Michka,
I am so pleased that you are asking lots and lots of questions!!! My only request is that when you meet with your Dr. you share his/her responses on the board as well. Thus, we can create quite the body of knowledge regarding liver mets.
My liver met has returned twice to the "generally" same location in my liver, the left lobe. To date, it does not appear to have scattered into multiple mets.
Below is the article I located comparing/contrasting resection to cryoablation. (sorry...I had to copy the entire thing to this post as I don't know how to insert a document) It is very scientific and might be a good discussion point if your Oncologist is very numbers oriented. There were graphs in the article that did not copy. If you are interested, you can locate this article on the Web for an easier read.
I will keep you posted following my appointment with the interventional radiologist.
Cryoablation and liver resection for noncolorectal liver metastases
John D. Goering, M.D., David M. Mahvi, M.D., John E. Niederhuber, M.D.,
Deb Chicks, R.N., Layton F. Rikkers, M.D.*
University of Wisconsin-Madison, Department of Surgery Division of General Surgery, H4/710 Clinical Science Center, 600 Highland Avenue,
Madison, WI 53792 USA
Manuscript received December 17, 2001; revised manuscript January 5, 2002
Abstract
Background:
Liver resection for noncolorectal liver metastases has merit for selected primary tumor types. The role of cryosurgical tumor
ablation within this cohort of patients has not been evaluated. This is a single institutional review of treatment outcomes using cryosurgical
ablation and conventional resection techniques for noncolorectal liver metastases.
Methods:
The medical records of 42 patients undergoing 48 hepatic tumor ablative procedures from February 1991 through May 2001 at
a single institution were retrospectively reviewed. Overall survival and local hepatic tumor recurrence-free survival were analyzed for
different surgical procedures and primary tumor types.
Results:
Overall survival rates at 1, 3, and 5 years are 82%, 55%, and 39%, respectively (median survival, 45 months). Local hepatic tumor
recurrence-free survival rates for resection only (n 25) and cryosurgery with or without resection (n 23), at 3 years are 24% and 19%,
respectively. The survival rates at 5 years are 40% and 37%, for resection only and cryosurgery with or without resection, respectively.
Conclusion:
Cryosurgical hepatic tumor ablation for metastatic noncolorectal primary tumors results in survival and local hepatic tumor
recurrence rates similar to resection alone. The combination of cryosurgery and resection extends the cohort of patients with surgically
treatable disease. © 2002 Excerpta Medica, Inc. All rights reserved.
Keywords:
Cryoablation; Hepatic metastases; Liver resection
Hepatic resection for colorectal metastases has gained acceptance
as a potentially curative therapy with five-year
survival rates from 20% to 50% [1– 8]. However, the majority
of patients with metastatic disease to the liver are not
surgical candidates because of the number or distribution of
metastases or the presence of extrahepatic disease. Because
of the success of liver resection for metastatic colon cancer,
resective therapies have been applied to noncolorectal liver
metastases. Several series have reported improved survival
rates for patients undergoing curative or palliative liver
resections for noncolorectal metastatic disease [9 –11].
However, these studies have included only those patients
deemed suitable for conventional hepatic resection and have
generally excluded patients with bilobar or anatomically
unresectable disease.
Ablative therapies, such as cryosurgery and radiofrequency
ablation, are alternative options for complete hepatic
tumor ablation. Cryoablation alone or in combination
with hepatic resection increases the number of patients with
colorectal metastases who can be treated surgically [12–16].
Patients amenable to cryoablation, either alone or in combination
with resection, include those with bilobar disease,
or underlying liver dysfunction [12,17]. Cryoblation in
combination with hepatic resection is an aggressive surgical
approach and should be utilized only if survival is enhanced
and operative morbidity and mortality are low. The purpose
of this single institutional study is to assess survival and
local hepatic recurrence following hepatic resection and
cryosurgical ablation of noncolorectal liver metastases.
Methods
The medical records of all patients who underwent hepatic
resection or cryosurgical ablation of noncolorectal
liver metastases at the University of Wisconsin Hospital
from February 1991 through May 2001 were retrospectively
reviewed. Patients undergoing hepatic resection for direct
* Corresponding author. Tel.: 1-608-265-8854; fax: 1-608-263-
7652.
E-mail address:
rikkers@surgery.wisc.edu
The American Journal of Surgery 183 (2002) 384–389
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved.
PII: S0002-9610(02)00806-1
tumor extension to the liver from an adjacent primary tumor
were excluded. Curative procedures were de
fined as (1)
resections in which all gross tumor was removed with histological
proof of negative margins or (2) intraoperative
ultrasound evidence of complete iceball coverage of hepatic
tumor or (3) in the case of ovarian cancer, 90% or more
concurrent extra-hepatic tumor debulking.
Patient records were reviewed and analyzed for the following
factors: (1) demographics, (2) primary tumor type;
(3) synchronous or metachronous presentation; (4) unilobar
or bilobar disease; (5) number of hepatic lesions; (6) curative
or palliative resection; (7) resection or cryosurgical
tumor ablation; and (8) extent of hepatic resection. Outcome
measures included: local liver recurrence-free survival, disease-
free survival, and overall survival. Subgroup analysis
compared outcome measures between different surgical
procedures (resection and cryosurgery) and different tumor
group primaries.
Intraoperative ultrasound was performed using a dedicated
high-frequency 7.0 MHz T-shaped transducer to delineate
all hepatic lesions. In patients undergoing a combined
procedure, the resection was done first, followed by
cryoablation of the remaining lesions. Cryoablation was
performed under intraoperative ultrasound guidance to con-
fi
rm the location of all lesions and their relationship to
major biliary and vascular structures. An 18-gauge, Tefloncoated
needle was inserted into the tumor followed by a
cryoprobe using the Seldinger technique. Selection of probe
size was determined based on the required iceball size that
would be necessary to create a 1 cm margin around the
tumor. Multiple cryoprobes were placed in larger lesions
when necessary to achieve a 1 cm margin. Either liquid
nitrogen or argon gas units (Cryomedical Sciences, Inc.,
Rockford, Md., and EndoCare, Inc., Irvine, CA) were used
in this series. Cryogen was infused through the probes,
creating a temperature below 160 °C at the tip. Two 10-min
freeze cycles with an intervening 5-min thaw were completed
for each lesion [12].
Survival rates were estimated with the Kaplan-Meier
estimator. Differences in survival rates between groups
were tested for with the log-rank test. For disease-free
survival and local hepatic recurrence-free survival, the end
point event was recurrence or death. Differences between
study groups were tested for with t-tests. A 5% critical level
was used to determine statistical significance. All analyses
were performed with SAS statistical software (SAS Institute
Inc., Cary, NC).
Results
Patient and tumor characteristics
Forty-eight hepatic tumor ablations (resection and/or
cryosurgery) were completed in 42 patients (6 patients had
2 operative procedures due to local recurrence of liver
tumor). Twenty-
five patients underwent resection only, 16
received cryoablation only and in 7 patients a combination
of resection and cryoablation was utilized (Table 1). The
median age of the patients was 48 years (range 2–77 years).
Twenty five female and 17 male patients were treated.
Tables 1 and 2 summarize the characteristics of the metastases,
the treatment administered, and the types of tumors.
In total, there were 32 resections and 23 cryoablations
(Table 1). Twenty of the liver resections were lobar or
greater. Only 4 of the 48 procedures were not potentially
curative. Tumor types were grouped by anatomic association
in a manner similar to that proposed in an earlier study
[11] (Table 2).
Of the patients with neuroendocrine tumors, one patient
with a nonfunctional islet cell tumor, one with a carcinoid
primary, and the patient with a gastrinoma underwent two
operative procedures, the second one for local liver recurrence.
Three patients underwent resection and/or cryosurgical
ablation of hepatic tumors for palliation of endocrinetype
symptoms.
Of the patients with genitourinary tumors, one patient
Table 1
Characteristics of metastases and therapy
Resection only Cryoablation only Both resection
and cryoablation
Total
Number of metastases (mean and range) 1.72 (1
–10) 3.19 (1–30) 6.43 (1–12) 2.9 (1–30)
Presentation
Synchronous 6 2 5 13
Metachronous 19 14 2 35
Location of metastases
Right lobe 11 11 2 24
Left lobe 8 3 0 11
Bilobar 6 2 5 13
Extent of resection
Wedge 9 3 12
Lobectomy 12 3 15
Ext. Lobectomy 4 1 5
385 J.D. Goering et al. / The American Journal of Surgery 183 (2002) 384–389
with ovarian cancer and one individual with testicular cancer
also underwent two operative procedures. All ovarian
cancer patients had preoperative chemotherapy and prior
tumor debulking. In addition, 5 of the 7 ovarian cancer
patients had concomitant extrahepatic tumor debulking at
the time of hepatic tumor ablation. Both testicular cancer
patients had undergone prior chemotherapy without evidence
of extrahepatic disease at the time of hepatic tumor
ablation. One of the renal cancer patients was a 2-year old
boy with bilateral Wilm
’s tumor, the remaining two individuals
were adults with renal cell carcinoma.
Fourteen patients had soft tissue tumors. The primary
sites of the sarcomas were visceral (n 3), retroperitoneal
(n 1), ovarian (n 2), uterine (n 1), and extremity (n
2). Leiomyosarcoma made up 45% of the histologic
subtypes. One melanoma patient presented 5 years after eye
enucleation for ocular melanoma.
Outcomes
There was one operative mortality (2%). The median
follow-up time is 48 months. The overall 1-, 3-, and 5-year
survival rates are 82%, 55%, and 39%, respectively, with a
median overall survival of 45 months (Fig. 1). The 1- and
3-year disease-free survival rates are 41% and 19%, respectively.
The 1- and 3-year local hepatic tumor recurrence-free
survival rates are 43% and 21%, respectively (Fig. 2).
Overall survival rates for the resection-only group (
n
25) at 1-, 3-, and 5-years are 79%, 49%, and 40%, respectively.
In comparison, survival rates for the cryoablationonly
and combined treatment groups (
n 23) at 1-, 3-, and
5 years are 86%, 62%, and 37%, respectively (Fig. 3). The
difference in survival based on treatment is not statistically
significant (p 0.57). Local hepatic tumor recurrence-free
survival rates at 3 years for resection only and cryoablation
alone or combined with resection are 24% and 19%, respectively
(Fig. 4).
Survival rates for patients with neuroendocrine, genitourinary,
and soft tissue tumors at 3 years are 91%, 52%, and
34% (p 0.26), respectively (Fig. 5). (Local hepatic tumor
Table 2
Types of tumors
Resection
only
Cryoablation
only
Both
resection
and
cryoablation
Total
Neuroendocrine
Islet Cell
Nonfunctional 1 2 3 6
Gastrinoma 1 1 0 2
Carcinoid 2 2 1 5
Genitourinary
Ovarian 2 6 0 8
Renal 2 1 0 3
Testicular 1 1 1 3
Uterine 0 1 0 1
Cervix 1 0 0 1
Soft tissue
Sarcoma 9 0 1 10
Breast 2 1 0 3
Melanoma 2 0 0 2
Gastrointestinal
Esophageal 1 0 0 1
Cloacogenic 0 0 1 1
Pancreatic 0 1 0 1
Head/neck
Adenocystic 1 0 0 1
Fig. 1. Overall survival for all patients.
Fig. 2. Overall hepatic recurrence-free survival for all patients.
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J.D. Goering et al. / The American Journal of Surgery 183 (2002) 384–389
recurrence-free survival rates at 3 years for neuroendocrine,
genitourinary, and soft tissue tumors are 32%, 19%, and
20%, respectively (Fig. 6).) Among the ovarian cancer patients,
3 of 7 patients died within 19 months of surgery. The
remaining 4 patients, with 1 patient undergoing 2 ablative
procedures, are alive with hepatic recurrent disease occurring
1, 4, 7, 9, and 12 months after surgery. The two patients
with cervical and uterine primary tumors died with recurrent
disease at 6 and 4 months postoperatively. One testicular
cancer patient had a 44-month survival, whereas the other is
alive without disease 76 months after resection. The patient
with bilateral Wilm
’s tumor is alive without disease almost
5 years after hepatic resection for a metachronous lesion. In
addition, 1 renal cancer patient is alive without disease 3
years after resection, although the other renal cancer patient
died one year after resection.
Five of 9 patients with sarcoma primaries died within 3
years of surgery. The remaining 4 patients are alive with
recurrent liver disease occurring between 4 and 60 months
post-treatment. Both patients with melanoma died within 4
months after undergoing liver resection. Two of 3 patients
with metastatic breast cancer are alive without disease although
one underwent resection only 1 month ago.
There were only three patients with gastrointestinal primary
tumors, (esophageal adenocarcinoma, pancreatic adenocarcinoma,
and cloacogenic carcinoma) and two recurred
within five months. Two died within seven months and one
(cloacogenic carcinoma) remains alive with disease. One
patient with adenocystic carcinoma metastases from a submandibular
gland primary tumor underwent a wedge resection
and concomitant extrahepatic tumor debulking. Hepatic
tumor recurrence developed 11 months postoperatively.
Fig. 3. Overall survival by procedure. (circles
resection only; plus signs
cryoablation with or without resection; P 0.57).
Fig. 4. Hepatic recurrence-free survival by procedure. (circles resection
only; plus signs cryoablation with or without resection).
Fig. 5. Survival by tumor class. (plus signs genitournary; circles
neuroendocrine; squares
soft tissue; P 0.26).
Fig. 6. Hepatic recurrence-free survival by tumor class. (plus signs
genitourinary; circles
neuroendocrine; squares soft tissue)
387 J.D. Goering et al. / The American Journal of Surgery 183 (2002) 384–389
Discussion
This report suggests that cryoablation alone or combined
with surgical resection results in similar survival rates when
compared to resection alone in selected patients with noncolorectal
liver metastases. Liver resection for metastatic
colorectal carcinoma is now accepted as a potentially curative
modality [3
–6]. All colorectal carcinoma patients with
anatomically resectable disease isolated to the liver are
candidates for resection. In addition, several series have
shown that cryoablation alone or in combination with hepatic
resection for colorectal hepatic metastases increases
the number of patients amenable to surgical treatment [12–
16]. The outcome for patients who undergo liver resection
for isolated hepatic metastases from noncolorectal primary
tumors is less clear due to the smaller patient populations
that have been studied. Results from this series and others
[9
–11] suggest that surgical therapy for carefully selected
patients with isolated hepatic metastatic disease from noncolorectal
primaries improves survival. In addition, results
of this study suggest that cryosurgical ablation may increase
the number of patients amenable to surgical therapy with
liver metastases from noncolorectal primary tumors.
The overall 5-year survival rate of 39% (median survival
of 45 months) in this series is similar to that reported by the
Gustave Roussy Institute [10] (36%) and Memorial Sloan-
Kettering Cancer Center (MSKCC) [11] (37%). These series
are not directly comparable, however, because of the
heterogeneity of the patient populations. For example, the
MSKCC study did not include patients with neuroendocrine
tumors who tend to have a survival advantage due to more
indolent tumor biology. The present investigation, in contrast
to the other reports, includes treatment with both liver
resection and cryoablation.
Patients with neuroendocrine primary tumors demonstrated
the best outcome with a 3-year survival rate of 91%,
which compares favorably to previous series reporting a
4-year survival rate of 73% [18] and a 5-year survival rate
of 73% [19]. These investigations have not only demonstrated
a probable survival benefit following resection of
neuroendocrine hepatic metastases, but also significant palliation
from the associated endocrine syndromes. In one
study, patients deemed unresectable by conventional resection
techniques had a 5-year survival rate of only 29% [19].
In the present series, 9 of 13 cases with neuroendocrine
metastases required cryosurgery to ablate all disease. Thus,
in this group of patients, the addition of cryosurgical ablation
may improve survival and provide more effective palliation
than was previously possible by hepatic resection
alone.
Patients with genitourinary tumors had a 52% 3-year
survival rate. The MSKCC series, which demonstrated a
60% 5-year survival rate for patients with genitourinary
metastases, included mainly patients with testicular, adrenal
and renal cell cancers, which have previously been shown to
have prolonged survival [20–22]. In contrast, ovarian cancer
was the predominant tumor type in the genitourinary
group in the present series, which may account for the
poorer survival rate in this group of patients. In an earlier
study, there were no 5-year survivors with hepatic metastases
from ovarian, endometrial and cervical primary tumors,
suggesting a worse prognosis for these tumors when they
metastasize [9]. Looking more closely at our series, we
found a trend toward improved survival outcomes for renal
and testicular cancer primaries, consistent with other small
series [10,23,24].
Patients with soft tissue tumors had a 34% 3-year survival
rate. Other series have reported 5-year survival rates of
approximately 20% after resection of liver metastases secondary
to sarcomas [10,11,25]. The two melanoma patients
in our series had limited survival. Two of 4 patients in the
MSKCC series with melanoma survived longer than 5 years
after hepatic resection [11]. Two of 3 patients with metastatic
breast cancer are alive without disease. Others have
reported 5-year survival rates of approximately 20% after
liver resection for metastatic breast cancer with one study
demonstrating median survival of 38 months [10,26–29].
Hepatic resection for noncolorectal gastrointestinal adenocarcinomas
has generally resulted in limited survival
[30]. One exception may be metastatic gastric adenocarcinoma
where long-term survivors have been reported after
liver resection in Japan [31]. These results have not been
duplicated in a Western series. None of our 3 patients were
long-term survivors. Hepatic resection for patients with
these tumor types should be confined to clinical trials.
Summary
Cryosurgical hepatic tumor ablation for noncolorectal
primary tumors is a reasonable alternative for some patients
who are unresectable by conventional means because of
anatomic location of metastases. Overall survival and local
hepatic recurrence-free survival rates were similar whether
patients were treated with cryoablation or with conventional
hepatic resection. Thus, cryosurgical ablation allows surgical
management of a greater number of patients with liver
metastases from a variety of tumors. Selection of patients
for this treatment option requires careful preoperative and
intraoperative assessment to exclude extrahepatic tumor and
diffuse hepatic disease. Hepatic resection and/or cryosurgical
ablation for metastases from neuroendocrine, renal, adrenal,
Wilm
’s, and testicular liver tumors appears to provide
a survival advantage when compared to nonoperative management
of these patients. In addition, careful selection of
patients with hepatic metastases from sarcomas, and from
ovarian, breast, and melanoma primary tumors may yield a
20% five-year survival rate after hepatic ablative procedures.
Surgical treatment for metastatic noncolorectal gastrointestinal
adenocarcinomas cannot be supported at the
present time.
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