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Colorectal liver metastases: making the unresectable resectable using irreversible electroporation for microscopic positive margins - a case report.

Schoellhammer HF, Goldner B, Merchant SJ, Kessler J, Fong Y, Gagandeep S - BMC Cancer (2015)

Bottom Line: Chemotherapy with FOLFOX and cetuximab was initiated, with subsequent conversion to resectability of the CRLM.Resection of tumor impinging on the left and middle hepatic veins would have required left hepatectomy, with insufficient remnant liver volume.The patient is alive and without recurrent disease now 30 months after resection.

View Article: PubMed Central - PubMed

Affiliation: Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA. hschoellhammer@coh.org.

ABSTRACT

Background: Irreversible electroporation (IRE) is a non-thermal injury tissue ablation technique that uses electrical pulses to cause cell death. IRE damages the endothelial cells of blood vessels; however these cells re-grow, and thus IRE does not result in permanent damage to blood vessels. We report the novel use of IRE for ablation of microscopically positive margins after resection of colorectal liver metastases (CRLM) impinging on hepatic veins.

Case presentation: A 68-year-old female was found to have colon cancer and synchronous bilateral unresectable liver metastases. Chemotherapy with FOLFOX and cetuximab was initiated, with subsequent conversion to resectability of the CRLM. The patient underwent colectomy followed by right liver posterior sectionectomy with wedge resection of segment 5. Resection of tumor impinging on the left and middle hepatic veins would have required left hepatectomy, with insufficient remnant liver volume. The CRLM were meticulously dissected off the hepatic veins leaving a microscopically positive margin, and IRE was then used for margin ablation, leaving intact hepatic veins and venous blood flow. The patient is alive and without recurrent disease now 30 months after resection. Herein we review the IRE technology and its use in ablation of liver metastases.

Conclusions: Use of IRE margin ablation for microscopically-positive CRLM resection may lead to long-term patient survival; further prospective randomized trials are needed to confirm this finding.

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Related in: MedlinePlus

On initial presentation the patient was found to have multiple hypodense hepatic metastases in segments 2 and 4A as well as segments 5-7 and the burden of disease was deemed not resectable.
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Fig1: On initial presentation the patient was found to have multiple hypodense hepatic metastases in segments 2 and 4A as well as segments 5-7 and the burden of disease was deemed not resectable.

Mentions: The patient is a 68-year-old female who sought medical care at an outside facility after passing bright red blood per rectum. Laboratory evaluation demonstrated anemia. The patient was otherwise without other complaints at the time of presentation, denying nausea, vomiting, change in bowel habits, jaundice, decreased appetite and early satiety. The patient underwent a diagnostic colonoscopy which demonstrated a friable ulcerated circumferential mass in the mid-transverse colon, causing 50% occlusion of the lumen; biopsy of the mass demonstrated colonic adenocarcinoma that was KRAS wild-type. The patient underwent full staging with CT scans of the chest, abdomen, and pelvis, which confirmed the mass in the mid-transverse colon, as well as multiple large hypodense hepatic lesions located in segments 2, 4A, 5, 6, 7 (Figure 1). This workup was performed at the outside facility, including the performance of CT-guided liver biopsy which confirmed metastatic adenocarcinoma. Liver function tests and coagulation parameters were all normal at the time of presentation.Figure 1


Colorectal liver metastases: making the unresectable resectable using irreversible electroporation for microscopic positive margins - a case report.

Schoellhammer HF, Goldner B, Merchant SJ, Kessler J, Fong Y, Gagandeep S - BMC Cancer (2015)

On initial presentation the patient was found to have multiple hypodense hepatic metastases in segments 2 and 4A as well as segments 5-7 and the burden of disease was deemed not resectable.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4404004&req=5

Fig1: On initial presentation the patient was found to have multiple hypodense hepatic metastases in segments 2 and 4A as well as segments 5-7 and the burden of disease was deemed not resectable.
Mentions: The patient is a 68-year-old female who sought medical care at an outside facility after passing bright red blood per rectum. Laboratory evaluation demonstrated anemia. The patient was otherwise without other complaints at the time of presentation, denying nausea, vomiting, change in bowel habits, jaundice, decreased appetite and early satiety. The patient underwent a diagnostic colonoscopy which demonstrated a friable ulcerated circumferential mass in the mid-transverse colon, causing 50% occlusion of the lumen; biopsy of the mass demonstrated colonic adenocarcinoma that was KRAS wild-type. The patient underwent full staging with CT scans of the chest, abdomen, and pelvis, which confirmed the mass in the mid-transverse colon, as well as multiple large hypodense hepatic lesions located in segments 2, 4A, 5, 6, 7 (Figure 1). This workup was performed at the outside facility, including the performance of CT-guided liver biopsy which confirmed metastatic adenocarcinoma. Liver function tests and coagulation parameters were all normal at the time of presentation.Figure 1

Bottom Line: Chemotherapy with FOLFOX and cetuximab was initiated, with subsequent conversion to resectability of the CRLM.Resection of tumor impinging on the left and middle hepatic veins would have required left hepatectomy, with insufficient remnant liver volume.The patient is alive and without recurrent disease now 30 months after resection.

View Article: PubMed Central - PubMed

Affiliation: Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA. hschoellhammer@coh.org.

ABSTRACT

Background: Irreversible electroporation (IRE) is a non-thermal injury tissue ablation technique that uses electrical pulses to cause cell death. IRE damages the endothelial cells of blood vessels; however these cells re-grow, and thus IRE does not result in permanent damage to blood vessels. We report the novel use of IRE for ablation of microscopically positive margins after resection of colorectal liver metastases (CRLM) impinging on hepatic veins.

Case presentation: A 68-year-old female was found to have colon cancer and synchronous bilateral unresectable liver metastases. Chemotherapy with FOLFOX and cetuximab was initiated, with subsequent conversion to resectability of the CRLM. The patient underwent colectomy followed by right liver posterior sectionectomy with wedge resection of segment 5. Resection of tumor impinging on the left and middle hepatic veins would have required left hepatectomy, with insufficient remnant liver volume. The CRLM were meticulously dissected off the hepatic veins leaving a microscopically positive margin, and IRE was then used for margin ablation, leaving intact hepatic veins and venous blood flow. The patient is alive and without recurrent disease now 30 months after resection. Herein we review the IRE technology and its use in ablation of liver metastases.

Conclusions: Use of IRE margin ablation for microscopically-positive CRLM resection may lead to long-term patient survival; further prospective randomized trials are needed to confirm this finding.

Show MeSH
Related in: MedlinePlus