases (CLM), with a 5-year survival rate ranging from 35% to 58%. Unfortunately, only about 20% of patients are eligible for resection. There are a number of options for extending resection to more advanced patients including systemic chemotherapy, portal vein embolization (PVE), two stage hepatectomy, ablation and hepatic artery infusion (HAI). There are few phase III trials comparing these treatment modalities, and choosing the right treatment is patient dependent. Treating hepatic metastases requires a multidisciplinary approach and knowledge of all treatment options as there continues to be advances in management of CLM. If a patient can undergo a treatment modality in order to increase their potential for future resection this should be the primary goal. If the patient is still deemed unresectable then treatments that lengthen disease-free and overall-survival should be pursued. These include chemotherapy, ablation, HAI, chemoembolization, radioembolization (RE) and stereotactic radiotherapy.

Hepatic radioembolization as a bridge to liver surgery

Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.