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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

Appearance of the liver remnant 18 months after resection; there is no evidence of recurrent disease at the site of margin ablation in segments 2/4A (arrow) or in the remainder of the liver, the middle and left hepatic veins are patent, and the liver remnant has undergone hypertrophy.
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Fig5: Appearance of the liver remnant 18 months after resection; there is no evidence of recurrent disease at the site of margin ablation in segments 2/4A (arrow) or in the remainder of the liver, the middle and left hepatic veins are patent, and the liver remnant has undergone hypertrophy.

Mentions: Pathology of the resected right colon demonstrated well-to-moderately differentiated adenocarcinoma invading through the muscularis propria to the subserosal tissue. All margins were negative and 0/43 regional lymph nodes were positive for carcinoma. The final pathology of the resected right posterior section demonstrated three masses, the largest of which was 3 cm, and negative margins. Pathologic result of the segment 2/4A resection specimen demonstrated a 3.6 cm mass with viable carcinoma present at the inked margin of resection, as had been anticipated, and which had been ablated by IRE. The patient now continues to be under active surveillance and has shown no demonstrable evidence of recurrence along the ablated margin 30 months after the operation (Figure 5).Figure 5


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)

Appearance of the liver remnant 18 months after resection; there is no evidence of recurrent disease at the site of margin ablation in segments 2/4A (arrow) or in the remainder of the liver, the middle and left hepatic veins are patent, and the liver remnant has undergone hypertrophy.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig5: Appearance of the liver remnant 18 months after resection; there is no evidence of recurrent disease at the site of margin ablation in segments 2/4A (arrow) or in the remainder of the liver, the middle and left hepatic veins are patent, and the liver remnant has undergone hypertrophy.
Mentions: Pathology of the resected right colon demonstrated well-to-moderately differentiated adenocarcinoma invading through the muscularis propria to the subserosal tissue. All margins were negative and 0/43 regional lymph nodes were positive for carcinoma. The final pathology of the resected right posterior section demonstrated three masses, the largest of which was 3 cm, and negative margins. Pathologic result of the segment 2/4A resection specimen demonstrated a 3.6 cm mass with viable carcinoma present at the inked margin of resection, as had been anticipated, and which had been ablated by IRE. The patient now continues to be under active surveillance and has shown no demonstrable evidence of recurrence along the ablated margin 30 months after the operation (Figure 5).Figure 5

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