Reduction in Recurrence Risk for Involved or Inadequate Margins With Edge Cryotherapy After Liver Resection for Colorectal Metastases

Abstract

The usefulness of additional edge cryotherapy after liver resection for liver metastases from colorectal cancer to improve involved or inadequate (less than 1 cm) margins is uncertain. Design: Retrospective analysis of prospectively collected data. Setting: Department of surgery at a university hospital. Patients: Eighty-six consecutive patients with hepatic metastases from colorectal cancer in whom we applied additional edge cryotherapy to involved or inadequate margins. This group was compared with 134 patients who underwent resection without edge cryotherapy (control group) during the same period. Intervention: Potentially curative treatment was achieved by adding edge cryotherapy to insufficient resection sites in patients not eligible for further resection. Main Outcome Measures: Edge recurrence rate in the study group; validation of an additional treatment to improve curative resectability; and comparison of morbidity and local recurrence rates with the control group. Results: At a median follow-up of 39 months, 47 patients were alive and 39 had died. Local recurrence at the resection site was diagnosed in 9 patients (10%), of which 7 occurred in patients with involved margins and 2 in patients with resection margin less than 1 cm. Thirtysix patients (42%) experienced recurrence in the remnant liver. Extrahepatic recurrence occurred in 38 patients (44%), the lungs being the most common site (22 patients [26%]). Conclusions: Edge cryotherapy is a potent additional surgical treatment option in patients with liver metastases from colorectal cancer. The percentage of patients who can be treated for cure can be increased, especially if complex liver surgery is demanded.

Resection and Ablation for Colorectal Liver Metastases

“…Other more treatable cryotherapy-related complications include hepatic abscess formation, haemorrhage, biliary injury and pleural effusion. Hepatic abscess is common (0.9% -11.8%) but usually seen when combined colonic resection and liver cryotherapy are performed synchronously [57,61,[64][65][66][69][70][71][72]. Bleeding from liver cracks can easily be controlled by pressure or suture [58,66,69].…”

“…Hepatic abscess is common (0.9% -11.8%) but usually seen when combined colonic resection and liver cryotherapy are performed synchronously [57,61,[64][65][66][69][70][71][72]. Bleeding from liver cracks can easily be controlled by pressure or suture [58,66,69]. The susceptibility of biliary tree to thermal injury may complicate cryo-treatment with biloma or bile fistula [57,58,63,64,66,69,71,72].…”

“…The susceptibility of biliary tree to thermal injury may complicate cryo-treatment with biloma or bile fistula [57,58,63,64,66,69,71,72]. Pleural effusion is common, as it is after other liver surgeries, and may very often be treated conservatively [63,[69][70][71]73].…”

“…In some centres, edge cryotherapy had been employed to suboptimal resection margins obtaining median and 5-year survivals of 39 months and 36% [69,82,88,89], respectively; resembling that of clear-margin resections [82,84,[88][89][90]. The median, 1-, 2-, 3-, 5-, and 10-year disease-free survivals reported were 9 -27 months [59,72,77,78,81,82,84,86,88], 38% -41% [58,78,82,86], 16% -35% [58,78,86], 8% -17% [78,82,86], 12% -13% [59,82], and 11% [82], respectively (Figure 4).…”

“…Whilst the extent and site of extrahepatic recurrence were similar following both hepatic cryotherapy and resection, this was not the case with intrahepatic recurrences. CLM patients treated with cryotherapy were noted to have higher rates of intrahepatic recurrences, partly due to disease recurrence at cryoablated sites [59]; the appearance of which may be detected as late as 39 months post-cryotherapy, and rarely up to 98 months [69,86]. Cryosite recurrence frequently occurs -rates of up to 44% have been reported by two different institutions [74,86].…”