Short- and-long term results of intraoperative radiofrequency ablation of liver metastases

BACKGROUND: Surgical resection is the only therapeutic option with curative effect on malignant liver tumours, but in over 70% of cases, this is not a feasible option. A prospective study was performed to assess the short- and long-term effects of intraoperative radiofrequency ablation on unresectable liver metastases. PATIENTS: Between 1997 and 2001, 57 patients (mean age 61.9 years; range 31-83 years) with 297 unresectable liver metastases (colorectal adenocarcinoma, n=38; carcinoid tumour, n=4; malignant melanoma, n=3; other metastases, n=12) underwent intraoperative radiofrequency ablation. RESULTS: No mortality was observed in patients managed solely with radiofrequency ablation. Eight postoperative complications occurred in eight patients (14%). Three occurred when radiofrequency ablation was combined with resection. Of the 33 patients completely ablated, 30 patients are still alive and 21 are disease-free after a median follow-up of 18.1 months (range 2-43). Ten patients underwent more than one intraoperative radiofrequency ablation episode. Overall survival was 72.5% at 1 year and 52.5% at 3 years. Complete ablation and the number of lesions were significant independent prognostic factors for survival, with p<0.001 and p<0.0001, respectively. CONCLUSION: Radiofrequency ablation is a safe and effective option for patients with inoperable liver metastases without extra hepatic disease. Prospective controlled trials comparing the results of different treatments are required to assess which patients will benefit best from this emerging new treatment.     

Impact of concomitant ablation on the perioperative outcomes of patients with colorectal liver metastases undergoing hepatectomy: a propensity score matched nationwide analysis

BackgroundIntraoperative ablation (IA) is often performed at the time of liver resection (LR) for colorectal liver metastases (CRLMs) but its impact on postoperative outcomes remains poorly understood.MethodsThe ACS-NSQIP targeted hepatectomy database was used to identify patients who underwent LR vs LR + IA for CRLMs during 2014–2016. Perioperative outcomes were compared following propensity score match based on age, receipt of neoadjuvant therapy, operative approach, liver resection type, tumor diameter and number of metastases.ResultsAmong 1,384 patients, 692 (50%) underwent LR alone and 692 (50%) underwent LR + IA. After propensity score matching, overall morbidity (22% vs 13%, P < 0.0001) was increased among patients undergoing LR alone compared to LR + IA, whereas mortality did not differ (1.1% vs 0.8%, P=0.5911). On multivariable analysis, ASA class ≥3 (OR: 1.5, 95% CI: 1.06–2.3), preoperative biliary stent (OR: 3.5, 95% CI: 0.9–13.01), biliary reconstruction (OR: 5.02, 95% CI: 1.3–18.6), operative time > 245 minutes (OR: 1.8, 95% CI:1.3–2.4) and IA (OR:0.5, 95% CI:0.3–0.7) were associated with overall morbidity.ConclusionsIn this propensity matched nationwide analysis of patients undergoing LR for CRLM, the use of concomitant IA was associated with decreased postoperative morbidity compared to LR alone. These findings suggest that IA combined with LR is a safe approach that may expand the number of patients who are candidates for curative-intent surgical strategies.     

Short- and long-term results of extended left hepatectomy for colorectal metastases

BackgroundAn extended left hepatectomy is a complex hepatic resection often performed for large tumours in close relationship to major hilar structures. Operative outcomes of this resection for colorectal liver metastases (CLM) remain unclear. The aim of the present study was to assess short- and long-term outcome for patients with CLM after an extended left hepatectomy.MethodsA retrospective analysis of consecutive patients undergoing an extended left hepatectomy for CLM in a large, single-centre cohort between January 1990 and January 2006 was performed.ResultsThirty-one patients (3.9%) from a consecutive series of 802 patients who had undergone hepatic resection were identified as having met the definition of an extended left hepatectomy and were included for further analysis. Maximum tumour size was more than 60 mm in 15 patients, with a median size of 67.5 mm for the total group (range: 20 to 160 mm). Twenty-six patients presented with initially unresectable metastases, related to large tumour size in 11 patients and to a close relation with major vascular structures in six patients. Preoperative chemotherapy was administered to 29 patients. Combined vascular resection was performed in five patients. The mortality rate at 90 days was zero and post-operative morbidity occurred in 17 patients. R0 and R1 resections were performed in 17 and 11 patients, respectively. Three- and 5-year overall survival was 38% and 27%, respectively. Disease-free survival was 9% and 4% at 3 and 5 years. Morbidity did not differ between patients with and without a caudate lobectomy (9 of 17 patients vs. 8 of 14 patients, respectively) (P= 0.815).ConclusionsAn extended left hepatectomy for CLM can provide significant long-term survival. However, morbidity is increased in this complex procedure. A caudate lobectomy does not impact surgical outcome.Large case series demonstrating that extended left hepatectomy for colorectal liver metastases is associated with significant morbidity but provides significant long-term survival     

Hepatectomy vs radiofrequency ablation for colorectal liver metastasis:A propensity score analysis

AIM:To compare outcomes from radiofrequency ablation(RFA) and hepatectomy for treatment of colorectal liver metastasis(CRLM).METHODS:From January 2000 to December 2009,408 patients underwent curative intent treatment for CRLM.We excluded patients using the criteria:size of CRLM 3 cm,number of CRLM ≥ 5,percutaneous RFA,follow-up period 12 mo,double primary cancer,or treatment with both RFA and hepatectomy.We matched 51 patients who underwent RFA with 102 patients who underwent hepatectomy by propensity scores.RESULTS:The median follow-up period was 45 mo(range,12 mo to 158 mo).Hepatic recurrence was more frequent in the RFA than the hepatectomy group(P = 0.021) although extrahepatic recurrence curves were similar(P = 0.716).Survival curves of hepatectomy group were better than that of RFA for multiple,large( 2 cm) CRLM(P = 0.034).However,survival curves were similar for single or small(≤ 2 cm) CRLM(P = 0.714,P = 0.740).CONCLUSION:Hepatectomy is better than RFA for the treatment of CRLM.However,RFA might be suitable for selected patients with single,small(≤ 2 cm) CRLM.     

Comparative analysis of radiofrequency ablation and resection for resectable colorectal liver metastases

AIM:To evaluate the therapeutic efficacy of radiofrequency ablation(RFA)for resectable colorectal liver metastases(CRLM)compared with that of resection.METHODS:Between June 2004 and June 2009,we retrospectively analyzed 29 patients with resectable CRLMs;17 patients underwent RFA,and 12 underwent hepatic resection.All of the patients were informed about the treatment modalities and were allowed to choose either of them.RFA including an intraoperative approach was performed by a radiologist;otherwise,hepatic resection was performed by a surgeon.Comparative analysis of the two groups was performed,including comparisons of gender,age,and clinical outcomes,such as primary tumor stage and survival rates.RESULTS:The mean tumor size was significantly larger in the resection group(3.59 cm vs 2.02 cm,P<0.01),and the 5-year overall survival(OS)rate for all patients was 44.7%.There was no difference in the 5-year OS rates between the RFA and resection groups(37.8%vs66.7%).Univariate analysis indicated significantly lower5-year OS rates for patients with a tumor size>3cm.The 5-year disease-free survival(DFS)rates were17.6%and 22.2%in the RFA and resection groups,respectively(P=0.119).Univariate analysis revealed that in cases of male gender,age>65 years,T stage<Ⅳ,absence of lymphatic metastasis,and tumor size>3 cm,RFA resulted in significantly inferior 5-year DFS rates compared with surgical resection.CONCLUSION:Surgical resection revealed superior outcomes in the treatment of resectable CRLMs,particularly in cases with a hepatic tumor size>3 cm.     

Patterns of complications following intraoperative radiofrequency ablation for liver metastases

Background

Intraoperative radiofrequency ablation (IRFA) is added to surgery to obtain hepatic clearance of liver metastases. Complications occurring in IRFA should differ from those associated with wedge or anatomic liver resection.

Methods

Patients with liver metastases treated with IRFA from 2000 to 2010 were retrospectively analysed. Postoperative outcomes are reported according to the Clavien–Dindo system of classification.

Results

A total of 151 patients underwent 173 procedures for 430 metastases. Of these, 97 procedures involved IRFA plus liver resection and 76 involved IRFA only. The median number of lesions treated by IRFA was two (range: 1–11). A total of 123 (71.1%) procedures were carried out in patients who had received preoperative chemotherapy. The mortality rate was 1.2%. Thirty (39.5%) IRFA-only patients and 45 (46.4%) IRFA-plus-resection patients presented complications. Immediate complications (n = 4) were associated with IRFA plus resection. American Society of Anesthesiologists (ASA) class, previous abdominal surgery or hepatic resection, body mass index, number of IRFA procedures, portal pedicle clamping, total vascular exclusion and preoperative chemotherapy were not associated with a greater number of complications of Grade III or higher severity. Length of surgery >4 h [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.1–6.3; P < 0.05] and an associated contaminating procedure (OR 3.72, 95% CI 1.53–9.06; P < 0.005) led to a greater frequency of complications of Grade III or higher.

Conclusions

Mortality and morbidity after IRFA, with or without resection, are low. Nevertheless, long interventions and concurrent bowel operations increase the risk for septic complications.     

A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases

Objectives

Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM.

Methods

Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

Results

Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24–44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10–29 months). The 3-year disease-free survival rate was 20% (range: 6–27%).

Conclusions

Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.     

手术切除联合射频消融治疗结肠癌肝转移疗效分析

目的 探讨手术联合射频消融治疗结肠癌肝转移患者的治疗效果。方法 对2008年1月至2014年3月我科诊治的结肠癌肝转移接受结肠癌根治术和肝内肿瘤灶切除治疗的17例和结肠癌根治术后对肝内肿瘤行射频消融（RFA）治疗的12例患者的临床资料进行回顾性分析。绘制Kaplan-Meier生存曲线,进行生存分析。结果 单纯手术治疗的17例患者均于术后20个月内死亡,平均生存时间为（13.412±0.912）月,而手术联合射频消融治疗的12例患者随访6~28个月,平均生存时间为（18.496±2.139）月（P<0.05）;RFA治疗后患者均出现不同程度的恶心、呕吐、胸闷、右上腹痛、发热,血清ALT和AST轻度升高。结论 手术联合射频消融治疗结肠癌肝转移是一种可行的、安全的、有效的方法,可以明显延长患者的生存期。     

Local radiofrequency ablation techniques for liver metastases of colorectal cancer

Local ablative techniques have been used for several decades in the treatment of colorectal liver metastases and are gaining more and more interest. At this time radiofrequency ablation is the most popular local ablative technique with interesting results on local tumour control, disease free and overall survival. However, the exact place in the treatment of non-resectable colorectal liver metastases and its possible place in the treatment of resectable liver metastases has still to be defined. This article describes the feasibility, advantages and disadvantages of radiofrequency ablation, together with the results of the most cited articles, to form a critical review on the use of this technique in the treatment of colorectal liver metastases.     

Evaluation of aggressively treated patients with unresectable multiple liver metastases from colorectal cancer

PURPOSE: The aim of this study was to assess the value of aggressively treating patients with unresectable liver metastases from colorectal cancer and a poor prognosis. METHODS: From 1988 to 1999, 64 patients with unresectable multiple liver metastases from colorectal cancer who had received hepatic arterial infusion chemotherapy were investigated. All patients did not have synchronous extrahepatic metastases at the time of initiating our treatment. When liver metastases were suitable for resection after hepatic arterial infusion chemotherapy, we excised them and repeated prophylactic hepatic arterial infusion chemotherapy as long as possible. We evaluated the efficacy of hepatic arterial infusion chemotherapy by computed tomography and divided these patients into responders and nonresponders. We performed univariate analysis using the log-rank test to calculate predictive factors. In addition, the Cox proportional hazards model was used to perform multivariate analysis of factors related to survival. RESULTS: The survival rate of all patients was 67.8 percent after 1 year and 10 percent after 5 years. However, the survival rate for 16 patients who received hepatectomy after hepatic arterial infusion chemotherapy was 35.1 percent after five years. Multivariate analysis demonstrated that the response after hepatic arterial infusion chemotherapy was the most indicative prognostic factor. CONCLUSIONS: The prognosis of selected patients who responded to hepatic arterial infusion chemotherapy and received hepatectomy was improved. Applying aggressive treatment as outlined in our strategy may improve the chances of long-term survival.     

Repeat hepatectomy for recurrent colorectal liver metastases: A comparative analysis of short- and long-term results

Background: Liver recurrence after resection of colorectal liver metastases(CRLM) is frequent. Repeat hepatectomy has been shown to have satisfactory perioperative results. However, the long-term outcomes and the benefts for patients with early recurrence have not been clarifed. The aim of this study was to compare the short-and long-term outcomes of patients undergoing single hepatectomy and repeat hepatectomy for CRLM. Additionally, the oncological outcomes of patients with early( ≤ 6 months) ...     

Improved survival after resection of colorectal liver metastases in patients with unresectable lung metastases

BackgroundModern systemic therapies considerably improve tumour control and thus open the possibility of new surgical approaches in metastatic colorectal cancer. In this retrospective clinical cohort with a comparison group, we investigated whether liver resection in a combined liver–lung-metastasised stage is justified if pulmonary disease is not resected.MethodsFrom 283 patients treated in our institution between 2000 and 2014 for combined colorectal liver- and lung metastases, 35 patients had their pulmonary metastases left in situ while they were eligible for both treatment options: resection versus non-resection of liver metastases. Effectively, 15 of these patients received whereas 20 did not receive a liver resection. In these patients, we compared overall survival and determined risk factors that are associated with poor survival, applying a Cox-Proportional Hazards model.ResultsPatients whose liver metastases were resected showed significantly longer median survival compared to patients who did not undergo hepatic surgery (median 2.6 vs 1.5 years, P = 0.0182). The Cox-Proportional Hazards model revealed hepatic metastasectomy to be the strongest determinant of patient survival (HR 5.27; CI: (1.89, 14.65)).ConclusionOur results suggest that surgical removal of liver metastases may be beneficial in selected patients even if concomitant lung metastases cannot be resected.     

Microwave ablation versus radiofrequency ablation for perivascular hepatocellular carcinoma: a propensity score analysis

BackgroundTo compare the efficacy and safety of microwave ablation (MWA) and radiofrequency ablation (RFA) as first-line treatments for perivascular HCC.MethodsThis multicentre study enrolled 170 patients with perivascular HCC who underwent MWA or RFA. The ablation response, progression-free survival (PFS), overall survival (OS), and complications between the treatment groups for the total and propensity score-matched (PSM) cohorts were compared.ResultsThe disease control rates for MWA and RFA were similar in total (94% vs. 91%, p = 0.492) and PSM (93% vs. 93%, p = 1.00) cohorts. The PFS rates at 1, 3, and 5 years were 71%, 55% and 52% in MWA group and 61%, 33% and 28% in RFA group (p = 0.017). The OS rates were comparable between two groups in total (p = 0.249) and PSM cohorts (p = 0.345). In subgroup analyses, the PFS of patients with periportal HCC (45 vs. 36 months, p = 0.048) and a single HCC nodule (51 vs. 42 months, p = 0.014) were significantly better in MWA group than RFA. Major complications were more frequent in the MWA group than in RFA (27% vs. 7%, p < 0.001).ConclusionCompared with RFA, MWA provides better control of tumour progression especially in periportal HCC or single-nodule perivascular HCC patients.