Gillams, Alice

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doi:10.1136/bmj.39184.565532.80  2007;334;1056-1057  BMJ  Alice Gillams     metastases in colorectal cancerMinimally invasive treatment for liver and lung  http://bmj.com/cgi/content/full/334/7602/1056Updated information and services can be found at:   These include:  References    http://bmj.com/cgi/content/full/334/7602/1056#BIBLThis article cites 6 articles, 3 of which can be accessed free at: Rapid responses  http://bmj.com/cgi/eletter-submit/334/7602/1056You can respond to this article at:   serviceEmail alertingbox at the top left of the article Receive free email alerts when new articles cite this article - sign up in theTopic collections (371 articles)  Cancer: lung    (1232 articles)  Cancer: gastroenterological    (276 articles)  Interventional radiology     Articles on similar topics can be found in the following collections   Notes   To order reprints follow the "Request Permissions" link in the navigation box   http://resources.bmj.com/bmj/subscribers go to:  BMJ To subscribe to  on 7 September 2007  bmj.com Downloaded from Practice1056	 	 	 BMJ | 19 May 2007 | VoluMe 334 the patientA 59 year old woman had an anterior resection for pri‑mary Dukes’s C rectal carcinoma in 2004 followed by adjuvant chemotherapy. Two years later, on routine com‑puted tomography surveillance, she was found to have liver (fig 1) and lung (fig 2) metastases.surveillance after resection of primary colorectal cancerSurveillance is indicated in patients with Dukes’s B or Dukes’s C colorectal carcinoma who are potential can‑didates for further therapeutic intervention. The optimal surveillance strategy is a matter of debate.1‑3 An ongoing trial (FACS) is looking at the cost effectiveness of intensive follow‑up or no follow‑up in patients with successfully resected colorectal cancer (www.facs.soton.ac.uk/). Cur‑rently, most centres opt for computed tomography scans at six or 12 monthly intervals for the first two or three years, combined with regular measurements of serum carcinoembryonic antigen.Because the liver metastases were centrally located in our patient, surgery would have involved removal of three quarters of the liver, followed by pulmonary lobectomy for the lung metastasis. Liver resection and pulmonary resection are associated with a small increase in mortality—less than 5% for liver resection and less than 2% for pulmonary resection—and combined liver and lung resection has been reported to improve sur‑vival for patients with metastases from colorectal cancer.4 However, in light of the substantial morbidity (<37%) associated with major liver surgery and the need for two surgical procedures, the patient opted for radiofrequency ablation to both areas (fig 3). Our standard investigation for radiofrequency ablation is high quality, contrast enhanced, multidetector com‑puted tomography, with occasional positron emission tomography‑computed tomography or liver magnetic resonance imaging where specific questions need to be answered. These last two tests are used more often when investigating patients for liver resection; this is warranted given that resection is a more invasive and expensive procedure.The liver lesions were ablated under general anaes‑thesia using an array of three water cooled electrodes. One month later, the patient had ablation of the lung metastasis, which was performed under conscious seda‑tion (midazolam and fentanyl) with a single water cooled electrode. After ablation, she received systemic chemo‑therapy with oxaliplatin and fluorouracil.OutcomeFollow‑up scans performed four to five months after abla‑tion show absent enhancement at the treated sites in the liver and lung consistent with ablated tumour (figs 4, 5). What is radiofrequency ablation?Radiofrequency ablation is a minimally invasive, image guided technique that delivers focused thermal energy directly to the tumour. Needle electrodes are positioned percutaneously into the tumour and an alternating current is applied which produces ionic agitation, frictional heat‑ing, and cell death. After successful ablation, computed tomography scans show an area of absent enhancement, which becomes smaller over time. Radiofrequency abla‑tion for primary and secondary liver and lung tumours has been approved by the National Institute for Health and Clinical Excellence within the context of ongoing audit and research (www.nice.org.uk/). Other focal abla‑tive techniques for the destruction of tumour include cryotherapy, microwaves, lasers, and high intensity ratiONaL iMagiNg Minimally invasive treatment for liver and lung metastases in colorectal cancerAlice GillamsThis series provides an update on the best use of different imaging methods for common or important clinical presentations. The series editors are Fergus Gleeson, consultant radiologist, Churchill Hospital, Oxford, and Kamini Patel, consultant radiologist, Homerton University Hospital, LondonThe Royal Free and UCL Medical School and UCLH, London  WCIE 6BTCorrespondence to: a Gillams, Special Xray, uCH, london  NW1 2Bu  a.gillams@medphys.ucl.ac.ukBMJ 2007:334:1056-7doi: 10.1136/bmj. 39184.565532.80From the archive: For more about lung metastases from colorectal cancer see: Treasure T, utley M, Hunt I. When professional opinion is not enough. BMJ 2007;334:831-2. (april 21.)Fig 1 | Axial computed tomography of the liver showing two irregular hypoattenuating mass lesions, 4.0 cm and 4.3 cm in diameter (arrows).Fig 2 | Axial computed tomography section through the lung showing a 3.8 cm tumour in the right upper lobe (arrow) on 7 September 2007  bmj.com Downloaded from PracticeBMJ | 19 May 2007 | VoluMe 334           1057focused ultrasound, but radiofrequency ablation is the most widely used technique at present.complicationsComplications after liver ablation include bleeding and abscess formation. Thermal injury to adjacent vulnerable structures, such as the bowel, can usually be avoided. Complications after lung ablation include pneumothorax (which occurs in about 40% of patients, although only 10% need aspiration or intercostal tube insertion), haem‑orrhage, pleural effusion, and infection. Contraindications to radiofrequency ablation include a predisposition to bleeding or, in the case of lung ablation, limited pulmo‑nary reserve (forced expiratory volume in one second <1.0 litre). Treatment of small areas can be performed under conscious sedation; general anaesthesia is needed for larger treatments. Most patients spend one night in hospital.indicationsRadiofrequency ablation is used in patients with limited numbers of moderately sized (<5 cm diameter) metastases for whom surgical resection is not an option. Surgery may be contraindicated for many reasons including the loca‑tion or distribution of the tumour or associated comorbid‑ity. As a result, only 15% of patients with liver metastases are candidates for surgery. Yet colon cancer is the third most common cause of death from cancer, and 50% of patients with colorectal cancer develop liver metastases. In the absence of imaging follow‑up most patients present with extensive tumour. As both liver resection and abla‑tion can be applied only to patients with limited disease, surveillance scans, which detect limited disease that can subsequently be treated, should help improve survival. Radiofrequency can be used in isolation or in conjunction with surgical resection or chemotherapy.survivalAlthough no randomised controlled trials exist to date, several centres have published results from case series of more than 100 patients. In our series of 167 patients with colorectal liver metastases who could not undergo resec‑tion, a subgroup of patients with five or fewer metastases, the largest of which measured less than 5 cm, and with no extrahepatic disease had a five year survival of 29%.5 Other groups report similar results.6 These results are not dissimilar to those for surgical resection in patients suit‑able for surgery, who have a five year survival of around 40%. Anecdotal evidence suggests that the combination of destruction of all macroscopically detected tumours with radiofrequency ablation followed by aggressive systemic chemotherapy improves survival the most. We therefore gave our patient systemic chemotherapy after ablation. Systemic chemotherapy is the first line of treat‑ment for patients whose tumours are too large for them to undergo ablation or resection. This treatment aims to reduce the size of the tumour, so that surgery or ablation can be carried out.1	 Chau	I,	Allen	MJ,	Cunningham	D,	Norman	AR,	Brown	G,	Ford	HE,	et	al.	The	value	of	routine	serum	carcino-embryonic	antigen	measurement	and	computed	tomography	in	the	surveillance	of	patients	after	adjuvant	chemotherapy	for	colorectal	cancer.	J Clin Oncol	2004;22:1420-9.2	 Mortazavi	A,	Shaukat	A,	Othman	E,	Kepner	JL,	Fakih	MG,	Kuvshinoff	BW,	et	al.	Postoperative	computed	tomography	scan	surveillance	for	patients	with	stage	II	and	III	colorectal	cancer:	worthy	of	further	study?	Am J Clin Oncol	2005;28:30-5.3	 Desch	CE,	Benson	AB	III,	Somerfield	MR,	Flynn	PJ,	Krause	C,	Loprinzi	CL,	et	al.	Colorectal	cancer	surveillance:	2005	update	of	an	American	Society	of	Clinical	Oncology	practice	guideline.	J Clin Oncol	2005;23:8512-9.4	 Shah	SA,	Haddad	R,	Al	Sukhni	W,	Kim	RD,	Greig	PD,	Grant	DR,	et	al.	Surgical	resection	of	hepatic	and	pulmonary	metastases	from	colorectal	carcinoma.	J Am Coll Surg	2006;202:468-75.5	 Gillams	AR,	Lees	WR.	Radio-frequency	ablation	of	colorectal	liver	metastases	in	167	patients.	Eur Radiol	2004;14:2261-7.6	 Solbiati	L,	Livraghi	T,	Goldberg	SN,	Ierace	T,	Meloni	F,	Dellanoce	M,	et	al.	Percutaneous	radio-frequency	ablation	of	hepatic	metastases	from	colorectal	cancer:	long-term	results	in	117	patients.	Radiology	2001;221:159-66.Fig 3 | Oblique reformatted computed tomography image, along the line of the electrode, taken during the lung ablation shows the electrode inserted, through the anterior chest wall into the tumourFig 5 | Computed tomography scan of the lung at four months after ablation showing a homogeneous ablation zone with no enhancement, indicating successful ablationFig 4 | Computed tomography scans of the liver at five months after ablation showing a shrinking zone of ablation (arrows). Viable tumour is not seenLearNiNg POiNtsRegular		computed	tomography	is	the	recommended	imaging	technique	for	the	follow-up	of	patients	with	colorectal	cancer	Radiofrequency	ablation	is	less	invasive	than	surgery	and	can	provide	a	five	year	survival	of	29%	for	patients	with	limited	liver	metastases	after	primary	colorectal	cancerRadiofrequency	ablation	is	also	effective	for	lung	tumours,	either	primary	or	secondary on 7 September 2007  bmj.com Downloaded from 

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1 Chau The and chemotherapy Clin

Solbiati et from 2001;221:159-66.

The series editors are Fergus Gleeson, consultant radiologist, Churchill Hospital, Oxford, and Kamini Patel,

Minimally invasive treatment for liver and lung metastases in colorectal cancer

Alice Gillams

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Minimally invasive treatment for liver and lung metastases in colorectal cancer

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