Ablation therapy for patients with colorectal liver metastases with and without extrahepatic metastases: evaluation of long-term outcomes and prognostic factors.

PURPOSE: Ablation is a valuable treatment alternative to surgery for colorectal liver metastases. This study reports the long-term clinical outcomes in patients treated with ablation for colorectal liver metastases with or without extrahepatic metastases. METHODS: Patients with colorectal liver metastases treated with ultrasound-guided ablation at Herlev Hospital, Denmark were included in this retrospective study. RESULTS: This study included 284 patients with 582 metastases. Complete ablation was obtained in 258 patients (91%) evaluated within 6 weeks. During follow-up, 94 patients (33%) developed local recurrence. The median survival for all patients was 31 months, with 1-, 3-, and 5-year survival rates of 82%, 45%, and 21%, respectively. The median survival for patients with extrahepatic metastases (n=49, 17%) was 24 months compared with 33 months for patients without (P=0.142). Propensity score-adjusted Cox regression showed that extrahepatic metastases were associated with increased mortality, with a hazard ratio (HR) of 1.45 (95% confidence interval [CI], 1.02 to 2.05; P=0.039). In multivariate Cox regression analysis for all patients, increased mortality risk was found for a diameter ≥2.6 cm (HR, 1.59; 95% CI, 1.23 to 2.05), >1 metastasis (HR, 1.66; 95% CI, 1.28 to 2.16), and extrahepatic metastases (HR, 1.45; 95% CI, 1.04 to 2.03). Male sex (HR, 0.75; 95% CI, 0.58 to 0.98) and receiving chemotherapy (HR, 0.69; 95% CI, 0.52 to 0.92) were associated with decreased mortality. CONCLUSION: Ablation for colorectal liver metastases offers acceptable survival rates, including for patients with extrahepatic metastases. In addition, chemotherapy was associated with improved survival for both patients with and without extrahepatic metastases.

Highlights of the development in ultrasound during the last 70 years: A historical review.

This review looks at highlights of the development in ultrasound, ranging from interventional ultrasound and Doppler to the newest techniques like contrast-enhanced ultrasound and elastography, and gives reference to some of the valuable articles in Acta Radiologica. Ultrasound equipment is now available in any size and for any purpose, ranging from handheld devices to high-end devices, and the scientific societies include ultrasound professionals of all disciplines publishing guidelines and recommendations. Interventional ultrasound is expanding the field of use of ultrasound-guided interventions into nearly all specialties of medicine, from ultrasound guidance in minimally invasive robotic procedures to simple ultrasound-guided punctures performed by general practitioners. Each medical specialty is urged to define minimum requirements for equipment, education, training, and maintenance of skills, also for medical students. The clinical application of contrast-enhanced ultrasound and elastography is a topic often seen in current research settings.

Preoperative CT versus diffusion weighted magnetic resonance imaging of the liver in patients with rectal cancer; a prospective randomized trial.

Introduction. Colorectal cancer is one of the most frequent cancers in the world and liver metastases are seen in up to 19% of patients with colorectal cancers. Detection of liver metastases is not only vital for sufficient treatment and survival, but also for a better estimation of prognosis. The aim of this study was to evaluate the feasibility of diffusion weighted MRI of the liver as part of a combined MR evaluation of patients with rectal cancers and compare it with the standard preoperative evaluation of the liver with CT. Methods. Consecutive patients diagnosed with rectal cancers were asked to participate in the study. Preoperative CT and diffusion weighted MR (DWMR) were compared to contrast enhanced laparoscopic ultrasound (CELUS). Results. A total of 35 patients were included, 15 patients in Group-1 having the standard CT evaluation of the liver and 20 patients in Group-2 having the standard CT evaluation of the liver and DWMR of the liver. Compared with CELUS, the per-patient sensitivity/specificity was 50/100% for CT, and for DWMR: 100/94% and 100/100% for Reader 1 and 2, respectively. The per-lesion sensitivity of CT and DWMR were 17% and 89%, respectively compared with CELUS. Furthermore, one patient had non-resectable metastases after DWMR despite being diagnosed with resectable metastases after CT. Another patient was diagnosed with multiple liver metastases during CELUS, despite a negative CT-scan. Discussion. DWMR is feasible for preoperative evaluation of liver metastases. The current standard preoperative evaluation with CT-scan results in disadvantages like missed metastases and futile operations. We recommend that patients with rectal cancer, who are scheduled for MR of the rectum, should have a DWMR of the liver performed at the same time.

Seeding after ultrasound-guided percutaneous biopsy of liver metastases in patients with colorectal or breast cancer.

BACKGROUND: Neoplasm seeding is a serious complication after liver metastases biopsy. Reported incidences vary between 10% and 19% for colorectal cancer (CRC) and are unknown for breast cancer (BC). The aim of this retrospective study was to determine the frequency of tumor seeding after ultrasound-guided percutaneous biopsy of CRC and BC liver metastases. MATERIAL AND METHODS: Unselected liver biopsies performed in the period of 2005-2012 at our institution were extracted from the National Pathology Registry. Medical records including imaging from patients with biopsy-verified BC and CRC liver metastases were retrospectively reviewed. The endpoint was the development of abdominal wall recurrence following liver biopsy. RESULTS: Of total 2981 biopsies we identified 278 patients with CRC and 155 patients with BC biopsy-verified liver metastases. During the median follow-up of 25 months after biopsy (range 3-253 months), no seeding was recorded in patients with BC. Within the median follow-up of 34 months (3-111 months), seeding was registered in 17/278 (6%) of patients with CRC; three patients of 278 (1%) had undoubtedly biopsy-related seeding, which became apparent six, nine, and 26 months after biopsy, respectively; and in nine patients (3%) seeding occurred due to either biopsy or other interventions; and five patients had seeding, which were assessed as a consequence of other invasive procedures than biopsies. The median overall survival of the 17 patients with seeding was 70 months compared to 39 months of patients without seeding. CONCLUSIONS: The results showed no seeding in BC patients. Seeding rate after biopsy in CRC patients is not negligible, however, without affecting outcome.

Fast-track, ambulatory ultrasound-guided Tru-Cut liver biopsy is feasible and cost-efficient.

INTRODUCTION: Most institutions perform percutaneous liver biopsy with a post-biopsy patient observation period lasting up to eight hours, which is resource-demanding. This study aimed to evaluate the safety of liver biopsy performed in a fast-track set-up with an only one-hour post-biopsy observation time. METHODS: Patients referred to our institution underwent fast-track ultrasound-guided 18-gauge Tru-Cut liver biopsy procedures. Each single biopsy procedure was followed by a post-procedure observational period of one hour and an additional focused assessment with sonography for trauma before patient discharge. All patients underwent a clinical follow-up programme at revisit in order to register any delayed onset of major complications. RESULTS: Out of 200 completed biopsy procedures, two major complications were registered post biopsy and they were treated appropriately. All patients were safely discharged from our institution. No fatality or long-term complications were found during this study. CONCLUSION: The fast-track approach reported herein is a feasible option when adequate patient information is given. Besides the obvious, positive effect on patient logistics and departmental throughput, this approach may also reduce diagnostic work-up time and bring financial benefits. Therefore, we encourage the use of this approach in institutions comparable to our own. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Clinical outcome of percutaneous RF-ablation of non-operable patients with liver metastasis from breast cancer.

PURPOSE: Despite improved anti-neoplastic treatment the prognosis for patients with liver metastases from metastatic breast cancer remains poor. MATERIALS AND METHODS: Thirty-two consecutive patients with metastatic breast cancer treated with radiofrequency ablation (RFA) at the Department of Oncology, Herlev Hospital, University of Copenhagen, from 1996 to 2010. RESULTS: Time to intrahepatic progression was median 11 months (range 1.6-184 months). Median survival after first RFA was 33.5 months. Survival at 1, 2 and 3 years was 87, 68 and 48 %, respectively. The local recurrence rate was 22 %. CONCLUSIONS: In this small, highly selected cohort we found RFA safe and efficacious with a low local recurrence rate and a median survival above that expected with systemic treatment. Our data are in line with previous studies and underscore the need for a large prospective study using optimal chemotherapy regimens and RFA/surgery to clarify whether intense treatment protocols can prolong survival for certain patient groups.

[Contrast enhanced ultrasound improves detection and quantification of intra-abdominal bleeding]. / Ultralyd med kontrast forbedrer påvisning og kvantificering af intraabdominal blødning.

A 71-year-old man had a coarse needle biopsy performed. After the biopsy symptoms of abdominal bleeding were deteced. An acute ultrasound examination was performed as Focussed Assessment with Sonography in Trauma (FAST). The findings were inconclusive and a Contrast Enhanced Ultrasound (CEUS) was carried out. CEUS immediately demonstrated as well a rim around the liver with clear borders as a large amount of abdominal fluid. Upon these findings immediate surgery was performed. CEUS improves the contrast between areas with and without perfusion, which enhance the presence of haemorrhagic fluid, independently of the fluid's echo-pattern. CEUS seems to be a fast and valuable extension to FAST.

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases.

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n=13), presacral (n=9), pouch of Douglas (n=7), internal genitals (n=2) and between the bowel loops (n=2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n=18), transvaginal (n=11), transperineal ( n=2) or transgluteal (n=2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.

[Diagnosis and biopsy of liver metastases using ultrasound contrast agent]. / Diagnostik og biopsi af levermetastaser med anvendelse af ultralydkontrast.

In the presented case, liver metastases were not visible on conventional ultrasound imaging. After a contrast agent was given, multiple metastases were seen, and an ultrasound-guided biopsy was performed, guided by the contrast image.

[Local treatment of liver tumors]. / Lokal behandling af levertumorer.

Local treatment of non-resectable liver tumors is common. This brief review describes the local treatment techniques used in Denmark. The techniques are evaluated according to the evidence in literature. The primary local treatment is Radiofrequency Ablation of both primary liver tumors and liver metastasis. Radiofrequency treatment is based on case-control studies, but the impact of the treatment seems obvious. However, randomized controlled studies are necessary in the future in order to guide indications according to different stages of disease, techniques and treatment regimes.

[Focal nodular hyperplasia]. / Fokal nodulaer hyperplasi.

INTRODUCTION: Focal nodular hyperplasia (FNH) is a benign lesion of the liver and is most commonly seen in women in the reproductive age. This article is a retrospective study of FNH. MATERIAL AND METHOD: Patients with histologically verified FNH were included. The relationship between tumor size, sex and estrogen was investigated. RESULTS: 24 patients were included. In 19 cases, the diagnosis was made coincidentally during the investigation or treatment of another disease. There was no difference in average tumor-size between sexes, but estrogen-treated women had larger tumors. Biopsies were needed in order to establish the diagnosis and to rule out malignancy. In most cases, the chosen strategy of management was expectancy rather than surgery. CONCLUSION: FNH is a benign liver disease and is often diagnosed coincidentally. An association between tumor size and estrogen treatment remains elusive. Diagnostic Imaging with contrast enhancement may produce characteristic features of FNH. However, biopsy remains the best option to diagnose FNH and to rule out malignancy.

[Ultrasound-guided radiofrequency ablation of malignant liver tumors]. / UL-vejledt radiofrekvensbehandling af maligne levertumorer.

INTRODUCTION: Radio frequency ablation (RFA) of malignant tumours is a new and promising treatment modality. The aim of this study was to evaluate the method in patients with non-resectable liver tumours. MATERIAL AND METHODS: RFA was performed under the guidance of ultrasonography and general anaesthesia in 37 patients from December 1998 to November 2001. Six patients had primary liver cancers, and 31 metastases from other cancer, often colorectal cancer. RESULTS: Eight patients could not be evaluated because of the short follow-up time. Twenty-four of 29 patients (83%) achieved a complete tumour response. Twelve patients (41%) are alive after 3-28 (median 16) months, without recurrence. Twelve patients (41%) are alive after 1-34 (median 14) months, with recurrence. Five patients (14%) died after 4-26 (median 11) months, because of recurrence in the liver and/or other organs. Four patients had minor complications and one a major complication. There was no postoperative mortality. DISCUSSION: RFA can be offered to patients with non-resectable liver tumours when it is technically possible. The treatment can be performed with few complications, requires only a short hospital stay, and is cheaper than other treatments. Prolonged survival is attained in 40-50% cent of the patients.

Improved detection and biopsy of solid liver lesions using pulse-inversion ultrasound scanning and contrast agent infusion.

The purpose of this study was to assess the ability of pulse-inversion ultrasound (US) scanning (PIUS), combined with an IV contrast agent, to detect malignant liver lesions and its impact on patient management (resectability). Additionally, to determine the feasibility of US-guided biopsy of new PIUS-findings at the same session. A total of 30 patients with known or clinically suspected cancer underwent conventional B-mode scanning and PIUS with IV-administered contrast agent. The number of liver metastases in the right and the left liver lobe, respectively, was recorded. All patients with additional findings by PIUS underwent US-guided biopsy. PIUS provided additional information in 18 patients (60%); of these, 13 (43%) had additional metastases. Of 19 patients found resectable by conventional US, 9 (47%) were considered inoperable using PIUS supported by biopsies. Biopsies of additional findings were performed in 17 of 18 patients. All biopsies of additional findings confirmed malignancy. PIUS with an IV contrast agent increased the ability to detect liver metastases compared to conventional US scanning. The technique had a high impact on patient management. The results showed that PIUS-guided biopsy was possible. PIUS with IV contrast will undoubtedly become an important diagnostic tool in the evaluation of patients with metastatic liver disease.