Neo-adjuvant therapy improves resectability rates for colorectal liver metastases

PURPOSE: Liver resection improves survival in selected patients with colorectal liver metastases. However, the majority of patients with colorectal liver metastases have inoperable disease at presentation. Neo-adjuvant therapy (systemic or regional chemotherapy and interstitial laser therapy) used singly or in combination may convert a selected group of patients with irresectable liver metastases into an operable state. PATIENTS AND METHODS: We report a series of patients with initially inoperable multiple colorectal liver metastases who became operable after neo-adjuvant therapy. Operability was defined as unilateral disease limited to the liver. Twelve patients (7 female, 5 male, median age 57 years, range 38-69 years) with multiple inoperable colorectal liver metastases (8 synchronous, 4 metachronous) were initially treated with systemic chemotherapy (n = 7), hepatic arterial chemotherapy (n = 2) and chemotherapy plus interstitial laser therapy (n = 3). RESULTS: In all cases, a significant response was achieved which enabled subsequent liver resection to be undertaken. There was only one postoperative complication (8%) and no peri-operative deaths. 3 patients were operated on within the last 12 months and are still alive. Of the remainder, 1 died within 1 year with recurrent disease. The remaining patients have a median survival of 2.5 years, range 1.39-4 years. CONCLUSIONS: These results are similar to those reported for patients undergoing resection for operable metastases without neo-adjuvant therapy. Aggressive multimodality treatment of colorectal liver metastases in specialised centres may improve the resectability rates and survival in a selected group of patients.     

Repeat hepatic surgery for colorectal cancer metastasis to the liver.

OBJECTIVE: The authors addressed whether a repeat hepatic operation is warranted in patients with recurrent isolated hepatic metastases. Are the results as good after second operation as after first hepatic operation? SUMMARY BACKGROUND DATA: Five-year survival after initial hepatic operation for colorectal metastases is approximately 33%. Because available alternative methods of treatment provide inferior results, hepatic resection for isolated colorectal metastasis currently is well accepted as the best treatment option. However, the main cause of death after liver resection for colorectal metastasis is tumor recurrence. METHODS: Records of 95 patients undergoing initial hepatic operation and 10 patients undergoing repeat operation for isolated hepatic metastases were reviewed for operative morbidity and mortality, survival, disease-free survival, and pattern of failure. The literature on repeat hepatic resection for colorectal metastases was reviewed. RESULTS: The mean interval between the initial colon operation and first hepatic resection was 14 months. The mean interval between the first and second hepatic operation was 17 months. Operative mortality was 0%. At a mean follow-up of 33 +/- 27 months, survival in these ten patients was 100% at 1 year and 88% +/- 12% at 2 years. Disease-free survival at 1 and 3 years was 60% +/- 16% and 45% +/- 17%, respectively. After second hepatic operation, recurrence has been identified in 60% of patients at a mean of 24 +/- 30 months (median 9 months). Two of these ten patients had a third hepatic resection. Survival and disease-free survival for the 10 patients compared favorably with the 95 patients who underwent initial hepatic resection. CONCLUSIONS: Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic operations in terms of operative mortality and morbidity, survival, disease-free survival, and pattern of recurrence. This work helps to establish that repeat hepatic operation is the most successful form of treatment for isolated recurrent colorectal metastases.     

Repeat hepatic resection for recurrent colorectal liver metastases is associated with favourable long-term survival

BACKGROUND: The management of patients with recurrent colorectal liver metastases (RCLM) remains controversial. This study aimed to determine whether repeat liver resection for RCLM could be performed with acceptable morbidity, mortality and long-term survival. METHODS: Of 1121 consecutive liver resections performed and prospectively analysed between 1987 and 2005, 852 'curative' resections were performed on patients with colorectal liver metastases. Single liver resection was performed in 718 patients, and 71 repeat hepatic resections for RCLM were performed in 66 patients. RESULTS: There were no postoperative deaths following repeat hepatic resection compared with a postoperative mortality rate of 1.4 per cent after single hepatic resection. Postoperative morbidity was comparable following single and repeat hepatectomy (26.1 versus 18 per cent; P = 0.172), although median blood loss was greater during repeat resection (450 versus 350 ml; P = 0.006). Actuarial 1-, 3- and 5-year survival rates were 94, 68 and 44 per cent after repeat hepatic resection for RCLM, compared with 89.3, 51.7 and 29.5 per cent respectively following single hepatectomy. CONCLUSION: The beneficial outcomes observed after repeat liver resection in selected patients with RCLM confirm the experience of others and support its status as the preferred choice of treatment for such patients.     

Long-term results of treating hepatic colorectal metastases with cryosurgery

BACKGROUND: The purpose of this study was to determine the long-term efficacy of cryosurgery as an adjunct to hepatic resection in patients with colorectal liver metastases not amenable to resection alone. METHODS: Thirty patients met the following inclusion criteria: metastases confined to the liver and judged irresectable, ten or fewer metastases, cryosurgery alone or in combination with hepatic resection allowed tumour clearance. RESULTS: Median follow-up was 26 (range 9--73) months. Overall 1- and 2-year survival rates were 76 and 61 per cent respectively. Median survival was 32 months. Disease-free survival at 1 year was 35 per cent, at 2 years 7 per cent. Six patients developed recurrence at the site of cryosurgery; given that the total number of cryosurgery-treated lesions was 69 the local recurrence rate was 9 per cent. CONCLUSION: In patients with colorectal liver metastases, local ablative techniques can be used as an effective adjunct to hepatic resection to obtain tumour clearance.     

Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases

BACKGROUND: Extrahepatic disease has always been considered an absolute contraindication to hepatectomy for liver metastases. The present study reports the long-term outcome and prognostic factors of patients undergoing resection of extrahepatic disease simultaneously with hepatectomy for liver metastases. METHODS: From January 1987 to January 2001, 111 (30 per cent) of 376 patients who had hepatectomy for colorectal liver metastases underwent simultaneous resection of extrahepatic disease with curative intent. RESULTS: Surgery was considered R0 in 77 patients (69 per cent) and palliative (R1 or R2) in 34 patients (31 per cent). The mortality rate was 4 per cent and the morbidity rate 28 per cent. After a median follow-up of 4.9 years, the overall 3- and 5-year survival rates were 38 and 20 per cent respectively. The 5-year overall survival rate of patients with R0 resection only (n = 75) was 29 per cent. The difference in survival between patients with and without extrahepatic disease discovered incidentally at operation was significant, as was the number of liver metastases. CONCLUSION: Extrahepatic disease in patients with colorectal cancer who also have liver metastases should no longer be considered an absolute contraindication to hepatectomy. However, the presence of more than five liver metastases and the incidental intraoperative discovery of extrahepatic disease remain contraindications to hepatic resection.     

A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer

BACKGROUND: The aim of this population-based study was to evaluate the incidence, management and prognosis of patients with hepatic metastases related to colorectal cancer using data from the Digestive Cancer Registry of Calvados, France. METHODS: Of 1325 patients with colorectal cancer registered between January 1994 and December 1999, 358 developed hepatic metastases. Logistic regression was used to analyse prognostic factors. Survival analysis was carried out with Cox's proportional hazards model. RESULTS: Some 18.8 per cent of patients had synchronous metastases, while 29.3 per cent developed metastases at 3 years. Of patients with hepatic metastases, 17.3 per cent had a surgical resection, 40.2 per cent were treated with palliative chemotherapy and 42.5 per cent had symptomatic treatment. Factors associated with receiving symptomatic treatment only were age over 75 years and more than one metastasis, but not place of treatment. Median survival after a diagnosis of hepatic metastases was 10.7 (range 4.6-23.1) months. Significant adverse prognostic factors were: age over 75 years (P = 0.001), lymph node invasion of primary tumour (P = 0.024), bilateral distribution of metastases (P = 0.001), other metastases (P = 0.004) and symptomatic treatment only (P = 0.041). CONCLUSION: Despite improvement in treatment for hepatic metastases, age and extent of disease remain limiting factors for surgical resection and palliative chemotherapy.     

Complete hepatic resection of metastases from leiohyosarcoma prolongs survival

Although liver resection has been shown to prolong survival in selected patients with metastases from colorectal cancer, the benefit for other metastatic tumors is unproved. To determine whether hepatic resection has a role in the management of metastatic leiomyosarcoma, medical records from 11 consecutive patients who underwent resection of isolated metastases from leiomyosarcoma between 1984 and 1995 were reviewed. All liver resections were for leiomyosarcomas originating in the viscera (n = 6) or retroperitoneum (n = 5). The average disease-free interval was 16 months. Five of 11 primary tumors were classified as low grade, whereas six were high grade. Hepatic resections included lobectomy or extended lobectomy (n = 4), segmentectomy and/or wedge resection (n = 5), and complex resection (n = 2). There were no operative deaths. Median survival of all patients after liver resection was 39 months. Patients who underwent complete resection of hepatic metastases (n = 6) had a significantly longer survival than those who had incomplete resections (n = 5) (P = 0.03, log-rank test). Furthermore, five of six patients who underwent complete resection are alive after hepatectomy with a median follow-up of 53 months. Therefore, in selected patients with isolated liver metastases from visceral and retroperitoneal leiomyosarcomas, complete resection of hepatic metastases results in prolonged survival. Presented in part at the Fiftieth Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, Ill., March 20–23, 1997.     

Sequential hepatic and pulmonary resections for metastatic colorectal cancer

BACKGROUND: Resection of pulmonary or hepatic colorectal metastases is associated with a 5-year survival rate of 25-40 per cent. This report analyses outcome following sequential resection of colorectal metastases to both organs. METHODS: Seventeen patients with histologically confirmed colorectal adenocarcinoma and resection of liver and lung metastases were identified from a prospective database. RESULTS: The median interval between resection of the primary tumour and first metastasis was 21 (range 0-64) months. The interval between resection of the first and subsequent metastases was 18 (range 1-74) months. No patient died in the postoperative period and there were two perioperative complications. The overall survival rate in 17 patients was 70 per cent at 2 years from resection of metastasis to the second organ, but the disease-free survival rate at 2 years was only 24 per cent. CONCLUSION: Although few long-term survivors were observed in this small series, sequential resection of hepatic and pulmonary metastases is warranted in a highly selected group of patients.     

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors.

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.     

Aggressive repeat liver resection for hepatic metastases of colorectal carcinoma

Although hepatectomy for liver metastases from colorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site after hepatectomy. Thirty patients underwent hepatectomy for hepatic metastases and 17 of them had recurrence in the remnant liver during the following 12-year period. Six of the 17 patients underwent a removal of isolated hepatic recurrences. Two of the six patients underwent a third hepatectomy, and three patients underwent partial lung resection on a total of five occasions. There were no operative deaths while complications after a third hepatectomy contributed to a high morbidity rate of 40 per cent. The mean length of survival of the six patients was 28.5 months from the second hepatectomy. The prognosis of the six patients who underwent a repeat hepatectomy was significantly better than that of patients with unresectable recurrence after an initial hepatectomy (p<0.01). The overall 5-year survival of 29 patients excluding one inhospital death was 44.7 per cent. Our results reveal that aggressive removal of isolated and resectable recurrent disease has the potential to improve the prognosis of selected patients with metastatic cancer.     

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases

OBJECTIVE: To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors. SUMMARY BACKGROUND DATA: Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance. METHODS: Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1). RESULTS: There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully. CONCLUSIONS: Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.     

Treatment strategy for synchronous metastases of colorectal cancer: is hepatic resection after an observation interval appropriate?

Background In cases of synchronous colorectal hepatic metastases, the primary colorectal cancer strongly influences on the metastases. Our treatment policy has been to conduct hepatic resection for the metastases at an interval of 3 months after colorectal resection. We examined the appropriateness of interval hepatic resection for synchronous hepatic metastasis. Materials and methods The subjects were 164 patients who underwent resection of hepatic metastasis of colorectal cancer (synchronous, 70 patients; metachronous, 94 patients). Background factors for hepatic metastasis and postoperative results were compared for synchronous and metachronous cases. Results The cumulative survival rate for 164 patients at 3, 5, and 10 years postoperatively was 71.9%, 51.8%, and 36.6%, and the post-resection recurrence rate in remnant livers was 26.8%. Interval resection for synchronous hepatic metastases was conducted in 49 cases after a mean interval of 131 days. No difference was seen in postoperative outcome between synchronous and metachronous cases. Conclusion The outcome was similarly favorable in cases of synchronous hepatic metastasis and in cases of metachronous metastasis. Delaying resection allows accurate understanding of the number and location of hepatic metastases, and is beneficial in determining candidates for surgery and in selecting surgical procedure.     

Survival after hepatic resection for malignant tumours.

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.     

Radiofrequency ablation for unresectable tumors of the liver

Surgical resection of primary or metastatic tumors of the liver offers patients the best long-term survival. Liver resections may not be appropriate in patients with bilobar metastases, liver dysfunction, or severe comorbidities. Radiofrequency ablation (RFA) is a technique used to destroy unresectable hepatic tumors through thermocoagulation. We retrospectively reviewed a consecutive series of patients undergoing RFA with unresectable hepatic tumors for local recurrence and overall survival. Under an Institutional Review Board-approved protocol, all patients treated with RFA at the University of Alabama at Birmingham from September 1, 1998, to June 15, 2005, were identified. During this time period, 189 lesions in 107 patients were treated with RFA. Patients' charts were retrospectively reviewed. Data is presented as mean +/- SEM. Significance is defined as P < 0.05. Patient demographics revealed 62 per cent males and 38 per cent females with a mean age of 59 (+/- 1) years. Hepatocellular carcinoma (HCC) represented 54 per cent of the tumors treated. Metastatic colorectal cancer represented 22 per cent and the remaining 24 per cent were other metastatic tumors. Overall recurrence rates for all tumors after RFA was 53 per cent. Local recurrence rates for HCC, colorectal cancer, and other metastatic lesions were 27.6 per cent, 29.1 per cent, and 52 per cent, respectively. The morbidity rate for the procedure was 11 per cent. There was one mortality (0.9%) related to RFA. Laparoscopic RFA for HCC in Childs-Pugh Class C cirrhotics (n = 6) resulted in 50 per cent of patients being transplanted with no evidence of disease at a mean follow-up period of 14 months. RFA is a safe and effective way for treating HCC and other unresectable tumors in the liver that are not eligible for hepatic resection. More effective control of systemic recurrence will dictate survival in the majority of patients with metastatic cancers. Local ablation for HCC in cirrhotic patients may be an effective bridge to transplantation. Liver transplantation may still be the most effective long-term treatment for localized HCC.     

One hundred patients with hepatic metastases from colorectal cancer treated by resection: analysis of prognostic determinants

One hundred patients with hepatic metastases from colorectal cancer underwent 'radical' liver resection from 1980 to 1989. At least 1 cm of normal parenchyma surrounded the tumour and no microscopic invasion of resection margins was evident. The disease was staged according to our own staging system. Lobectomy was performed in 50 patients and non-anatomical resection in the remainder. The postoperative mortality rate was 5 per cent and the major morbidity rate was 11 per cent. The actuarial 5-year survival rate for patients in stages I, II and III was 42 per cent, 34 per cent and 15 per cent respectively (P less than 0.001). The overall actuarial 5-year survival rate was 30 per cent. The prognostic importance of various patient and tumour variables was evaluated by univariate analysis and then by multivariate analysis. Age of patient, site of primary, disease-free interval between treatment of primary and of hepatic metastases, preoperative carcinoembryonic antigen levels, and number of metastases, did not relate to prognosis, while sex (P = 0.024), stage of primary (P = 0.026), extent of liver involvement (P less than 0.001), distribution of metastases (P = 0.01) and type of surgery (P = 0.028) significantly affected prognosis as single factors. Multivariate analysis revealed that only the extent of liver involvement and stage of the primary tumour were independent predictors of survival. We conclude that liver resection is effective in selected patients with hepatic metastases from colorectal cancer. In resectable patients it is not yet possible to formulate a clear prognosis based on clinical factors. The extent of liver involvement and the staging system used may be significant, although not absolute, indicators of outcome.     

Adjuvant intra-arterial chemotherapy after curative resection of liver metastasis from colorectal cancer. Results of a pilot study in 30 patients

OBJECTIVE: Five-year survival after simple resection of liver metastases from colorectal carcinoma ranges from 20 to 40%. The aim was to study the reliability and long term results of adjuvant intra-arterial chemotherapy after resection of colorectal liver metastases. PATIENTS AND METHOD: From 1991 to 1997, 30 patients after a complete resection of liver metastases from colorectal cancer were included (16 men, 14 women, mean age: 62 years). There were 2 stage I, 19 stages II, 2 stages III, 5 stages IV and 2 stages V according to Gayowski staging system. During laparotomy, a catheter was placed in the gastroduodenal artery in order to perfuse the proper hepatic artery. Chemotherapy included 5 Fluorouracil (12 mg/m2) and Leucovorin (200 mg/m2) and was administered once a week during six months. Mean follow-up was 52 months. RESULTS: Adjuvant intra-arterial chemotherapy had to be interrupted before six months in 9 patients because leukopenia (n = 2), infection or obstruction of the catheter (n = 5), duodenal migration of the catheter (n = 1) and occurrence of multiple extrahepatic metastases (n = 1). No death was in relation with the method. Five-year survival rate was 41.8% for the global series. Five-year disease free survival rate was 21.4%. Causes of death were: hepatic recurrence only (n = 3), extrahepatic + hepatic recurrence (n = 4), extrahepatic recurrence (n = 2). Two patients died of another carcinoma (esophagus, ovary), without evidence of recurrence of the colorectal carcinoma. At the present, there is a recurrence in 4 living patients. CONCLUSION: Although the benefit on survival is not significant, these results suggest a longest time of remission in patients with adjuvant intra-arterial chemotherapy. Trials comparing and/or combining this method to intravenous chemotherapy should be proposed in patients after resection of colorectal liver metastases.     

Outcome of patients with rectal cancer treated by stapled anterior resection

The mortality, morbidity and long-term survival in stapled anterior resection for rectal carcinoma has been analysed in 74 patients. Twelve patients were Dukes' A, 26 B, 29 C, and 7 'D' (submitted to hepatic resection). Operative mortality rate was 3 per cent. Three patients (4 per cent) had clinical anastomotic leakage. Two patients (3 per cent) developed anastomotic stenosis. Local recurrence was present in three patients (4 per cent). The mean (+/- s.e.m.) overall survival rate at 5 years was 67 +/- 6 per cent. There was no significant difference in survival between Dukes' B and C (70 +/- 10 per cent versus 59 +/- 10 per cent, P = 0.209). Patients with absent local spread had a significantly better 5-year survival rate than those with positive local lymph nodes (80 +/- 7 per cent versus 54 +/- 9 per cent, P less than 0.01). The present results confirm the satisfactory use of the EEA stapler device for colorectal anastomoses in rectal cancer and in patients with resectable liver metastasis.     

Adjuvant regional chemotherapy after hepatic resection for colorectal metastases.

BACKGROUND: This study explored the possibility of achieving a better survival rate and reduced recurrence in the remaining liver in patients with colorectal hepatic metastases undergoing hepatic resection. Adjuvant postoperative regional chemotherapy was administered via the hepatic artery or the portal vein. METHODS: A retrospective study was performed on 174 patients after hepatic resection for colorectal metastases. These comprised 78 patients who had hepatic artery infusion (HAI) chemotherapy (HAI group), 30 who had portal vein infusion (PVI) chemotherapy (PVI group) and 66 who had no regional chemotherapy (resection alone group). The three groups were compared with one another in terms of complications, survival rate and patterns of recurrence. RESULTS: Severe complications did not occur at any point during adjuvant HAI or PVI chemotherapy. The 5-year disease-free survival rate of patients in the HAI, PVI and resection alone groups were 35, 13 and 9 per cent respectively, including six hospital deaths. Patients in the HAI group showed significantly improved recurrence rates in the remaining liver compared with the resection alone group (P = 0.03), and more prolonged disease-free and overall survival than those in the PVI (P = 0.01 and P = 0.02 respectively) and resection alone (P = 0.0001 and P = 0.0006 respectively) groups. CONCLUSION: This study suggests that adjuvant HAI chemotherapy after hepatic resection may have therapeutic potential for improved management of patients with colorectal metastases.     

Transcatheter arterial chemoembolization with or without radiofrequency ablation in the management of patients with advanced hepatic malignancy

Transcatheter arterial chemoembolization (TACE) is efficacious against hepatic malignancies by rendering tumors ischemic while delivering high-dose chemotherapy. The added benefit of radiofrequency ablation (RFA) has not been determined. We sought to review our experience with TACE with or without RFA in the treatment of hepatocellular carcinoma and colorectal liver metastases in patients not amenable to resection. TACE and RFA were undertaken in 13 patients with hepatocellular carcinoma (n = 7) or colorectal liver metastases (n = 6). Concurrently 24 patients underwent TACE alone for hepatocellular carcinoma (n = 15) or colorectal liver metastases (n = 9). Patients undergoing TACE with or without RFA were similar in age, gender, and diagnosis. Overall follow-up was 9.1 months +/- 7.1. One-year survival was greater in patients undergoing TACE with RFA than with TACE alone (100% vs 67%, P = 0.04). Mean survival was longer after TACE with RFA compared with TACE alone (25.3 months +/- 15.9 vs 11.4 months +/- 7.3, P < 0.05). No patients suffered significant complications. The addition of RFA to TACE improves survival in patients with unresectable primary or metastatic hepatic malignancies. RFA with TACE should be in the armamentarium of surgeons caring for patients with malignant liver lesions.     

Laparoscopic in situ ablation of liver cancer with cryotherapy and radiofrequency ablation

BACKGROUND: In situ ablation has potential for the treatment of patients with liver cancer either as a single-modality treatment or in combination with liver resection. METHODS: Laparoscopy and intraoperative ultrasonography was used to target cryotherapy and radiofrequency ablation. Thirty-eight patients with 146 liver lesions were treated between January 1995 and December 2000 using cryotherapy alone (nine patients), combined cryotherapy and radiofrequency (eight), radiofrequency alone (15) and in situ ablation with liver resection (six). Cancers treated were metastases from colorectal tumours (n = 25), hepatocellular carcinoma (n = 5), and neuro endocrine (n = 5), melanoma (n = 2) and renal cell (n = 1) metastases. Complications and survival after in situ ablation were compared with age- and disease-matched controls treated with systemic chemotherapy. RESULTS: The mean age was 61.6 years. At mean follow-up of 26.6 (range 3-62, median 26) months, 22 patients were alive. Survival was increased following in situ ablation compared with that in controls (P < 0.001). Local recurrence at the ablation site was noted in 12 of 44 lesions following cryotherapy and in 20 of 102 lesions after radiofrequency ablation, and new disease in the liver was found in six of 17 and six of 29 patients respectively. The complication rate was higher with cryotherapy than with radiofrequency ablation (four of 17 versus one of 29). Intraoperative ultrasonography identified 14 new hepatic lesions (10 per cent) not seen on preoperative imaging. CONCLUSION: Laparoscopic in situ ablation should include ultrasonography to stage the disease. In situ ablation appears to have a survival benefit and should be considered for the treatment of liver cancer in appropriate patients.