Robust evidence for long-term survival with 90Y radioembolization in chemorefractory liver-predominant metastatic colorectal cancer.

OBJECTIVES: Our aim was to provide further evidence for the efficacy/safety of radioembolization using yttrium-90-resin microspheres for unresectable chemorefractory liver metastases from colorectal cancer (mCRC). METHODS: We followed 104 consecutively treated patients until death. Overall survival (OS) was calculated from the day of the first radioembolization procedure. Response was defined by changes in tumour volume as defined by Response Evaluation Criteria in Solid Tumours (RECIST) v1.0 and/or a ≥30 % reduction in serum carcinoembryonic antigen (CEA) at 3 months. RESULTS: Survival varied between 23 months in patients who had a complete response to prior chemotherapy and 13 months in patients with a partial response or stable disease. Median OS also significantly improved (from 5.8 months to 17.1 months) if response durability to radioembolization extended beyond 6 months. Patients with a positive trend in CEA serum levels (≥30 % reduction) at 3 months post-radioembolization also had a survival advantage compared with those who did not: 15.0 vs 6.7 months. Radioembolization was well tolerated. Grade 3 increases in bilirubin were reported in 5.0 % of patients at 3 months postprocedure. CONCLUSIONS: After multiple chemotherapies, many patients still have a good performance status and are eligible for radioembolization. This single procedure can achieve meaningful survivals and is generally well tolerated. KEY POINTS: • After multiple chemotherapies, many patients are still eligible for radioembolization (RE). • RE can achieve meaningful survival in patients with chemorefractory liver-predominant metastatic colorectal cancer (mCRC). • Tumour responsiveness to prior systemic treatments is a significant determinant of overall survival (OS) after RE. • Radioembolization in patients with a good performance status is generally well tolerated.

[Stabilization of the pelvic ring with photodynamic bone stabilization (IlluminOss™)]. / Stabilisierung einer Beckeninsuffizienzfraktur mit einem photosensiblen Kunststoff (IlluminOss™).

We describe the case of an 88-year-old woman who presented with painful symptoms of the pelvis after low-energy trauma. Conservative treatment with pain therapy and pain-adapted mobilization was unsuccessful. Diagnostics showed a fragility fracture of the pelvic ring; therefore, we performed photodynamic bone stabilization (IlluminOss™) of the pubic bone and percutaneous cement-augmented fixation of the iliosacral joint assisted by computed tomography (CT) fluoroscopy. Imaging showed a stable healed fracture 4 months after surgery.

Radioembolization with Yttrium-90 microspheres (SIRT) in pancreatic cancer patients with liver metastases: efficacy, safety and prognostic factors.

OBJECTIVE: To analyze the clinical efficacy of (90)Y radioembolization in liver metastases from pancreatic cancer, to describe treatment toxicities and to identify biomarkers as predictors of outcome. METHODS: Data from 19 pancreatic cancer patients (9 females/10 males) who had received (90)Y radioembolization for metastatic liver disease between 06/2004 and 01/2011 were analyzed retrospectively. RESULTS: The median age at (90)Y radioembolization was 63 years (range 43-77). In 16 patients, previous palliative gemcitabine-based chemotherapy was given for metastatic disease. Objective response in the liver after (90)Y radioembolization was 47%. Median local progression-free survival in the liver was 3.4 months (range 0.9-45.0). Median overall survival (OS) was 9.0 months (range 0.9-53.0) and 1-year survival was 24%. Cox regression models for baseline biomarkers at (90)Y radioembolization revealed correlations of increased carbohydrate antigen 19-9 (p = 0.02) and C-reactive protein (p = 0.03) with shorter OS. Short-term adverse events (nausea, vomiting, fatigue, fever and abdominal pain) did not exceed grade 3. As long-term adverse events, liver abscesses, gastroduodenal ulceration, cholestasis and cholangitis, ascites and spleen infarction were observed. CONCLUSION: (90)Y radioembolization is able to induce an encouraging local response rate of liver metastases of pancreatic cancer patients. Most short-term toxicities are manageable; however, patients should be followed up carefully for severe long-term toxicities.

[Diagnosis of and therapy for hepatocellular carcinoma]. / Diagnostik und Therapie des hepatozellulären Karzinoms.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

[Polydipsia, increasing fatigue and a huge mediastinal tumor in a 49-year-old woman]. / Polydipsie, zunehmende Müdigkeit und große mediastinale Raumforderung bei einer 49-jährigen Patientin.

A 49-year-old woman presented with unspecific symptoms including polydipsia, increasing fatigue for several weeks, and vague abdominal pain. Serum calcium (5.30 mmol/l; normal range 2.00-2.60) and parathyroid hormone levels (> 2500.0 ng/l; normal range 15.0-68.0) were extremely elevated. Imaging studies showed a huge mediastinal tumor. Based on these findings a hypercalcemic crisis caused by primary hyperparathyroidism was diagnosed. After intensive care treatment and further diagnostic procedures, the patient's parathyroid adenoma was removed by parathyroidectomy. The postoperative course was uneventful.

Multi-modal access method (eye-tracking + switch-scanning) for individuals with severe motor impairment: A preliminary investigation.

Individuals with severe motor impairments often require alternative means to access computers and communication technology. A range of alternative access devices exist; however, most rely on use of a single access modality. While this approach works for some individuals, it can be limiting for others. This study explored the use of a multi-modal prototype (eye-tracking + switch-scanning) on typing performance with a range of individuals with motor impairments. The multi-modal prototype was compared to eye-tracking alone for this study. Results indicated that the multi-modal prototype had significantly slower typing rate but significantly lower total errors compared to eye-tracking alone. Analysis of individual data revealed four subgroups of clinical relevance including individuals that 1) benefit from multi-modal, 2) benefit from eye-tracking, 3) demonstrate learning and 4) demonstrate fluctuating performance.

Multimodality treatment with conventional transcatheter arterial chemoembolization and radiofrequency ablation for unresectable hepatocellular carcinoma.

BACKGROUND/AIMS: To evaluate the efficacy of multimodality treatment consisting of conventional transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) in patients with non-resectable and non-ablatable hepatocellular carcinoma (HCC). METHODS: In this retrospective study, 85 consecutive patients with HCC (59 solitary, 29 multifocal HCC) received TACE followed by RFA between 2001 and 2010. The mean number of tumors per patient was 1.6 ± 0.7 with a mean size of 3.0 ± 0.9 cm. Both local efficacy and patient survival were evaluated. RESULTS: Of 120 treated HCCs, 99 (82.5%) showed a complete response (CR), while in 21 HCCs (17.5%) a partial response was depicted. Patients with solitary HCC revealed CR in 91% (51/56); in patients with multifocal HCC (n = 29) CR was achieved in 75% (48 of 64 HCCs). The median survival for all patients was 25.5 months. The 1-, 2-, 3- and 5-year survival rates were 84.6, 58.7, 37.6 and 14.6%, respectively. Statistical analysis revealed a significant difference in survival between Barcelona Clinic Liver Cancer (BCLC) A (73.4 months) and B (50.3 months) patients, while analyses failed to show a difference for Child-Pugh score, Cancer of Liver Italian Program (CLIP) score and tumor distribution pattern. CONCLUSION: TACE combined with RFA provides an effective treatment approach with high local tumor control rates and promising survival data, especially for BCLC A patients. Randomized trials are needed to compare this multimodality approach with a single modality approach for early-stage HCC.

Multimodality treatment for early-stage hepatocellular carcinoma: a bridging therapy for liver transplantation.

PURPOSE: To evaluate the efficiency of a multimodality approach consisting of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) as bridging therapy for patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) and to evaluate the histopathological response in explant specimens. MATERIALS AND METHODS: Between April 2001 and November 2011, 36 patients with 50 HCC nodules (1.4-5.0 cm, median 2.8 cm) on the waiting list for liver transplantation were treated by TACE and RFA. The drop-out rate during the follow-up period was recorded. The local efficacy was evaluated by histopathological examination of the explanted livers. RESULTS: During a median follow-up time of 29 (4.0-95.3) months the cumulative drop-out rate for the patients on the waiting list was 0, 2.8, 5.5, 11.0, 13.9 and 16.7% at 3, 6, 12, 24, 36 and 48 months, respectively. 16 patients (with 26 HCC lesions) out of 36 (44.4%) were transplanted by the end of study with a median waiting list time of 13.7 (2.5-37.8) months. The histopathological examination of the explanted specimens revealed a complete necrosis in 20 of 26 HCCs (76.9%), whereas 6 (23.1%) nodules showed viable residual tumor tissue. All transplanted patients are alive at a median time of 29.9 months. Imaging correlation showed 100% specificity and 66.7% sensitivity for the depiction of residual or recurrent tumor. CONCLUSION: We conclude that TACE combined with RFA could provide an effective treatment to decrease the drop-out rate from the OLT waiting list for HCC patients. Furthermore, this combination therapy results in high rates of complete tumor necrosis as evaluated in the histopathological analysis of the explanted livers. Further randomized trials are needed to demonstrate if there is a benefit in comparison with a single-treatment approach.

Arterial therapies of non-colorectal cancer metastases to the liver (from chemoembolization to radioembolization).

Treatment of primary and secondary hepatic malignancies with transarterial chemoembolization (TACE) represents an essential component of interventional oncology known for many years and performed by many interventional radiologists first in primary liver tumors and nowadays even in metastases of different origins. Radioembolization (RE) has been introduced to the clinical arsenal of cytoreductive modalities in recent years. There is growing evidence for efficiency in liver tumors of various entities, with the most prominent ones being hepatocellular carcinoma, colorectal cancer, and neuroendocrine tumors. Hepatic metastases of other tumor entities (breast cancer, malignant melanoma, and pancreatic cancer) are treatment-sensitive. This article focuses on procedural and technical aspects for selection, preparation, and performance of treatment as well as the results in metastatic breast cancer, neuroendocrine tumors, melanoma, and pancreatic cancer giving an overview of the results after RE, transarterial embolization, or TACE.

[Diagnosis and multimodal therapy for hepatocellular carcinoma]. / Diagnose und multimodale Therapie des hepatozellulären Karzinoms.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death in the world. The majority of HCCs develops on the basis of a chronic liver disease. This often complicates diagnosis and therapy. Non-invasive diagnostic criteria are based on dynamic imaging techniques and the serum level of AFP (alpha-fetoprotein). When evaluating HCC patients for therapy, besides tumor burden and localisation, the therapeutic evaluation must also consider the general condition of the patient and his/her liver function. For this purpose, the BCLC algorithm of the Barcelona Clinic for Liver Disease has proven helpful. Only one-third of the patients can be cured by resection, transplantation or local tumour ablation. In locally advanced cases transarterial procedures including transarterial chemoembolisation and radioembolisation are applied. HCC is a chemo-resistant tumour and chemotherapy is not accepted as standard of care in HCC. Sorafenib is the first systemic treatment with proven efficacy approved for the treatment of advanced and metastatic HCC. Interdisciplinary management of HCC patients is essential in order to provide every patient with the optimal therapy at his specific stage of disease.

Combined use of 64-slice computed tomography angiography and gated myocardial perfusion SPECT for the detection of functionally relevant coronary artery stenoses. First results in a clinical setting concerning patients with stable angina.

AIM: In patients with stable angina pectoris both morphological and functional information about the coronary artery tree should be present before revascularization therapy is performed. High accuracy was shown for spiral computed tomography (MDCT) angiography acquired with a 64-slice CT scanner compared to invasive coronary angiography (ICA) in detecting "obstructive" coronary artery disease (CAD). Gated myocardial SPECT (MPI) is an established method for the noninvasive assessment of functional significance of coronary stenoses. Aim of the study was to evaluate the combination of 64-slice CT angiography plus MPI in comparison to ICA plus MPI in the detection of hemodynamically relevant coronary artery stenoses in a clinical setting. PATIENTS, METHODS: 30 patients (63 +/- 10.8 years, 23 men) with stable angina (21 with suspected, 9 with known CAD) were investigated. MPI, 64-slice CT angiography and ICA were performed, reversible and fixed perfusion defects were allocated to determining lesions separately for MDCT angiography and ICA. The combination of MDCT angiography plus MPI was compared to the results of ICA plus MPI. RESULTS: Sensitivity, specificity, negative and positive predictive value for the combination of MDCT angiography plus MPI was 85%, 97%, 98% and 79%, respectively, on a vessel-based and 93%, 87%, 93% and 88%, respectively, on a patient-based level. 19 coronary arteries with stenoses > or =50% in both ICA and MDCT angiography showed no ischemia in MPI. CONCLUSION: The combination of 64-slice CT angiography and gated myocardial SPECT enabled a comprehensive non-invasive view of the anatomical and functional status of the coronary artery tree.

Percutaneous radiofrequency ablation of pulmonary tumors--is there a difference between treatment under general anaesthesia and under conscious sedation?

OBJECTIVE: This retrospective study aimed to compare feasibility, complication rate and local tumor control after radiofrequency ablation (RFA) of pulmonary tumors under conscious analgo-sedation (AS) versus general anaesthesia (GA). MATERIALS AND METHODS: Within 36 months 21 patients had RFA (36 tumors, 26 treatment sessions). One patient suffered from NSCLC, 20 had metastases (breast (8/20), colorectal (6/20), renal cell (2/20), pharyngeal carcinoma (1/20), malignant melanoma (3/20)). Patients were no surgical candidates due to underlying comorbidities. Eleven of 26 treatments were performed under GA, while in 15 of 26 treatments AS was used. Follow-up was scheduled 24 h, 6 weeks, 3 months, 6 months and then every 6 months after treatment. RESULTS: RFA was feasible in all treatments under GA, while under AS targeting of the lesion was not possible in 2/15. Six adverse events occurred in the GA group (three major, three minor), while seven complications happened in the AS group (three major, four minor) (p=0.57). During follow-up of 3-36 months local recurrence was detected in 3 of 21 tumors in the GA group and in 2 of 15 tumors in the AS group (p=0.79). DISCUSSION: Hospitalization, complication rates and types, and the rate of local tumor control did not differ substantially among both groups. Furthermore, there was no significant difference in technical success and feasibility. CONCLUSION: RFA of pulmonary tumors under GA or AS did not result in different tumor control and complication rates, respectively. Therefore, AS should be used except in anxious or agitated patients.

[Liver tumor ablation]. / Tumorablation der Leber.

Minimal-invasive techniques for ablation of primary and secondary hepatic tumors gain increasingly clinical importance. This is especially true since surgical resection and classic chemotherapy is successful only in a limited number of patients. Local ablative methods incorporate chemo- (percutaneous alcohol instillation, transarterial chemoembolization), thermo- (radiofrequency-, laser-, microwave-, cryoablation, high intensive focused ultrasound) and radio-ablative techniques (interstitial brachytherapy, selective internal radiotherapy). Regarding their implementation and specific effects these methods are varying widely, nevertheless all of them have a high therapeutical efficacy together with a low complication rate in common-correct application presumed. The knowledge on specific indications and contraindications is crucial to implement these methods into multimodality therapy concepts.

Safety of Radioembolization with (90)Yttrium Resin Microspheres Depending on Coiling or No-Coiling of Aberrant/High-Risk Vessels.

PURPOSE: To evaluate the safety of radioembolization (RE) with (90)Yttrium ((90)Y) resin microspheres depending on coiling or no-coiling of aberrant/high-risk vessels. MATERIALS AND METHODS: Early and late toxicity after 566 RE procedures were analyzed retrospectively in accordance with the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v3.0). For optimal safety, aberrant vessels were either coil embolized (n = 240/566, coiling group) or a more peripheral position of the catheter tip was chosen to treat right or left liver lobes (n = 326/566, no-coiling group). RESULTS: Clinically relevant late toxicities (≥ Grade 3) were observed in 1% of our overall cohort. The no-coiling group had significantly less "any" (P = 0.0001) or "clinically relevant" (P = 0.0003) early toxicity. There was no significant difference (P > 0.05) in delayed toxicity in the coiling versus the no-coiling group. No RE-induced liver disease was noted after all 566 procedures. CONCLUSION: RE with (90)Y resin microspheres is a safe and effective treatment option. Performing RE without coil embolization of aberrant vessels prior to treatment could be an alternative for experienced centers.

Reverse transcriptase-polymerase chain reaction analysis of thyrocyte-relevant genes in fine-needle aspiration biopsies of the human thyroid.

Currently, fine-needle aspiration cytology is a valuable tool in the routine diagnosis of suspicious thyroid nodules. We present a very sensitive method for the molecular analysis of the expression of several genes important for normal thyroid function in parallel to the cytological diagnosis. We adapted reverse transcriptase polymerase chain reaction (RT-PCR) to amplify thyroid-typical mRNAs in samples of thyroid carcinoma cells as small as those obtained by fine-needle aspiration biopsy (FNAB), ie, 100-1000 cells, and applied this procedure to four routinely taken FNABs. Gene products such as thyroglobulin (Tg), thyroid-stimulating hormone-receptor (TSHr), sodium/iodide-symporter (NIS), type I iodothyronine-5'-deiodinase (DI), and type II iodothyronine-5'-deiodinase (DII) were analyzed. To establish RT-PCR protocols, serial dilutions of follicular thyroid carcinoma cells, FTC-133, which express these genes at low levels, were initially used for RNA isolation. Successful RNA isolation and reverse transcription were checked by the amplification of beta-actin mRNA. We detected the mRNAs coding for Tg in as little as 10 cells, for NIS in 100 cells, and for TSHr, DI, and DII in 10,000 cells. After preparing cytological smears of four routinely taken FNABs, all above-mentioned thyroid-typical mRNAs were observed by using the material remaining in the needle for RNA isolation followed by RT-PCR. This method offers the possibility of obtaining two different types of information from the same routinely taken thyroid FNAB: the cytological diagnosis and the expression pattern of several diagnostically relevant genes. Therefore, a more specific diagnosis could be rendered in the preoperative state, and may lead to more specific therapy.

Practical vascular anatomy in the preparation of radioembolization.

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.

FDG-PET-CT and whole-body MRI for triage in patients planned for radioembolisation therapy.

PURPOSE: The purpose was to evaluate the potential of FDG-PET-CT and whole-body MRI (WB-MRI) as diagnostic triage methods for patients planned for radioembolisation of metastatic liver disease. MATERIALS AND METHODS: 135 patients with multifocal liver metastases were evaluated for potential palliative therapy with radioembolisation using 90-Yttrium microspheres. All patients were examined consecutively with FDG-PET-CT and WB-MRI for exclusion of relevant extra-hepatic tumor manifestations. All patients underwent 99mTc-albumine angiography followed by scintigraphy to exclude significant hepato-pulmonary shunting. RESULTS: Out of the 135 patients included into the pre-therapeutic diagnostic algorithm, 56% were eligible and received radioembolisation, while 44% could not be treated. In 91% the exclusion criteria was diagnosis of significant extra-hepatic metastatic disease. In 85% exclusion diagnosis was made concordantly by both FDG-PET-CT and WB-MRI, in 9% diagnosis was provided by PET-CT, in 6% by WB-MRI alone. Patient-based sensitivity for detection of extra-hepatic disease was 94% for PET-CT and 91% for WB-MRI. False-positive diagnosis of extrahepatic disease leading to exclusion for radioembolisation therapy was made in 2% of patients, in one patient by PET-CT and in one patient by WB-MRI alone. Overall, specificity for inclusion of radioembolisation therapy by combining both modalities was 99%. In 9% of patients angiographic diagnosis made radioembolisation impossible, in 7% solely the angiographic findings were decisive. CONCLUSION: Both FDG-PET-CT and WB-MRI are efficient diagnostic triage methods for patients planned for radioembolisation of liver metastases. Overall, FDG-PET-CT shows a trend to higher diagnostic accuracy compared to WB-MRI and may be used as imaging method of choice as a standalone examination. In combination, both modalities exhibited high sensitivity for the diagnosis of extra-hepatic tumor manifestations and result in high specificity.

Changes in normal liver and spleen volume after radioembolization with (90)Y-resin microspheres in metastatic breast cancer patients: findings and clinical significance.

PURPOSE: In clinical trials with yttrium-90-resin-microspheres for the management of colorectal cancer liver metastases, it was observed that radioembolization might result in splenomegaly and an increase in portal vein size. Subclinical hepatitis in normal liver tissue as well as the effects of radioembolization and prior chemotherapy are suspected to be responsible for this phenomenon. The purpose of this study was to quantify the changes in liver and spleen volume and portal vein diameter after radioembolization. METHODS: Twenty-seven patients with liver-dominant metastatic disease from breast cancer who had not responded to chemotherapy or had to abandon chemotherapy because of its toxic effects were evaluated. Changes in liver and spleen volume and portal vein diameter as well as liver tumor volume and diameter were quantified using computed tomography scans. RESULTS: Radioembolization was associated with a significant mean decrease in the whole liver volume of 10.2% (median 16.7%; P = 0.0024), mainly caused by a reduction in the right lobe volume (mean 16.0%; P < 0.0001). These changes were accompanied by a significant increase in the diameter of the main portal vein (mean 6.8%; P < 0.0001) as well as splenic volume (mean 50.4%; P < 0.0001). Liver-tumor volume and diameter decreased by a median of 24 and 39.7%. CONCLUSIONS: Radioembolization is an effective treatment for tumor size reduction in patients with breast cancer liver metastases. Treatment is associated with changes of hepatic parenchymal volume, splenic volume, and portal vein size that appear not to represent clinically important sequelae in this patient cohort.

Radiofrequency ablation after selective internal radiation therapy with Yttrium90 microspheres in metastatic liver disease-Is it feasible?

This retrospective study analyzes, whether patients suffering from extensive hepatic metastatic disease treated with SIRT can become suitable candidates for RFA.Within 38 months 46 patients (26 female, 20 male; age 32-75 years) bearing an extensive hepatic metastatic disease were treated with SIRT. Patients suffered from metastases of breast cancer (16/46), colorectal cancer (CRC) (21/46), neuroendocrine (3/46), and other primary carcinomas (6/46). The indication for SIRT was otherwise untreatable metastases confined to the liver. Forty-three patients received single-session whole-liver radioembolization treatment using Yttrium90 resin microspheres with a mean activity of 2.13GBq. In 1 patient SIRT was confined to the left and in 2 patients to the right liver lobe. In 3 patients major complications (2/3 gastric ulceration and 1/3 oedematous pancreatitis) and in 24 patients minor complications occurred (acute abdominal/epigastric pain and/or nausea). Follow-up CT and/or MRI were obtained in 44 of 46 patients. In 5 of 44 patients tumor load decreased substantially (3/5 breast cancer, 1/5 CRC and 1/5 pancreatic cancer) making RFA feasible. The patients were referred for RFA after the first 3-month follow-up. RFA of the liver was successful in all cases in terms of complete ablation. In selected patients radioembolization is able to downstage liver metastases to an extent making a subsequent RFA suitable and therefore allows increasing the number of patients with a "complete response" after a minimally invasive therapy.