
    Local Control: Liver Metastases Part 1 Surgical & Ablative Methods
    written and compiled by doctordee  may 2001 


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Metastatic Disease -- Local Control -- Treatment Options by Site - Liver Part 1

Liver Metastases: General Discussion

Part 1 Surgical and Ablative Methods
* Surgical Resection 
* Cryosurgery 
* Radio Frequency Ablation [RFA] 
* Microwave Ablation 
 
Part 2 Methods other than Surgical or Ablative    
* Percutaneous Ethanol Injection 
* Hepatic Arterial Infusion [HAI] 
* Arterial Embolization and Chemoembolization
* Isolated Liver Perfusion [IHP] 
* Stop-flow Perfusion 
* Radiation/Radioisotope Embolization  

How to Use This Page
The index gives some methods of treatment. Under each method, often with a short explanation at the beginning, there is a collection of medical journal article references relating to that technique, its success with LMS or sarcomas if such is available, and further information about its use and complications. Generally, the best way to deal with LMS metastases is by surgical resection, if it is at all possible. 
Should you be interested in a specific technique, abstracts can be highlighted and copied, and then printed out and taken with you to your doctor for further discussion. The institution where the research was done is often listed in the citation, should you or your doctor wish to contact the researchers.
Sites considered are: Liver, Lung, Lung&Liver, Limb, Brain, Bone&Spine. 
[ ] will indicate editorial comment by the compiler. Some sentences are highlighted in bold, again done by the compiler.
Liver Metastases-General Discussion 
Liver metastasis is a life-threatening prognostic aspect. However, tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. Remember, the liver has the capacity to regenerate its tissue, not like lung or kidney.

It is now accepted that liver resection should be done surgically as the treatment of choice when the complete excision of all demonstrable tumor with clear resection margins is feasible.  http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract
 [In the presence of other abdominal tumors or of inoperable lung tumors, however, this may not be the treatment of choice.]

If liver tumors are inoperable, ablative methods are probably the techniques of choice, if the tumor size and location are favorable.  If the liver tumors are inoperable, and cannot be ablated, neoadjuvant treatment with chemotherapy or one of these techniques might downsize the tumors so that they become surgically resectable.
Regional chemotherapy might be useful combined with hepatic resection or as palliative therapy. Patients with localized, unresectable hepatic metastases or coexisting serious medical condition(s) may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, microwave, laser, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization or chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival.  
For primary or secondary tumors of the liver, six existing minimally invasive techniques for the treatment of primary and secondary malignant hepatic tumors--radio-frequency ablation, microwave ablation, laser ablation, cryosurgical ablation, ethanol ablation, and chemoembolization have each exceeded clinical results obtained with conventional chemo- or radiation therapy. Thus, for nonsurgical patients, these techniques are becoming standard independent or adjuvant therapies. In addition, with continued improvement in technology and increasing clinical experience, one or more of these minimally invasive techniques may soon challenge surgical resection as the treatment of choice for patients with limited hepatic tumor. 



Liver Metastases & Surgical Resection 



Surgical resection of hepatic metastases still holds a chance of cure, if there is no other disease, or if other deposits are also resectable. However, the overall survival rate is still low. If the hepatic metastases are resectable, resection is the best therapeutic choice. 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract

Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. GI tract cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, the majority of the patients relapse after hepatic resection, 50% relapsing in the liver. Re-resections of hepatic metastases also remain potentially curable procedures without other sites of disease. 
Furthermore, should there be a limited number of resectable pulmonary metastases as well as hepatic metastases, both the liver and the lung can be resected sequentially, in many cases yielding statistics not too different from cases that are solely liver or solely lung resections. 
Fundamental principles when resecting hepatic metastases are to resect all the lesions and to avoid major operative risk. In complex cases, the most frequent, these principles can only be completely followed in a specialized center. In consideration of the satisfactory results achieved with an aggressive policy of liver resection, it is probably best to be referred to a specialized liver unit where major hepatic procedures, even if extended, can be safely performed. The first liver resection should be planned carefully, so that a second liver resection, if necessary, can be done efficaciously. 
Ultrasound at hepatic resection operations [intraoperative ultrasound] should be used; it can detect metastases not previously detected, and thereby help with resection boundaries. 
Patients who are found to have unresectable metastases might be able to have them resected if tumor bulk is reduced by appropriate chemotherapy or other percutaneous procedure. Another alternative for unresectable metastases is a two procedure metastectomy. First, some of the tumor is removed. The liver is allowed to recover and regenerate, so that removal of the rest of the tumor bulk with the second operation does not reduce the amount of functioning liver tissue below survival level. 
In a search of the literature, two studies were found dealing solely with leiomyosarcoma hepatic resections. The resection of all hepatic metastases in these patients resulted in prolonged survival. Studies of hepatic resections in other cancers were included in the following journal search in order to indicate the use of various techniques and strategies. Again, it is emphasized that these specialized & difficult operations be done at specialized liver centers, by surgeons experienced in the technique.  The first resection should be planned with the second in mind.
Selected Medical Journal Annotated References for this section are below.

Pubmed/Medline Search on Surgical Resection of Liver Metastases in Sarcomas for latest information:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=PubMed&term=sarcoma%20liver%20metastasis%20resection

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Liver Metastases & Surgical Resection 
Selected Medical Journal Annotated References 

[For the full abstract, use the links provided, or search on Pubmed.  Ed.]




Ann Surg 2000 Apr;231(4):500-5 
Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period. 
Lang H, Nussbaum KT, Kaudel P, Fruhauf N, Flemming P, Raab R. Klinik fur Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany. hauke.lang@uni-essen.de 

... Liver resection is the treatment of choice for hepatic metastases from colorectal carcinoma. In contrast, the role of liver resection for hepatic metastases from leiomyosarcoma has not been defined. 
... The records of 26 patients who between 1982 and 1996 underwent a total of 34 liver resections for hepatic metastases from leiomyosarcoma were reviewed. There were 23 first, 9 second, and 2 third liver resections. The records were analyzed with regard to survival and predictive factors. 
... In the 23 first liver resections, there were 15 R0  [R0 resection is clear surgical margins. Ed.], 3 R1, and 5 R2 resections. Median survival was 32 months after R0 resection and 20.5 months after R1/2 resection. The 5-year survival rate was 13% for all patients and 20% after R0 resection. In 10 patients with extrahepatic tumor at the time of the first liver resection, 6 R0 and 4 R2 resections were achieved. After R0 resection, the median survival was 40 months (range 5-84 months), with a 5-year survival rate of 33%. After repeat liver resection, the median survival was 31 months (range 5-51 months); after R0 resection, median survival was 31 months and after R1/2 resection it was 28 months. There was no 5-year survivor in the overall group after repeat liver resection. 
... Despite frequent tumor recurrence, the long-term outcome after liver resection for hepatic metastases from leiomyosarcoma is superior to that after chemotherapy and chemoembolization. Although survival after tumor debulking also seems to be more favorable than after nonoperative therapy, these data indicate that only an R0 resection offers the chance of long-term survival. The presence of extrahepatic tumor should not be considered a contraindication to liver resection if complete removal of all tumorous masses appears possible. In selected cases of intrahepatic tumor recurrence, even repeated liver resection might be worthwhile. In view of the poor results of chemoembolization and chemotherapy in hepatic metastases from leiomyosarcoma, liver resection should be attempted whenever possible. PMID: 10749609 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract


J Gastrointest Surg 1998 Mar-Apr;2(2):151-5 
Complete hepatic resection of metastases from leiomyosarcoma prolongs survival. 
Chen H, Pruitt A, Nicol TL, Gorgulu S, Choti MA.Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md, USA. 
... 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. PMID: 9834411 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract

Br J Surg 2000 Nov;87(11):1500-5 
Surgical treatment of adult primary hepatic sarcoma. 
Poggio JL, Nagorney DM, Nascimento AG, Rowland C, Kay P, Young RM, Donohue JH. Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA. 
... Twenty consecutive adult patients who had surgical treatment for primary hepatic sarcomas were reviewed. Patient age ranged from 23 to 80 years. .... Nineteen patients had hepatic resection and one patient had an orthotopic liver transplant. No patient received neoadjuvant chemotherapy or radiotherapy but radiotherapy was delivered intraoperatively in one patient. ... Leiomyosarcoma was the most common histological type of sarcoma diagnosed (five of 20 patients), ... Distant metastases (ten patients) and intrahepatic recurrence (six) were the predominant sites of initial treatment failure. ...Histological grade was the only factor significantly associated with overall patient survival (P= 0.03). With complete resection, patients with high-grade tumours had a 5-year survival rate of 18 (95 per cent confidence interval 5-62) per cent compared with 80 (52-100) per cent for patients with low-grade tumours. The 5-year survival rate for all 20 patients was 37 (20-60) per cent. CONCLUSION: Surgical resection is the only effective therapy for primary hepatic sarcomas at present. Better adjuvant therapy is necessary, especially for high-grade malignancies, owing to the high failure rate with operation alone. PMID: 11091236 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11091236&dopt=Abstract

Am Surg 2000 Jul;66(7):611-5 
Intraoperative ultrasound (IOUS) is essential in the management of metastatic colorectal liver lesions. 
Cervone A, Sardi A, Conaway GL. Department of Surgery, St Agnes Health Care, Baltimore, Maryland 21229, USA. 
Metastatic tumors to the liver account for the majority of hepatic neoplasms. Improvement in resection has been shown to be beneficial and has remained the treatment of choice, carrying a 5-year survival rate of approximately 20 to 30 per cent. In evaluating candidates for surgery, intraoperative assessment for resectability is a key factor and dictates surgical approach, as well as patient prognosis. Historically, imaging techniques such as CT scan, magnetic resonance imaging, and CT arterial portography (CTAP) have been used in preoperative evaluation. However, the sensitivities of these diagnostic tools have been found to be less than optimal. Intraoperative ultrasound (IOUS) has emerged as an important tool in accurately staging metastatic liver disease with a sensitivity of 98 per cent...The use of IOUS modified the management of 44 per cent of our patients with liver metastases. IOUS should be routinely used in patients undergoing liver resection for metastatic liver disease. PMID: 10917467 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10917467&dopt=Abstract

Ann Surg 2000 Dec;232(6):777-85 
Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors. 
Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H. Centre Hepato-Biliaire, Hopital Paul Brousse, Villejuif, and Universite Paris-Sud, France. rene.adam@pbr.ap-hop-paris.fr 
... Some patients with multiple hepatic colorectal metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization, or combined with a locally destructive technique. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. In selected patients with irresectable multiple metastases not amenable to a single hepatectomy procedure, two-stage hepatectomy might offer a chance of long-term remission. ... Two-stage hepatectomy was feasible in 13 of 16 patients (81%). There were no surgical deaths. The postoperative death rate (2 months or less) was 0% for the first-stage procedure and 15% for the second-stage one. Postoperative complication rates were 31% and 45%, respectively, with only one complication leading to reoperation. The 3-year survival rate was 35%, with four patients (31%) disease-free at 7, 22, 36, and 54 months. Median survival was 31 months from the second hepatectomy and 44 months from the diagnosis of metastases. ...Two-stage hepatectomy combined with chemotherapy may allow a long-term remission in selected patients with irresectable multiple metastases and increases the proportion of patients with resectable disease. PMID: 11088072 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11088072&dopt=Abstract

Arch Surg 2001 Mar;136(3):318-23 
Colorectal hepatic metastases: resection, local ablation, and hepatic artery infusion pump are associated with prolonged survival. 
Heslin MJ, Medina-Franco H, Parker M, Vickers SM, Aldrete J, Urist MM. 
Department of Surgery, University of Alabama, Birminghan 35294, USA. marty.heslin@ccc.uab.edu 
... Treatment of metastatic colorectal cancer to the liver is not uniform. We describe the management of metastatic colorectal cancer of the liver at a single institution during a 10-year period. ...Fifty-two patients underwent lobectomy or wedge resection, 5 underwent cryotherapy, and 16 had a hepatic artery infusion pump (HAIP) inserted... The 3-year actuarial survivals for patients who underwent resection, HAIP, or those with unresectable disease were 70 months, 32 months, and 3 months, respectively (P.001). .... Surgical resection should be attempted for hepatic colorectal metastases, as this is associated with prolonged overall survival. Hepatic artery infusion pump insertion seems to prolong overall survival for those with unresectable hepatic metastases, but it is not equal to resection. Aggressive surgical management of patients with hepatic colorectal metastases is safe, may prolong overall survival, and therefore should be considered in all patients with metastases confined to the liver. PMID: 11231853 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11231853&dopt=Abstract

Surg Oncol 2000 Aug;9(2):71-5 
Recurrent gastrointestinal stromal sarcomas. 
Eilber FC, Rosen G, Forscher C, Nelson SD, Dorey F, Eilber FR. Division of Surgical Oncology, 54-140 CHS, UCLA Medical Center, Los Angeles, CA 90095-1782, USA. feilber@surgery.medsch.ucla.edu 
Gastrointestinal stromal sarcomas, formerly categorized as leiomyosarcomas of gastrointestinal origin, have a common pattern of intraperitoneal dissemination. Despite surgical resection with or without adjuvant systemic chemotherapy the vast majority of these patients succumb to intraperitoneal sarcomatosis and/or hepatic metastases. ... we and several other centers have begun treating these patients with intraperitoneal chemotherapy. We have found that aggressive surgical resection with postoperative intraperitoneal chemotherapy has significantly lowered the peritoneal recurrence rate in patients with recurrent gastrointestinal stromal sarcomas as compared to those who have undergone surgical resection alone. However, this treatment approach has proven to be ineffective in preventing hepatic metastases, and thus has had little effect upon overall survival. With the treatment of primary rather than recurrent disease we hope to interrupt the disease process at an earlier stage ... PMID: 11094326 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11094326&dopt=Abstract

Med Oncol 2000 Aug;17(3):163-73 
Global approach to hepatic metastases from colorectal cancer: indication and outcome of intra-arterial chemotherapy and other hepatic-directed treatments. 
Fiorentini G, Poddie DB, Giorgi UD, Guglielminetti D, Giovanis P, Leoni M, Latino W, Dazzi C, Cariello A, Turci D, Marangolo M. Department of Oncology and Hematology, City Hospital, Ravenna, Italy. g.fiorentini@iol.it 
Liver metastases of colorectal cancer ...[has] a life-threatening prognostic aspect. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. ... Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy ... seems useful combined with hepatic resection or as palliative therapy. ... Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. ... PMID: 10962525 

Cancer 2000 Jul 15;89(2):276-84 
Microwave coagulation therapy for multiple hepatic metastases from colorectal carcinoma. 
Shibata T, Niinobu T, Ogata N, Takami M. Department of Surgery, Toyonaka Municipal Hospital, Osaka, Japan. 
...Compared with other treatments, microwave coagulation is a relatively less invasive treatment for various kinds of solid tumors. Although its effectiveness in primary hepatocellular carcinoma has been shown, its effectiveness in the treatment of hepatic metastases from colorectal carcinoma has been unclear. ... One-, 2-, and 3-year survival rates and mean survival times were 71%, 57%, 14%, and 27 months, respectively, in the microwave group, whereas they were 69%, 56%, 23%, and 25 months, respectively, in the hepatectomy group.[no significant difference in these results... ...Microwave coagulation therapy is suggested to be equally effective as hepatic resection in the treatment of multiple (two to nine) hepatic metastases from colorectal carcinoma, whereas its surgical invasiveness is less than that of hepatic resection. Copyright 2000 American Cancer Society. Clinical trial Randomized controlled trial PMID: 10918156 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10918156&dopt=Abstract

Surg Clin North Am 2000 Apr;80(2):603-32 
Hepatic malignancies. 
Tsao JI, DeSanctis J, Rossi RL, Oberfield RA. Department of Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA. 
The battle against malignancies of the liver is far from over, although tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. ...The battle continues in the laboratories, where investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. ... Publication Types: Review, tutorial PMID: 10836009 

Tumori 2000 Jan-Feb;86(1):1-7 
Surgical strategies in colorectal cancer metastatic to the liver. 
Bozzetti F, Bignami P, Baratti D.   Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy. dottfb@tin.it 
Surgical resection remains a milestone in the treatment of colorectal metastases to the liver. There is a distinct subset of patients who benefit from surgical resection in terms of longer survival or definitive cure. The main effort of the surgical oncological regards the safety of the procedure and the adequacy of the recommendation. ... It is now accepted that liver resection should be done when the complete excision of all demonstrable tumor with clear resection margins is feasible. Major contra-indication is represented by the presence of extra-hepatic intra-abdominal disease or of unresectable lung metastatic deposits. There is a wide literature indicating that in very selected patients liver reresection and multiorgan synchronous or metachronous resections are beneficial. .... PMID: 10778758  

Ann Surg 2000 Apr;231(4):487-99 
Extension of the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer: long-term results. 
Minagawa M, Makuuchi M, Torzilli G, Takayama T, Kawasaki S, Kosuge T, Yamamoto J, Imamura H. Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. 

... To evaluate retrospectively the long-term results of an approach consisting of performing surgery in every patient in whom radical removal of all metastatic disease was technically feasible
... The indications for surgical resection for liver metastases from colorectal cancer remain controversial. Several clinical risk factors have been reported to influence survival. 
... Between March 1980 and December 1997, 235 patients underwent hepatic resection for metastatic colorectal cancer. Survival rates and disease-free survival as a function of clinical and pathologic determinants were examined retrospectively with univariate and multivariate analyses. 
...The overall 3-, 5-, 10-, and 15-year survival rates were 51%, 38%, 26%, and 24%, respectively. The stage of the primary tumor, lymph node metastasis, and multiple nodules were significantly associated with a poor prognosis in both univariate and multivariate analyses. Disease-free survival was significantly influenced by lymph node metastasis, a short interval between treatment of the primary and metastatic tumors, and a high preoperative level of carcinoembryonic antigen. The 10-year survival rate of patients with four or more nodules (29%) was better than that of patients with two or three nodules (16%), and similar to that of patients with a solitary lesion (32%).
CONCLUSIONS: Surgical resection is useful for treating liver metastases from colorectal cancer. Although multiple metastases significantly impaired the prognosis, the life expectancy of patients with four or more nodules mandates removal. PMID: 10749608 


Baillieres Best Pract Res Clin Gastroenterol 1999 Dec;13(4):557-74 
Surgical treatment of malignant liver tumours. 
DeMatteo RP, Fong Y, Blumgart LH. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York,USA. 
Surgical resection is the mainstay of treatment for malignant liver tumours and offers the only chance of cure. Advances in radiological imaging, surgical technique and peri-operative management have enabled liver resection to be performed safely. Partial hepatectomy ... may be utilized for selected patients with liver metastases from other primary tumours. .... The role of cryosurgery has not been precisely defined, and it needs to be compared with other palliative therapies such as ethanol injection and hepatic artery embolization. Review, academic PMID: 10654920 

Ann Surg 1999 Dec;230(6):759-65; discussion 765-6 

Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection? 

Wigmore SJ, Madhavan K, Currie EJ, Bartolo DC, Garden OJ.   
University Department of Surgery, Royal Infirmary of Edinburgh, United Kingdom. 

... To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests. 
...Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. 
...The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). 
...No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. 
CONCLUSION: Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS group; their overall outcome was worse than that of the CS group. This observation is partly explained by a lower local recurrence rate in the CS group.PMID: 10615930 [Ed.  Expertise makes a difference.  Choose your surgeon and your other doctors carefully.  It usually is a good idea to find a specialist or subspecialist in the field.] 


Ann Surg Oncol 1999 Oct-Nov;6(7):645-50 
Comment in: Ann Surg Oncol. 1999 Oct-Nov;6(7):627-8 

Surgical resection and intraperitoneal chemotherapy for recurrent abdominal sarcomas. 
Eilber FC, Rosen G, Forscher C, Nelson SD, Dorey FJ, Eilber FR. Division of Surgical Oncology, UCLA Musculo-Skeletal Study Group, University of California, Los Angeles 90095, USA. 

... Recurrent abdominal sarcomas have an extremely high rate of recurrence and poor overall survival. A prospective study was initiated to assess the feasibility, toxicity, and benefit of surgical resection and intraperitoneal chemotherapy for improving local control of disease and overall survival. 
... Fifty-four patients underwent surgical excision of all gross disease and postoperative intraperitoneal chemotherapy with mitoxantrone. Thirty-five patients had peritoneal disease only (stage II), and 19 patients had peritoneal disease with hepatic metastases (stage III). 
...Nine (17%) patients remain free of disease with a mean follow-up of 37 months. The remaining 45 patients (83%) have had recurrence, with a mean interval to recurrence of 11 months. Stage (P = .001) and grade (P = .005) were the only two variables found to significantly affect recurrence. There was an overall peritoneal recurrence rate of 48% and an overall hepatic failure rate of 69%. Nineteen (35%) of the patients are alive, with a mean follow-up of 46 months. The overall 5-year survival was 31%. The 5-year survival for stage II patients was 46%; for stage III patients, it was only 5%. Stage (P = .001) and grade (P = .056) were the only two variables found to significantly affect survival. There were no treatment-related deaths, and only 5 patients (9%) developed local complications. 

CONCLUSIONS: Aggressive surgical resection and intraperitoneal chemotherapy for recurrent abdominal sarcomas is a feasible treatment approach with minimal toxicity. Although this treatment had little effect on the hepatic spread of this disease and thus overall survival, it appears to have significantly lowered the rate of peritoneal recurrence and may provide a survival benefit for patients with disease limited to the peritoneum. Publication Types: Clinical trial PMID: 10560849
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10560849&dopt=Abstract
 [Ed. Discussion of Hyperthermia concomitant with intraperitoneal chemotherapy for recurrent abdominal tumor or abdominal sarcomatosis is discussed on the Hyperthermia web page. ]


G Chir 1999 Jun-Jul;20(6-7):289-92 
[Recurrent liver metastases from colorectal cancer: their surgical treatment]. [Article in Italian] 
Tocchi A, Mazzoni G, Liotta G, Lepre L, Costa G, Miccini M. Istituto di I Clinica Chirurgica, Universita degli Studi La Sapienza, Roma. 
Records of 8 patients undergoing repeated operation for isolated hepatic metastasis were reviewed for operative morbidity and mortality, survival, disease-free survival. The mean interval between the initial colon operation and first hepatic resection and that between the first and the second hepatic operation were calculated. Both were found to be correlated with survival of these patients. Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic resections in terms of operative mortality and morbidity, survival, disease-free survival. Repeated hepatic operation is the most successful form of treatment for isolated recurrent colorectal metastasis. PMID: 10390924 

N Z Med J 1999 Mar 26;112(1084):91-3 
Hepatic resection for metastases in colorectal carcinoma. 
Jourdan JL, Cannan R, Stubbs R. The Wakefield Clinic for Gastrointestinal Diseases, Wellington. 
... CONCLUSIONS:Resection of colorectal liver metastases can achieve extension of life and long-term survival in selected patients. However, it remains a major undertaking and is probably best performed in units with appropriate expertise and experience. PMID: 10210294 


Gastroenterol Clin Biol 1998 Dec;22(12):1048-55 Comment in: Gastroenterol Clin Biol. 1998 Dec;22(12):1046-7 
[What are the real indications for hepatectomies in metastases of colorectal origin]? [Article in French] 
Elias D, Ducreux M, Rougier P, Sabourin JC, Cavalcanti A, Bonvalot S, Debaene B, Antoun S, Pignon JP, Lasser P. Departement de Chirurgie Carcinologique, Institut Gustave-Roussy, Villejuif. 
... CONCLUSION: Fundamental principles of the indications of hepatectomy for colorectal LM are to resect all the lesions and to avoid major operative risk. In complex cases, the most frequent, these principles can only be completely followed in a specialized center. PMID: 10051980 

Liver Transpl Surg 1999 Jan;5(1):65-80 
Management of hepatic metastases. 
Choti MA, Bulkley GB. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 
Although the liver is the most common site of metastatic disease from a variety of tumor types, isolated hepatic metastases most commonly occur from colorectal cancer and, less frequently, from ... gastrointestinal sarcoma, .... Complete evaluation of the extent of metastatic disease, both intrahepatically and extrahepatically, is important before considering treatment options. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%. Systemic and hepatic arterial infusion chemotherapy may be useful treatment options in patients with unresectable disease and possibly as an adjuvant treatment after liver resection. Other techniques of local tumor ablation, including cryotherapy and radiofrequency ablation, although promising, remain unproved. Management of hepatic metastases from .. noncolorectal primary tumors should be individualized based on the patient's clinical course, extent of disease, and symptoms. Review, academic PMID:9873095 

Br J Surg 1998 Oct;85(10):1423-7 
Results of surgical resection of liver metastases from non-colorectal primaries. 
Berney T, Mentha G, Roth AD, Morel P. Clinic of Digestive Surgery, Geneva University Hospital, Switzerland. 
... Advances in the field of liver surgery have lowered its associated mortality and morbidity rates, and hepatic resection for metastatic disease is increasingly performed. There are few well defined guidelines for the heterogeneous group of non-colorectal metastases. ... A retrospective study was performed of 34 patients who underwent 37 operations over a 10-year period. Compilation of data from 141 patients from eight additional recent series was performed in order to analyse the effect of histological type on survival. 
...There were no perioperative deaths. Complications occurred after seven of 37 procedures. Actuarial survival rates were 61, 43 and 27 per cent at 1, 2 and 5 years. Survival was significantly improved for curative versus palliative resection (P < 0.05), and for single versus multiple metastases (P < 0.05). A strong correlation was observed between time to presentation with metastasis and length of survival (P< 0.0001). ... CONCLUSION: The low mortality and morbidity rates and the satisfactory survival figures reported justify this type of surgery for selected patients, in the absence of therapeutic alternatives. PMID: 9782030 
Aust N Z J Surg 1998 Oct;68(10):716-21 
One hundred liver resections including comparison to non-resected liver-mobilized patients. 
Hardy KJ, Fletcher DR, Jones RM. Department of Surgery, University of Melbourne, Austin Campus, Victoria, Australia. surgery@austin.unimelb.edu.au 
...Major hepatic resection can be performed with low mortality, morbidity and short hospital stay, with a 5-year survival for colorectal carcinoma better than 50%. ... Re-resection is a safe and rewarding treatment and needs to be planned at the first resection. PMID: 9768608 

Am Surg 1998 Mar;64(3):211-20; discussion 220-1 
Surgical and nonsurgical management of primary and metastatic liver tumors. 
Zibari GB, Riche A, Zizzi HC, McMillan RW, Aultman DF, Boykin KN, Gonzalez E, Nandy I, Dies DF, Gholson CF, Holcombe RF, McDonald JC. Louisiana State University Medical Center, Department of Surgery, Shreveport 71130, USA. 
The medical records of 267 patients who had liver tumors, primary and metastatic, from 1988 to 1995 were retrospectively reviewed. ... The patients who underwent surgery had a 32 per cent 5-year survival rate compared to a 0 per cent 5-year survival in the patients who did not have surgery (p = 0.0001). The patients who had resections had a better survival rate than those deemed unresectable at surgery (62% versus 0% at 5-years with p = 0.0008). The perioperative morbidity rate was 16 per cent, with lobectomies having the best rate and trisegmentectomies having the worst. Perioperative mortality rate was zero for all liver resections. Hepatic resection and, in selected patients, liver transplantation are the only two available therapeutic modalities that produce long-term survival with a possible cure in patients with primary and metastatic liver tumor.  PMID: 9520809 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9520809&dopt=Abstract



Eur J Surg 1996 Sep;162(9):709-15 
Repeat resection of recurrent hepatic metastases--improvement in prognosis? 
Riesener KP, Kasperk R, Winkeltau G, Schumpelick V. Department of Surgery, Medical Faculty, Rhenish Westphalian Technical University, Aachen, Germany. 
... To find out if resection of recurrent hepatic metastases improves survival. ... 25 patients who had recurrent metastases after radical resection of hepatic metastases from colorectal and other primary carcinomas. ... Repeat liver resection with the intention to cure. .... Actuarial survival rates after radical repeat liver resections were 94% after one year, 53% after two years, and 24% after three years. ... CONCLUSIONS: Repeat hepatic resections seem to improve prognosis and are recommended in patients with recurrent metastases confined to the liver. Publication Types: Review Review of reported cases PMID: 8908452 



Surgery 1996 Oct;120(4):591-6 
Survival after repeat hepatic resection for recurrent colorectal hepatic metastases. 
Bines SD, Doolas A, Jenkins L, Millikan K, Roseman DL. Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III., USA. 
BACKGROUND: This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. ... In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection. PMID: 8862365 

Ann Surg 1996 Oct;224(4):509-20; discussion 520-2 
Resection of nonresectable liver metastases from colorectal cancer after neoadjuvant chemotherapy. 
Bismuth H, Adam R, Levi F, Farabos C, Waechter F, Castaing D, Majno P, Engerran L. Hepatobiliary Surgery and Liver Transplant Research Center, Laboratory of Biological and Chronotherapeutical Rhythms, Hopital Paul Brousse, Villejuif, France. 
... Resection is the best treatment of colorectal liver metastases, but it may be achieved in only 10% of patients. In the remaining 90%, survival is poor, even after partial response to chemotherapy. Little is known about the results of curative hepatectomy in patients whose metastases are downstaged by chemotherapy. ...CONCLUSIONS: Liver resection may be achieved in some previously unresectable patients with the help of an effective chemotherapy. The benefit in survival seems comparable to that obtained with primary liver resection (40% at 5 years). This therapeutic strategy involves a multimodal approach, including repeat hepatectomies and extrahepatic surgery. PMID: 8857855 


Cancer 2001 Feb 15;91(4):727-36 
P53 mutations in primary tumors and subsequent liver metastases are related to survival in patients with colorectal carcinoma who undergo liver resection. 
Yang Y, Forslund A, Remotti H, Lonnroth C, Andersson M, Brevinge H, Svanberg E, Lindner P, Hafstrom L, Naredi P, Lundholm K. Department of Oncology, Nanfang University Hospital, Guangzhou City, People's Republic of China. 
...... [ed. abstract heavily edited.] 
CONCLUSIONS: "The presence of p53 mutations in patients with metastatic lesions was related significantly (P < 0.003) to better survival after the patients underwent liver resection compared with patients with wild type p53 in their metastatic lesions. Explanations for this unexpected finding remain unclear, although the authors speculate that occult tumor cells with p53 mutations may be less responsive to growth factor(s) exposure during hepatic regeneration after resection." Copyright 2001 American Cancer Society. PMID: 11241240 

Chirurg 1999 Apr;70(4):439-46 
[Liver resection for non-colorectal, non-neuroendocrine hepatic metastases]. [Article in German] 
Lang H, Nussbaum KT, Weimann A, Raab R. Klinik fur Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover. 
Over a period of 11 years a total of 140 liver resections for non-colorectal, non-neuroendocrine hepatic metastases were performed in 127 patients (73 women, 54 men; median age 53 years). There were 120 first, 14 second and 6 third liver resections. Primary tumors were: ... leiomyosarcoma (n = 20), ... Extrahepatic tumor manifestation (including synchronous primary tumors) was found in 69/140 cases (49%); 61 of 120 patients with a first liver resection had extrahepatic tumor (51%). In the 120 first liver resections, 82 (68%) R0, 13 (11%) R1 and 25 (21%) R2 excisions were possible. Median survival after first liver resection was 20 months; after R0 [R0 is clear margins] resection a median survival of 28 months and after R1/2 resection of 8 months was achieved. The 5-year survival rate was 16% for the total group, 24% in patients with R0 resection and 0% for R1/2 resections. After a second liver resection (n = 14) there was a median survival of 28 months (5-year-survival-rate of 21%) for all patients and of 41 months (5-year survival rate 38%) after R0 resection. Morbidity and mortality after the first liver resection were 32.5% and 5.8%, respectively. In patients without extrahepatic tumor at the time of the first liver resection a median survival of 32 months (5-year survival rate 25%) and 7 months was achieved after R0 resection and R1/2 resection, respectively. In case of extrahepatic tumor the median survival was 24 months (5-year survival rate 23%) for R0 resection compared to 8 months after R1/2 resection. These data suggest that not the presence of extrahepatic tumor but rather the possibility of a R0 resection is most decisive for the prognosis after liver resection. We conclude that patients with liver metastases of non-colorectal, non-neuroendocrine tumors may benefit from liver resection. Similar to colorectal metastases, a second or third liver resection can be worthwhile in selected cases. Even in more unfavorable tumor entities, several cases of long-term survival were observed after surgical therapy. Therefore, the indication for liver resection should be considered carefully in every single case. PMID: 10354843 [ed. R0 is clear surgical margins. This is NOT LMS alone, but a mixture of cancers. None of the following articles are LMS alone, either. ] 



Semin Oncol 1999 Oct;26(5):514-23 
Surgical therapy of hepatic colorectal metastasis. 
Fong Y, Salo J. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. 
The liver is a common site of metastases from colorectal cancer. The data are convincing that liver resection is a safe and effective therapy for such metastatic disease. Even extensive resections can be performed with a less than 5% mortality rate at major centers and a 5-year survival rate of 30% to 40%. .... For unresectable disease, many methods for ablating tumors are now available that will likely prove to be useful adjuncts to current treatment. Review, tutorial PMID: 10528899 

Ann Surg 1999 Sep;230(3):309-18; discussion 318-21 
Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. 
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Hepatobiliary Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York 10021, USA. 
... data for 1001 consecutive patients undergoing liver resection for metastatic colorectal cancer ...were examined. These resections included 237 trisegmentectomies, 394 lobectomies, and 370 resections encompassing less than a lobe. The surgical mortality rate was 2.8%. ...: The 5-year survival rate was 37%, and the 10-year survival rate was 22%. Seven factors were found to be significant and independent predictors of poor long-term outcome by multivariate analysis: positive margin (p = 0.004), extrahepatic disease (p = 0.003), node-positive primary (p = 0.02), disease-free interval from primary to metastases <12 months (p = 0.03), number of hepatic tumors >1 (p = 0.0004), largest hepatic tumor >5 cm (p = 0.01), and carcinoembryonic antigen level >200 ng/ml (p = 0.01). When the last five of these criteria were used in a preoperative scoring system, assigning one point for each criterion, the total score was highly predictive of outcome (p < 0.0001). No patient with a score of 5 was a long-term survivor. CONCLUSION: Resection of hepatic colorectal metastases may produce long-term survival and cure. Long-term outcome can be predicted from five criteria that are readily available for all patients considered for resection. Patients with up to two criteria can have a favorable outcome. Patients with three, four, or five criteria should be considered for experimental adjuvant trials. Studies of preoperative staging techniques or of adjuvant therapies should consider using such a score for stratification of patients. PMID: 10493478 


Can J Surg 1997 Jun;40(3):175-81 
Long-term survival after hepatic cryosurgery versus surgical resection for metastatic colorectal carcinoma: a critical review of the literature. 
Tandan VR, Harmantas A, Gallinger S. Department of Surgery, University of Toronto, Mount Sinal Hospital, Ont. 
OBJECTIVE: To critically assess the evidence for long-term survival after hepatic resection and hepatic cryosurgery for metastatic colorectal cancer. The purpose of this review is to determine if a randomized controlled trial comparing these two treatment modalities is justified. ... CONCLUSIONS: Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease outside a clinical trial, and do not yet justify a randomized trial. A study that collects prospective data on 2 groups of patients (resectable v. unresectable) who differ only in the anatomic location of their metastases within the liver is needed. PMID: 9194777 


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Cryosurgery and Hepatic Metastases 
Cryosurgical ablation of hepatic metastases is safe, provides excellent palliation of symptoms, and in selected patients can be performed with curative intent. Indications for cryosurgical ablation included bilobar and centrally located disease [multiple unresectable liver metastases], poor medical risk, insufficient hepatic reserve, and involved margin after wedge resection. 
Cryosurgical ablation of hepatic tumors relies on nonspecific tissue necrosis due to freezing, as well as microvascular thrombosis. The tumor is flash frozen by the cryosurgery trochar to a very low temperature.  It is then allowed to defrost, and in that process the spicules of ice crystals formed physically tear apart the membrane of the cell.  The freezing-defrost cycle is repeated, so that all cells are lysed [broken apart].
Patients with selected primary and metastatic hepatic malignancies who are NOT candidates for surgical resection are afforded potentially curative benefit using this technique. Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease.   Surgical resection remains the treatment of choice for hepatic metastases of LMS. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract
Whether used alone or in association with surgical resection, cryotherapy of liver metastases is a specialized technique that should be done in a specialized liver facility, as should surgical resections of the liver. Intraoperative ultrasound should be used in all patients to help locate the tumor and guide the cryosurgical trochar to the lesions. 
Complications of the procedure include: the liver tissue cracking with subsequent bleeding--possibly requiring transfusion, bile leaks, injury to surrounding structures/organs [i.e. inferior vena cava], pleural effusions [water on the lung], postoperative biliary stenosis [bile duct narrowing]. 
Latest PubMed Search on Cryosurgery and Liver Metastases
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=PubMed&term=cryosurgery%20metastasis%20hepatic


Below are some selected abstracts of medical journal articles that deal with cryotherapy of liver metastases. 

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Cryosurgery in the Treatment of Liver Metastases
Selected Annotated Medical Journal References

[For the full abstract, use the links provided, or search on Pubmed.  Ed.]


Anticancer Res 2000 Sep-Oct;20(5C):3785-90 
Cryosurgery as a means to improve surgical treatment of patients with multiple unresectable liver metastases. 
Rivoire M, De Cian F, Meeus P, Gignoux B, Frering B, Kaemmerlen P. Department of Surgery, Centre Leon Berard, 28, Rue Laennec, 69373 Lyon, France. rivoire@lyon.fnclcc.fr 
... The aim of the study was to evaluate the results of cryosurgery in patients with multiple (five or more), heavily pretreated, unresectable liver metastases. ... 140 metastases were identified in 19 patients (mean, 7; range, 5-25) and 13 patients had a synchronous liver resection. Cryosurgery was used to treat 90 metastases (mean diameter, 30 mm; range, 10-135). There were no treatment-related deaths and the overall rate of complications was 21%. 
During a mean follow-up of 28 months (range, 5-60), tumours recurred at the site of cryosurgery in two patients (10%), in the remaining liver in nine patients (47%) and elsewhere in five patients (26%). Three patients had no evidence of disease 48, 50 and 60 months after liver cryosurgery, respectively. ... Cryosurgery may be effective in the treatment of patients with multiple unresectable liver metastases and should be investigated in multimodality treatment programmes. PMID: 11268455 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11268455&dopt=Abstract

Clin Exp Dermatol 1995 Jan;20(1):22-6 
Response of leiomyosarcoma to cryosurgery: clinicopathological and ultrastructural study. 
Montes LF, Ocampo J, Garcia NJ, Vaccaro F, Arra A, Abulafia J, Wilborn WH, Lembrande RG. Structural Research Center, Mobile, AL, USA. 
Two elderly patients with primary leiomyosarcoma (LMS) of the scalp were treated cryosurgically. Complete involution of both tumours with full epithelialization of the affected sites was achieved. Pretreatment biopsies and sequential biopsies obtained after treatment allowed observation of microscopical changes taking place during tumour involution. Gradual shrinkage of both LMS, closely monitored under the operating microscope, started immediately after the initial freezing. Light and electron microscopic observation of the shrinking LMS revealed a rapid disappearance of the tumoral architecture. ... Two years after treatment, both patients showed no signs of recurrence. These results suggest cryosurgery--performed in an extended protracted fashion--can be a valuable therapeutic choice in the management of LMS, particularly when surgical excision is not feasible. PMID: 7671391 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7671391&dopt=Abstract

Am J Surg 1999 Dec;178(6):592-9 
Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies. 
Pearson AS, Izzo F, Fleming RY, Ellis LM, Delrio P, Roh MS, Granchi J, Curley SA. Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. 
... The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA. ... Cryoablation was performed on 88 tumors in 54 patients, and RFA was used to treat 138 tumors in 92 patients. Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation (40.7% complication rate). In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01). 
...RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA. PMID: 10670879 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10670879&dopt=Abstract

J Surg Oncol 1998 Aug;68(4):242-5 
Cryosurgical ablation of unresectable hepatic metastases. [None are Sarcomas. ed.] 
Dale PS, Souza JW, Brewer DA. Division of Surgical Oncology, Mercer University School of Medicine, Macon, Georgia, USA. 
... Recent advancements in the technology of cryosurgery along with the development and refinement of intraoperative ultrasound have led to a feasible alternative for some patients with unresectable hepatic malignancy. This paper reports our first year's experience with cryosurgical ablation of unresectable hepatic malignancies... CONCLUSIONS: Cryosurgical ablation is a safe method of treating unresectable hepatic malignancies and it may extend survival in carefully selected patients. PMID: 9721710  
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9721710&dopt=Abstract

Am J Surg 1997 Dec;174(6):614-7; discussion 617-8 
Cryosurgical ablation of hepatic tumors. [None are Sarcomas...ed.] 
Crews KA, Kuhn JA, McCarty TM, Fisher TL, Goldstein RM, Preskitt JT. Department of Surgery, Baylor University Medical Center, Dallas 75246, USA. 
BACKGROUND: Cryosurgical ablation of hepatic tumors relies on nonspecific tissue necrosis due to freezing as well as microvascular thrombosis. Patients with selected primary and metastatic hepatic malignancies who are not candidates for surgical resection are afforded potentially curative benefit using this technique. ... Intraoperative ultrasound (IOUS) was used in all patients to help locate the tumor and guide the cryosurgical trocar to the lesions.  ...  Indications for cryosurgical ablation included bilobar and centrally located disease, poor medical risk, insufficient hepatic reserve, and involved margin after wedge resection. 
Major complications included hepatic parenchyma cracking requiring transfusion in 5 patients, 1 postoperative biliary stenosis, and 1 inferior vena cava injury. There were 3 postoperative deaths from non-hepatic-related events. ... The pattern of failure was identified at the site of cryosurgical ablation in 2 of 88 lesions. ...Cryosurgical ablation of selected hepatic malignancies is a safe and viable treatment for patients not amenable to surgical resection. PMID: 9409584 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9409584&dopt=Abstract

Am Surg 1997 Jan;63(1):63-8 
Cryosurgical ablation of hepatic metastases from colorectal carcinomas. 
Yeh KA, Fortunato L, Hoffman JP, Eisenberg BL. Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA. 
Surgical resection remains the only curative therapy for hepatic metastases from colon and rectal carcinoma. Many patients will be unresectable or have close microscopic margins. Cryoablation may improve local control and survival in those cases. ... We conclude that cryoablation of unresectable hepatic metastases or close resection margins is safe and may allow for improved survival in selected patients with metastatic colon and rectal carcinoma.PMID: 8985074
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8985074&dopt=Abstract


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Radio Frequency Ablation [RFA] of Hepatic Metastases 


Surgical Resection remains the therapeutic option of choice in the treatment of liver tumors. 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract
However, the majority of primary and metastatic tumors of the liver are not amenable to surgical resection at presentation. Radiofrequency ablation (RFA) is a new modality for local tumor destruction with minimal local and systemic complications. Radiofrequency heat ablation is useful as a primary treatment for unresectable liver cancers. The procedure can be used to treat the small residual tumor load in the contralateral [other side] lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy increases surgical resectability in patients previously judged unresectable. RFA can also be combined with cryosurgical ablation. Percutaneous RFA should be considered in high-risk patients or those with small local recurrences.
Radiofrequency Ablation is a specialized technique, and should be carried out in a specialized liver treatment center. Celiotomy [abdominal incision] or laparoscopic approaches are preferred for RFA because they allow IOUS [intraoperative ultrasound], which may demonstrate hidden additional metastases. Operative RFA also allows concomitant resection, Cryosurgical Ablation, or placement of a hepatic artery infusion pump, and isolation of the liver from adjacent organs. Laparoscopy and intraoperative ultrasound are essential in staging patients with hepatic malignant neoplasms. 
RFA can be carried out percutaneously [through the skin--meaning without a surgical incision.] Percutaneous RFA should be reserved for patients at high risk for anesthesia, those with recurrent or progressive lesions, and those with smaller lesions sufficiently isolated from adjacent organs. 
Radiofrequency ablation when combined with Cryosurgical Ablation reduces the morbidity of multiple freezes. Although RFA is safer than Cryosurgical Ablation and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy); it is usually limited by tumor size (<3 cm).  However, in some organs, RFA is used to "nibble" at large tumors, and can ablate them in skilled hands. 
Complications of RFA can include bleeding into the chest or abdominal cavities or other structures, burns of vascular structures or skin or diaphragm, persistent pain, pleural effusions [water on the lung], cholecystitis [gall bladder inflammation], abcesses, trauma to the liver, and liver failure. Some of the RFA complications can be fatal. 
RFA is a safe and effective alternative for the attempted ablation of unresectable hepatic malignancies and when used adjunctively can reduce the morbidity of cryosurgery. Percutaneous and laparoscopic RFA can be performed effectively with less than 24 hours of hospitalization. Radiofrequency ablation alone or combined with Surgical Resection or Cryosurgical Ablation resulted in reduced blood loss and shorter hospital stay. 
Latest Pubmed Search on RFA and Treatment of Liver Metastases
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=PubMed&term=radio%20frequency%20ablation%20hepatic%20metastasis

References for this section are below.

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RFA and Liver Metastases 
Selected Medical Journal Article Annotated References

[For the full abstract, use the links provided, or search on Pubmed.  Ed.]


J Surg Res 2001 Jan;95(1):8-12 
Radiofrequency ablation treatment of refractory carcinoid hepatic metastases. 
Wessels FJ, Schell SR. Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, 32610-0286, USA. schelsr@mail.surgery.ufl.edu 

Some patients exhibit hepatic metastases that are unresponsive to embolization. This report describes the use of radiofrequency ablation (RFA) as salvage treatment for these refractory metastases. These patients underwent surgical exploration and intraoperative ultrasound of their refractory lesions, followed by treatment with RFA. All three patients demonstrated decreased symptoms following treatment. This study demonstrates that utilization of RFA treatment for carcinoid metastases refractory to hepatic artery embolization may represent a useful adjunct for symptomatic control, and slowing of disease progression. [This is a summary. For the full abstract, use the links provided, or search on Pubmed.  Ed.] Copyright 2001 Academic Press. PMID: 11120628 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11120628&dopt=Abstract

Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000 Nov;172(11):905-10 
[Percutaneous radiofrequency ablation of hepatic neoplasms using a "cluster" electrode--first clinical results]. [Article in German] Trubenbach J, Konig CW, Duda SH, Schick F, Huppert PE, Claussen CD, Pereira PL. Abteilung fur Radiologische Diagnostik, Eberhard-Karls-Universitat Tubingen. jochen.truebenbach@med.uni-tuebingen.de 
 ... A total of 17 percutaneous RFA was performed. The mean total procedure time was 2.0 h (1.5-2.5 h). Placement of the clustered electrode within the neoplasms using a inter- or subcostal approach under local anesthesia was possible in all cases. Complications related to percutaneous treatment and technical problems were not encountered. Diameter of the ablated areas ranged between 3.0-7.0 cm. Technical success was observed in 13 of 15 neoplasms (86.6%). During a mean follow-up of 7.25 months (range 3-12 months) 8 of 12 neoplasms showed a complete necrosis...... Percutaneous RFA using a clustered electrode is a feasible, safe and effective procedure for the treatment of hepatic neoplasms up to 6 cm in size. Clinical trial PMID: 11142123 

Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000 Aug;172(8):692-700 
[MRI-guided percutaneous radiofrequency ablation of hepatic neoplasms--first technical and clinical experiences]. [Article in German] 
Huppert PE, Trubenbach J, Schick F, Pereira P, Konig C, Claussen CD. Abteilung fur Radiologische Diagnostik, Eberhard-Karls-Universitat Tubingen. PeterHuppert@t-online.de 
... 16 hepatic neoplasms (1.3-3.0 cm in diameter) in 11 patients were treated by 22 percutaneous RFA sessions during a prospective study. .... Pretreatment studies, evaluation of tumor necrosis (one week after last RFA), and further follow-up studies every 3 months were performed using 1.5 Tesla MR systems. ... The mean procedure time was 2.8 (1.5-3.3) h. Complications related to percutaneous treatment were not encountered. 14 of 16 neoplasms (87%) showed no CM enhancement during MRI after the last RFA and were judged to be completely necrotic. In 11 tumors one treatment session was necessary, in 4 tumors two and in one tumor three. Follow-up studies revealed persistent complete necrosis in 13 of 14 (93%) tumors during a period of 3-18 (median: 11.8) months. In 5 patients new intrahepatic tumors developed that were not suitable for further RFA treatment because of their number, size and location. CONCLUSION: MR-guided RFA using single cooled tip electrodes is safe and technically effective for treatment of hepatic neoplasms up to 3 cm in size, however further improvements are necessary. Publication Types: Clinical trial  PMID: 11013611 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11013611&dopt=Abstract

Ann Surg Oncol 2000 Sep;7(8):593-600 

Radiofrequency ablation of 231 unresectable hepatic tumors: indications, limitations, and complications. 

Wood TF, Rose DM, Chung M, Allegra DP, Foshag LJ, Bilchik AJ. Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California 90404, USA. 

... Radiofrequency ablation (RFA) is increasingly used for the local destruction of unresectable hepatic malignancies. There is little information on its optimal approach or potential complications. ...: Since late 1997, we have undertaken 91 RFA procedures to ablate 231 unresectable primary or metastatic liver tumors in 84 patients. RFA was performed via celiotomy (n = 39), laparoscopy (n = 27), or a percutaneous approach (n = 25). ...

...Intraoperative ultrasound (IOUS) detected intrahepatic disease not evident on the preoperative scans of 25 of 66 patients (38%) undergoing RFA via celiotomy or laparoscopy. In 38 of 84 patients (45%), RFA was combined with resection or cryosurgical ablation (CSA), or both. RFA was used to treat an average of 2.8 lesions per patient, and the median size of treated lesions was 2 cm (range, 0.3-9 cm). The average hospital stay was 3.6 days overall (1.8 days for percutaneous and laparoscopic cases). Ten patients underwent a second RFA procedure (sequential ablations) and, in one case, a third RFA procedure for large (one patient), progressive (seven patients), and/or recurrent (three patients) lesions. Seven (8%) patients had complications: one skin burn; one postoperative hemorrhage; two simple hepatic abscesses; one hepatic abscess associated with diaphragmatic heat necrosis following sequential percutaneous ablations of a large lesion; one postoperative myocardial infarction; and one liver failure. There were three deaths, one (1%) of which was directly related to the RFA procedure. Three of the complications, including one RFA-related death, occurred after percutaneous RFA. At a median follow-up of 9 months (range, 1-27 months), 15 patients (18%) had recurrences at an RFA site, and 36 patients (43%) remained clinically free of disease. 
... Celiotomy or laparoscopic approaches are preferred for RFA because they allow IOUS, which may demonstrate occult hepatic disease. Operative RFA also allows concomitant resection, CSA, or placement of a hepatic artery infusion pump, and isolation of the liver from adjacent organs. Percutaneous RFA should be reserved for patients at high risk for anesthesia, those with recurrent or progressive lesions, and those with smaller lesions sufficiently isolated from adjacent organs. Complications may be minimized when these approaches are applied selectively. Publication Types: Clinical trial Clinical trial, phase ii PMID: 11005558 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11005558&dopt=Abstract


Surg Endosc 2000 Sep;14(9):799-804 
Use of CT Hounsfield unit density to identify ablated tumor after laparoscopic radiofrequency ablation of hepatic tumors. 
Berber E, Foroutani A, Garland AM, Rogers SJ, Engle KL, Ryan TL, Siperstein AE. Department of General Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. 
BACKGROUND: When attempting to interpret CT scans after radiofrequency thermal ablation (RFA) of liver tumors, it is sometimes difficult to distinguish ablated from viable tumor tissue. Identification of the two types of tissue is specially problematic for lesions that are hypodense before ablation. ... CONCLUSIONS: This is the first study to define quantitative radiological criteria using HU density for the evaluation of ablated tissues. A lack of increase in HU density with contrast injection indicates necrotic tissue, whereas perfused tissue shows an increase in HU density. This technique can be used in the evaluation of patients undergoing RFA. PMID: 11000357 

Eur Radiol 2000;10(6):926-9 
Hemobilia, intrahepatic hematoma and acute thrombosis with cavernomatous transformation of the portal vein after percutaneous thermoablation of a liver metastasis. 
Francica G, Marone G, Solbiati L, D'Angelo V, Siani A. Divisione di Gastroenterologia, Ospedale Cardinale Ascalesi, Naples, Italy. giampierofrancica@libero.it 
... The case described emphasizes that radio-frequency interstitial hyperthermia may cause not only traumatic injury of the liver parenchyma but also thermally mediated damage of vascular structures. PMID: 10879704 

Arch Surg 2000 Jun;135(6):657-62; discussion 662-4 
Cryosurgical ablation and radiofrequency ablation for unresectable hepatic malignant neoplasms: a proposed algorithm. 
Bilchik AJ, Wood TF, Allegra D, Tsioulias GJ, Chung M, Rose DM, Ramming KP, Morton DL. John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif 90404, USA. bilchika@jwci.org 
...Thermal ablation of unresectable hepatic tumors can be achieved by cryosurgical ablation (CSA) or radiofrequency ablation (RFA). The relative advantages and disadvantages of each technique have not yet been determined.
 ...Laparoscopy identified extrahepatic disease in 12% of patients, and intraoperative hepatic ultrasound identified additional lesions in 33% of patients, despite extensive preoperative imaging. Radiofrequency ablation alone or combined with resection or CSA resulted in reduced blood loss (P<.05), thrombocytopenia (P<.05), and shorter hospital stay compared with CSA alone (P<.05). Median ablation times for lesions greater than 3 cm were 60 minutes with RFA and 15 minutes with CSA (P<.001). Local recurrence rates for lesions greater than 3 cm were also greater with RFA (38% vs 17%). 
CONCLUSIONS: Laparoscopy and intraoperative ultrasound are essential in staging patients with hepatic malignant neoplasms. Radiofrequency ablation when combined with CSA reduces the morbidity of multiple freezes. Although RFA is safer than CSA and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy), it is limited by tumor size (<3 cm). Percutaneous RFA should be considered in high-risk patients or those with small local recurrences. PMID: 10843361   http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10843361&dopt=Abstract

Radiology 2000 Mar;214(3):761-8 
Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions. 
Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Ierace T, Solbiati L, Gazelle GS. Department of Radiology, Ospedale Civile, Vimercate, Italy. lalivra@tin.it 
PURPOSE: To study local therapeutic efficacy, side effects, and complications of radio-frequency (RF) ablation in the treatment of medium and large hepatocellular carcinoma (HCC) lesions in patients with cirrhosis or chronic hepatitis. ... One-hundred fourteen patients who were under conscious sedation or general anesthesia had 126 HCCs greater than 3.0 cm in diameter treated with RF by using an internally cooled electrode. Eighty tumors were medium (3.1-5.0 cm), and 46 were large (5.1-9.5 cm). The mean diameter for all tumors was 5.4 cm. At imaging, 75 tumors were considered noninfiltrating, and 51 were considered infiltrating. 
...Complete necrosis was attained in 60 lesions (47.6%), nearly complete (90%-99%) necrosis in 40 lesions (31.7%), and partial (50%-89%) necrosis in the remaining 26 lesions (20.6%). Medium and/or noninfiltrating tumors were treated successfully significantly more often than large and/or infiltrating tumors. Two major complications (death, hemorrhage requiring laparotomy) and five minor complications (self-limited hemorrhage, persistent pain) were observed. The single death was due to a break in sterile technique rather than to the RF procedure itself. CONCLUSION: RF ablation appears to be an effective, safe, and relatively simple procedure for the treatment of medium and large HCCs.  PMID: 10715043 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10843361&dopt=Abstract

J Hepatobiliary Pancreat Surg 1999;6(2):190-4 
Recurrent hepatocellular carcinoma successfully treated with radiofrequency thermal ablation. 
Kainuma O, Asano T, Aoyama H, Shinohara Y. 
Second Department of Surgery, Chiba University School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan. 
We report a patient with hepatocellular carcinoma (HCC) who was successfully treated with radiofrequency thermal ablation (RFA). A 71-year-old man was admitted to our hospital in August 1996 with recurrence of HCC. Partial hepatic resection had been performed in January 1993 for HCC that had measured 1.3 cm in segment VIII, and subsequently he had received six sessions of percutaneous ethanol injection (PEI) for treatment of recurrence. Dynamic computed tomography (CT) performed in August 1996 showed two recurrent tumors, one measuring 3.8 cm in segment VIII adjacent to the right hepatic vein, and one measuring 2.0 cm in segment V. Three sessions of percutaneous RFA were performed. After this treatment, most of the tumor ... showed low density on dynamic CT, and the right hepatic vein was preserved. However, a remnant of the mass appeared near the right hepatic vein 2 months after the treatment. An additional two sessions of RFA were performed. ... and no sign of recurrence has been observed until September 1998. PMID: 10398909 

Am J Surg 1999 Dec;178(6):592-9 
Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies. 
Pearson AS, Izzo F, Fleming RY, Ellis LM, Delrio P, Roh MS, Granchi J, Curley SA. Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. 
... The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA. ... ...Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation ... In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01). ... RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA. PMID: 10670879 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10670879&dopt=Abstract

Cancer J Sci Am 1999 Nov-Dec;5(6):356-61 Comment in: Cancer J Sci Am. 1999 Nov-Dec;5(6):339-400 
Radiofrequency ablation: a minimally invasive technique with multiple applications. 
Bilchik AJ, Rose DM, Allegra DP, Bostick PJ, Hsueh E, Morton DL. John Wayne Cancer Institute at Saint John's Health
 ...RFA is a safe and effective alternative for the ablation of unresectable hepatic malignancies and when used adjunctively can reduce the morbidity of cryosurgery. Percutaneous and laparoscopic RFA can be performed effectively with less than 24 hours of hospitalization. Intraoperative ultrasonography is essential for accurate staging. PMID: 10606477 

Am Surg 1999 Nov;65(11):1009-14 
Radiofrequency ablation: a novel primary and adjunctive ablative technique for hepatic malignancies. 
Rose DM, Allegra DP, Bostick PJ, Foshag LJ, Bilchik AJ. John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA. 
The majority of primary and metastatic tumors of the liver are not amenable to surgical resection at presentation. Radiofrequency ablation (RFA) is a new modality for local tumor destruction with minimal local and systemic complications. We prospectively reviewed the experience with RFA at a single institute as a primary or adjunctive ablative technique in the treatment of hepatic malignancies. .... RFA is a safe and effective method of tumor ablation for hepatic malignancies. This technique can be performed laparoscopically, at celiotomy, or percutaneously and can be used as a primary technique or in conjunction with other interventional procedures. PMID: 10551746 

Ann Surg 1999 Jul;230(1):1-8 Comment in: Ann Surg. 1999 Jul;230(1):9-11 
Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies: results in 123 patients. 
Curley SA, Izzo F, Delrio P, Ellis LM, Granchi J, Vallone P, Fiore F, Pignata S, Daniele B, Cremona F. Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. 
... To describe the safety and efficacy of radiofrequency ablation (RFA) to treat unresectable malignant hepatic tumors in 123 patients. ... The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, or multifocality or inadequate functional hepatic reserve. Local application of heat is tumoricidal; therefore, the authors investigated a novel RFA system to treat patients with unresectable hepatic cancer. ... All treated tumors were completely necrotic on imaging studies after completion of RFA treatments. With a median follow-up of 15 months, tumor has recurred in 3 of 169 treated lesions (1.8%), but metastatic disease has developed at other sites in 34 patients (27.6%). ... RFA is a safe, well-tolerated, and effective treatment to achieve tumor destruction in patients with unresectable hepatic malignancies. Because patients are at risk for the development of new metastatic disease after RFA, multimodality treatment approaches that include RFA should be investigated. Publication Types: Clinical trial PMID: 10400029 

Radiology 1999 Jun;211(3):643-9 
Radio-frequency ablation of hepatic metastases: postprocedural assessment with a US microbubble contrast agent--early experience. 
Solbiati L, Goldberg SN, Ierace T, Dellanoce M, Livraghi T, Gazelle GS.   Department of Radiology, Ospedale Generale, Busto Arsizio, Italy. 
... Contrast-enhanced US may depict residual tumor after RF application and thereby enable additional directed therapy. The potential reduction in treatment sessions and/or ancillary imaging procedures might increase the ease and practicality of percutaneous ablation of focal hepatic metastases. PMID: 10352586 

Am J Surg 1999 Apr;177(4):303-6 
Clinical short-term results of radiofrequency ablation in primary and secondary liver tumors. 
Jiao LR, Hansen PD, Havlik R, Mitry RR, Pignatelli M, Habib N. Liver Surgery Section, Imperial College School of Medicine, The Hammersmith Hospital, London, England, U.K. 
... Radiofrequency ablation (RFA) is emerging as a new therapeutic method for management of solid tumors. We report here our experience in the use of this technique for management of primary and secondary unresectable liver cancers. ...Radiofrequency heat ablation is useful as a primary treatment for unresectable liver cancers. The procedure can be used to treat the small residual tumor load in the contralateral lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy seems to increase surgical resectability in patients judged unresectable. Publication Types: Clinical trial PMID: 10326848 

Radiology 1999 Mar;210(3):655-61 Comment in: Radiology. 2000 Jul;216(1):304-6 
Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. 
Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Solbiati L, Gazelle GS. Department of Radiology, Ospedale Civile, Vimercate, Italy. 
PURPOSE: To compare the effectiveness of radio-frequency (RF) ablation with that of percutaneous ethanol injection in the treatment of small hepatocellular carcinoma (HCC). ...: Complete necrosis was achieved in 47 of 52 tumors with RF ablation (90%) and in 48 of 60 tumors with percutaneous ethanol injection (80%). These results were obtained with an average of 1.2 sessions per tumor with RF ablation and 4.8 sessions per tumor with percutaneous ethanol injection. One major complication (hemothorax that required drainage) and four minor complications (intraperitoneal bleeding, hemobilia, pleural effusion, cholecystitis) occurred in patients treated with RF ablation; no complications occurred in patients treated with percutaneous ethanol injection. ... RF ablation results in a higher rate of complete necrosis and requires fewer treatment sessions than percutaneous ethanol injection. However, the complication rate is higher with RF ablation than with percutaneous ethanol injection. RF ablation is the treatment of choice for most patients with HCC. PMID: 10207464 


Liver Transpl Surg 1998 Jul;4(4):271-5 
An appraisal of percutaneous treatment of liver metastases. 

Mazziotti A, Grazi GL, Gardini A, Cescon M, Pierangeli F, Ercolani G, Jovine E, Cavallari A. 
Policlinico S. Orsola, University of Bologna, Italy. 

"Percutaneous treatments, such as ethanol injection and radiofrequency, have been recently proposed for the treatment of liver metastases. The aim of this study was to evaluate the effects of these treatments in a series of 8 patients who subsequently underwent liver resection. These patients had been treated with percutaneous methods between December 1995 and May 1997. ...In all patients, a progression of the disease occurred. Four patients underwent a right hepatectomy; 1 patient, a left lobectomy; 2 patients, a segmentectomy; and 1 patient, a wedge resection. There was no operative mortality in any of these 8 patients. Two patients presented with seeding of the neoplasm on the diaphragm, which was resected. Histologic examination of all surgical specimens revealed the presence of vital neoplastic tissue; only two specimens of carcinoid tumors showed more than 50% necrosis of the nodules treated percutaneously. These results led us to express doubts as to the efficacy of percutaneous ablative treatment for liver metastases." Copyright 1998 W.B. Saunders Company. PMID: 9649639 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9649639&dopt=Abstract


Eur Radiol 1998;8(7):1205-11 
Radio-frequency thermal ablation of liver metastases with a cooled-tip electrode needle: results of a pilot clinical trial. 
Lencioni R, Goletti O, Armillotta N, Paolicchi A, Moretti M, Cioni D, Donati F, Cicorelli A, Ricci S, Carrai M, Conte PF, Cavina E, Bartolozzi C. Division of Diagnostic and Interventional Radiology, Department of Oncology, University of Pisa, Via Roma 67, I-56 125 Pisa, Italy. 
The aim of this study was to evaluate feasibility, safety, and effectiveness of radio-frequency (RF) thermal ablation, performed by using a cooled-tip electrode needle, in the treatment of liver metastases. ... Complete tumor response (i. e., unenhancing area of thermal necrosis larger than the treated tumor) was seen in 41 (77 %) of 53 lesions, including 33 (87 %) of 38 lesions 3 cm or less in diameter. After a mean follow-up period of 6.5 +/- 2.1 months (range 3-9 months), recurrence of the treated lesion was seen in 5 (12 %) of the 41 cases. New metastatic lesions appeared in 7 patients. Two patients died after 6 and 8 months, respectively. Of the 27 patients still in follow-up, 14 are currently free of disease. Radio-frequency thermal ablation with a cooled-tip electrode needle is a safe and effective local treatment for hepatic metastases 3 cm or less in greatest dimension. Publication Types: Clinical trial PMID: 9724440 

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Liver Metastases & Microwave Ablation 

Surgery remains the treatment of choice for patients with resectable hepatic tumors. 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10749609&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834411&dopt=Abstract
However, when there are multiple tumors caused by intrahepatic metastases, multidisciplinary treatments consisting of reduction surgery, microwave ablation, ethanol injection, and intra-arterial chemotherapy might be useful. Non-resectable situations are often improved to resectable ones by use of the newer modalities. 
Furthermore, in situations where an operation is contraindicated, ablative techniques can still offer the possibility of cure, if other tumor is not present. 
Theoretical studies have suggested that microwave energy can increase the depth of heating compared with radiofrequency energy. Complications would be similar to RFA treatments. 
Latest Pubmed Search on Microwave Ablation and Hepatic Metastasis.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=PubMed&term=microwave%20ablation%20hepatic%20metastasis

References for this Section: Microwave Ablation & Liver Metastases  -- are below.

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Liver Metastases & Microwave Ablation 
Selected Medical Journal Article Annotated References

[For the full abstract, use the links provided, or search on Pubmed.  Ed.]



Cancer 2000 Jul 15;89(2):276-84 
Microwave coagulation therapy for multiple hepatic metastases from colorectal carcinoma. 
Shibata T, Niinobu T, Ogata N, Takami M. Department of Surgery, Toyonaka Municipal Hospital, Osaka, Japan. 
... Compared with other treatments, microwave coagulation is a relatively less invasive treatment for various kinds of solid tumors. Although its effectiveness in primary hepatocellular carcinoma has been shown, its effectiveness in the treatment of hepatic metastases from colorectal carcinoma has been unclear. The aim of this study was to evaluate its effectiveness in the treatment of multiple hepatic metastases from colorectal carcinoma by comparing this technique with that of hepatic resection. One-, 2-, and 3-year survival rates and mean survival times were 71%, 57%, 14%, and 27 months, respectively, in the microwave group, whereas they were 69%, 56%, 23%, and 25 months, respectively, in the hepatectomy group. The difference between these two groups was statistically not significant (P = 0.83). On the other hand, the amount of intraoperative blood loss in the microwave group (360 +/- 230 mL) was smaller than that in the hepatectomy group (910 +/- 490 mL, P < 0.05). ... Microwave coagulation therapy is suggested to be equally effective as hepatic resection in the treatment of multiple (two to nine) hepatic metastases from colorectal carcinoma, whereas its surgical invasiveness is less than that of hepatic resection. Copyright 2000 American Cancer Society. Publication Types: Clinical trial Randomized controlled trial PMID: 10918156
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10918156&dopt=Abstract

Gan To Kagaku Ryoho 2000 Oct;27(12):1842-5 
[Assessment of colorectal cancer patients exhibiting bilobular multiple hepatic metastases]. [Article in Japanese] 
Shibata T, Shimano T, Kitada M, Niinobu T, Fukushima Y, Hata S, Fujita J, Ikeda K, Hayashida H, Takahashi Y, Suzuki R, Nakamura T, Takami M. Dept. of Surgery, Toyonaka Municipal Hospital. 
We assessed 23 patients who underwent surgical therapy of hepatectomy or microwave coagulation therapy (MCT) for bilobular multiple hepatic metastatic foci following curative resection of the primary lesion of colorectal cancer. .... MCT was considered to be useful local therapy for cancer as the first therapy and as a therapy following recurrence. PMID: 11086426 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11086426&dopt=Abstract


Radiographics 2000 Jan-Feb;20(1):9-27 

Minimally invasive treatment of malignant hepatic tumors: at the threshold of a major breakthrough. 
Dodd GD 3rd, Soulen MC, Kane RA, Livraghi T, Lees WR, Yamashita Y, Gillams AR, Karahan OI, Rhim H. 
Department of Radiology, University of Texas Health Science Center at San Antonio, 78284-7800, USA. 

Six existing minimally invasive techniques for the treatment of primary and secondary malignant hepatic tumors--radio-frequency ablation, microwave ablation, laser ablation, cryoablation, ethanol ablation, and chemoembolization--are reviewed and debated by noted authorities from six institutions from around the world. All of the authors currently believe that surgery remains the treatment of choice for patients with resectable hepatic tumors. However, the clinical results of each of the minimally invasive techniques presented have exceeded those obtained with conventional chemotherapy or radiation therapy. Thus, for nonsurgical patients, these techniques are becoming standard independent or adjuvant therapies. In addition, with continued improvement in technology and increasing clinical experience, one or more of these minimally invasive techniques may soon challenge surgical resection as the treatment of choice for patients with limited hepatic tumor. Review, tutorial PMID: 10682768 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682768&dopt=Abstract


Endoscopy 2000 Aug;32(8):591-7 
Laparoscopic microwave coagulation therapy for hepatocellular carcinoma. 
Seki S, Sakaguchi H, Kadoya H, Morikawa H, Habu D, Nishiguchi S, Shiomi S, Kitada T, Kuroki T. 
Third Dept. of Internal Medicine, Osaka City University Medical School, Osaka, Japan. s.seki@med.osaka-cu.ac.jp 
... Several different effective forms of treatment are available, singly or in combination, for patients with hepatocellular carcinoma (HCC). These include surgical resection, transcatheter arterial embolization, percutaneous ethanol injection, and percutaneous microwave coagulation therapy. In this study, we carried out laparoscopic microwave coagulation therapy (LMCT), using laparoscopic microwave electrodes to treat HCC. ...The mean longest axis of the ... coagulated areas including the nodules was 40 mm, with additional therapy being required in two patients. Complete efficacy of the treatment was observed in 21 patients (87.5%), but local recurrences were seen in three of them one year after LMCT. The three-year survival rate was 92%... Hemostasis was complete, but mild pneumothorax occurred in three patients. ... LMCT under local anesthesia is a minimally invasive and effective therapy when carried out on a single occasion to treat HCCs located near the liver surface, and it can be safely performed under direct visual guidance. PMID: 10935786 

Am J Gastroenterol 1999 Jul;94(7):1914-7 
Standards for selecting percutaneous ethanol injection therapy or percutaneous microwave coagulation therapy for solitary small hepatocellular carcinoma: consideration of local recurrence. 
Horigome H, Nomura T, Saso K, Itoh M. First Department of Internal Medicine, Nagoya City University Medical School, Japan. 
... Percutaneous ethanol injection therapy (PEIT) and percutaneous microwave coagulation therapy (PMCT) are effective treatments for small hepatocellular carcinoma (HCC). There are no clear standards, however, for the selection of PEIT or PMCT. We determined standards based on local recurrence. ...PEIT was effective for treating well-differentiated HCC, and PMCT was effective for treating HCC measuring < or = 15 mm in diameter. PMCT was superior to PEIT for treating patients with HCC measuring < or = 15 mm in diameter. In such cases with well-differentiated HCC, PEIT was as effective as PMCT. CONCLUSIONS: The selection of PEIT or PMCT to treat patients with HCC should be based on tumor size and cell differentiation. PMID: 10406259 


Compiled by doctordee  May 2001

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