Liver metastases of neuroendocrine tumors: Conventional transarterial chemoembolization and thermal ablation.

PURPOSE: To identify prognostic factors for patients with neuroendocrine liver metastases (NELM) undergoing conventional transarterial chemoembolization (c-TACE), microwave ablation (MWA), or laser interstitial thermotherapy (LITT) and to determine the most effective therapy regarding volume reduction of NELM and survival. MATERIALS AND METHODS: Between 1996 and 2020, 130 patients (82 men, 48 women) were treated with c-TACE, and 40 patients were additionally treated with thermal ablation. Survival was retrospectively analyzed using the Kaplan-Meier-method. Additional analyses were performed depending on the therapeutic intention (curative, palliative, symptomatic). Prognostic factors were derived using Cox regression. To find predictive factors for volume reduction in response to c-TACE, a mixed-effects model was used. RESULTS: With c-TACE, an overall median volume reduction of 23.5 % was achieved. An average decrease in tumor volume was shown until the 6th c-TACE treatment, then the effect stopped. C-TACE interventions were most effective at the beginning of c-TACE therapy, and treatment breaks longer than 90 days negatively influenced the outcome. Significant prognostic factors for survival were number of liver lesions (p = 0.0001) and type of therapeutic intention (p < 0.0001). Minor complications and one major complication occurred in 20.3 % of LITT and only in 8.6 % of MWA interventions. Complete ablation was observed in 95.7 % (LITT) and 93.1 % (MWA) of interventions. CONCLUSION: New prognostic factors were found for survival and volume reduction. Efficacy of c-TACE decreases after the 6th intervention and treatment breaks longer than 90 days should be avoided. With thermal ablation, a high rate of complete ablation was achieved, and survival improved. KEY POINTS: · Number of liver lesions and therapeutic intention are prognostic factors for survival.. · Regarding volume reduction, C-TACE is most effective at the beginning of treatment and longer treatment breaks should be avoided.. · With MWA and LITT, a high rate of complete ablation was achieved. MWA trends toward fewer complications than LITT in the treatment of NELM (p = 0.07)..

Interventional oncological treatment of breast cancer liver metastasis (BCLM): single center long-term evaluation over 26 years using thermoablation techniques like LITT, MWA and TACE in a multimodal application.

The purpose of the study is to retrospectively evaluate the development and technological progress in local oncological treatments of patients with breast cancer liver metastasis (BCLM) using LITT (laser interstitial thermotherapy), MWA (microwave ablation) and TACE (transarterial chemoembolization) ablation techniques in a multimodal application. The study uses data generated between 1993 and 2020. Therapy results were evaluated using the Kaplan-Meier survival estimate, Cox proportional hazard regression and log-rank test. Cox regression analysis showed that the different treatment methods are statistically significant predictors of survival of patients. Median survival times for groups treated with LITT (212 patients) and LITT + TACE (215 patients) were 2.2 years and 2.1 years respectively; median survival times for groups treated with MWA (17 patients) and MWA + TACE (143 patients) were 5.6 and 2.4 years respectively. For LITT only treatments, the 1-, 3- and 5-year survival probability scored 80%, 37%, 22%. Results for combined LITT + TACE treatments were 76%, 34% and 15%. In group MWA, the 1-/3-/5-year survival probability rates were calculated as 89%, 89%, 89% (however, they should be interpreted carefully due to a relatively small sample size of n = 17 patients). Group MWA + TACE offered values of 77%, 38% and 22%. A separate group of 549 patients was analyzed with TACE monotherapy treatment. The estimated median survival time in this group was 0.8 years. The 1-/3-/5-year survival probability rates were 37%, 8% and 4%. Treatments with combined MWA and MWA + TACE resulted in the best median survival time estimations in this study.

Hypnotherapy and IBS: Implicit, long-term stress memory in the ENS?

The association between irritable bowel syndrome (IBS) and psychiatric and mood disorders may be more fundamental than was previously believed. Prenatal, perinatal, postnatal, and early-age conditions can have a key role in the development of IBS. Subthreshold mental disorders (SMDs) could also be a significant source of countless diverse diseases and may be a cause of IBS development. We hypothesize that stress-induced implicit memories may persist throughout life by epigenetic processes in the enteric nervous system (ENS). These stress-induced implicit memories may play an essential role in the emergence and maintenance of IBS. In recent decades, numerous studies have proven that hypnosis can improve the primary symptoms of IBS and also reduce noncolonic symptoms such as anxiety and depression and improve quality of life and cognitive function. These significant beneficial effects of hypnosis on IBS may be because hypnosis allows access to unconscious brain processes.

Transarterial Chemoembolization (TACE) Using Mitomycin with or without Irinotecan for Hepatocellular Carcinoma in European Patients.

BACKGROUND: We evaluated survival data and local tumor control in 2 groups of patients with hepatocellular carcinoma (HCC) treated with different chemotherapeutic agents for transarterial chemoembolization (TACE). METHODS: 28 patients (median age 63 years) with HCC were repeatedly treated with chemoembolization at 4-week intervals. 20 patients had Barcelona Clinic Liver Cancer (BCLC) stage B, while 8 patients obtained chemoembolization for bridging purposes (BCLC stage A). In total, 98 chemoembolizations were performed (median 3.0 treatments/patient). The administered chemotherapeutic agent comprised either mitomycin only (n = 14; 50%) or mitomycin in combination with irinotecan (n = 14; 50%). Lipiodol plus degradable starch microspheres was used for all embolizations. Local tumor response was assessed by magnetic resonance imaging using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Progression-free survival (PFS) was evaluated. RESULTS: In the mitomycin-irinotecan group, complete response (CR) was observed in 21.4%, partial response (PR) in 42.9%, stable disease (SD) in 28.6%, and progressive disease (PD) in 7.1%. In the mitomycin group, PR was observed in 57.2% of patients, SD in 21.4%, and PD in 21.4% (p = 0.043). The PFS of patients after chemoembolization with mitomycin was 4 months compared to the significantly longer PFS of 12 months in the mitomycin-irinotecan group (p = 0.003). CONCLUSION: Chemoembolization of HCC with mitomycin and irinotecan is the preferred treatment option for achieving local control and better PFS.

Transarterial chemoembolization (TACE) using mitomycin and lipiodol with or without degradable starch microspheres for hepatocellular carcinoma: comparative study.

BACKGROUND: To evaluate survival data and local tumor control after transarterial chemoembolization in two groups with different embolization protocols for the treatment of HCC patients. METHODS: Ninty-nine patients (mean age: 63.6 years), 78 male (78.8%) with HCC were repeatedly treated with chemoembolization in 4-week-intervals. Eighty-eight patients had BCLC-Stage-B and in 11 patients, chemoembolization was performed for bridging (BCLC-Stage-A). In total, 667 chemoembolization treatments were performed (mean 6.7 treatments/patient). The administered chemotherapeutic agent included mitomycin. For embolization, lipiodol only (n = 51;51.5%; mean age 63.8 years; 38 male), or lipiodol plus degradable starch microspheres (DSM) (n = 48; 48.5%; mean age 63.4 years; 40 male) were used. The local tumor response was assessed by MRI using Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1). Patient survival times were evaluated using Kaplan-Meier curves and log-rank tests. RESULTS: The local tumor control in the lipiodol-group was: PR (partial response) in 11 (21.6%), SD (stable disease) in 32 (62.7%) and PD (progressive disease) in 8 cases (15.7%). In the lipiodol-DSM-group, PR was seen in 14 (29.2%), SD in 22 (45.8%), and PD in 12 (25.0%) individuals (p = 0.211). The median survival of patients after chemoembolization with lipiodol was 25 months and in the lipiodol-DSM-group 28 months (p = 0.845). CONCLUSION: Our data suggest a slight benefit of the use of lipiodol and DSM in comparison of using lipiodol only for chemoembolization of HCC in terms of local tumor control and survival data, this trend did not reach the level of significance.

Ablation therapy of non-colorectal cancer lung metastases: retrospective analysis of tumour response post-laser-induced interstitial thermotherapy (LITT), radiofrequency ablation (RFA) and microwave ablation (MWA).

PURPOSE: To retrospectively compare the local tumour response and survival rates in patients with non-colorectal cancer lung metastases post-ablation therapy using laser-induced thermotherapy (LITT), radiofrequency ablation (RFA) and microwave ablation (MWA). MATERIAL AND METHODS: Retrospective analysis of 175 computed tomography (CT)-guided ablation sessions performed on 109 patients (43 males and 66 females, mean age: 56.6 years). Seventeen patients with 22 lesions underwent LITT treatment (tumour size: 1.2-4.8 cm), 29 patients with 49 lesions underwent RFA (tumour size: 0.8-4.5 cm) and 63 patients with 104 lesions underwent MWA treatment (tumour size: 0.6-5 cm). CT scans were performed 24-h post-therapy and on follow-up at 3, 6, 12, 18 and 24 months. RESULTS: The overall-survival rates at 1-, 2-, 3- and 4-year were 93.8, 56.3, 50.0 and 31.3% for patients treated with LITT; 81.5, 50.0, 45.5 and 24.2% for patients treated with RFA and 97.6, 79.9, 62.3 and 45.4% for patients treated with MWA, respectively. The mean survival time was 34.14 months for MWA, 34.79 months for RFA and 35.32 months for LITT. In paired comparison, a significant difference could be detected between MWA versus RFA (p = 0.032). The progression-free survival showed a median of 23.49 ± 0.62 months for MWA,19.88 ± 2.17 months for LITT and 16.66 ± 0.66 months for RFA (p = 0.048). The lowest recurrence rate was detected in lesions ablated with MWA (7.7%; 8 of 104 lesions) followed by RFA (20.4%; 10 of 49 lesions) and LITT (27.3%; 6 of 22 lesions) p value of 0.012. Pneumothorax was detected in 22.16% of MWA ablations, 22.73% of LITT ablations and 14.23% of RFA ablations. CONCLUSION: LITT, RFA and MWA may provide an effective therapeutic option for non-colorectal cancer lung metastases with an advantage for MWA regarding local tumour control and progression-free survival rate.

Thermal Ablation of Colorectal Lung Metastases: Retrospective Comparison Among Laser-Induced Thermotherapy, Radiofrequency Ablation, and Microwave Ablation.

OBJECTIVE: The purpose of this study is to retrospectively evaluate local tumor control, time to tumor progression, and survival rates among patients with lung metastatic colorectal cancer who have undergone ablation therapy performed using laser-induced thermotherapy (LITT), radiofrequency ablation (RFA), or microwave ablation (MWA). MATERIALS AND METHODS: Data for this retrospective study were collected from 231 CT-guided ablation sessions performed for 109 patients (71 men and 38 women; mean [± SD] age, 68.6 ± 11.2 years; range, 34-94 years) from May 2000 to May 2014. Twenty-one patients underwent LITT (31 ablations), 41 patients underwent RFA (75 ablations), and 47 patients underwent MWA (125 ablations). CT scans were acquired 24 hours after each therapy session and at follow-up visits occurring at 3, 6, 12, 18, and 24 months after ablation. Survival rates were calculated from the time of the first ablation session, with the use of Kaplan-Meier and log-rank tests. Changes in the volume of the ablated lesions were measured using the Kruskal-Wallis method. RESULTS: Local tumor control was achieved in 17 of 25 lesions (68.0%) treated with LITT, 45 of 65 lesions (69.2%) treated with RFA, and 91 of 103 lesions (88.3%) treated with MWA. Statistically significant differences were noted when MWA was compared with LITT at 18 months after ablation (p = 0.01) and when MWA was compared with RFA at 6 months (p = 0.004) and 18 months (p = 0.01) after ablation. The overall median time to local tumor progression was 7.6 months. The median time to local tumor progression was 10.4 months for lesions treated with LITT, 7.2 months for lesions treated with RFA, and 7.5 months for lesions treated with MWA, with no statistically significant difference noted. New pulmonary metastases developed in 47.6% of patients treated with LITT, in 51.2% of patients treated with RFA, and in 53.2% of patients treated with MWA. According to the Kaplan-Meier test, median survival was 22.1 months for patients who underwent LITT, 24.2 months for those receiving RFA, and 32.8 months for those who underwent MWA. The overall survival rate at 1, 2, and 4 years was 95.2%, 47.6%, and 23.8%, respectively, for patients treated with LITT; 76.9%, 50.8%, and 8.0%, respectively, for patients treated with RFA; and 82.7%, 67.5%, and 16.6%, respectively, for patients treated with MWA. The log-rank test revealed no statistically significant difference among LITT, RFA, and MWA. The progression-free survival rate at 1, 2, 3, and 4 years was 96.8%, 52.7%, 24.0%, and 19.1%, respectively, for patients who underwent LITT; 77.3%, 50.2%, 30.8%, and 16.4%, respectively, for patients who underwent RFA; and 54.6%, 29.1%, 10.0%, and 1.0%, respectively, for patients who underwent MWA, with no statistically significant difference noted among the three ablation methods. CONCLUSION: LITT, RFA, and MWA can be used as therapeutic options for lung metastases resulting from colorectal cancer. Statistically significant differences in local tumor control revealed a potential advantage in using MWA. No differences in time to tumor progression or survival rates were detected when the three different ablation methods were compared.

Modified MR defecography without rectal filling in obstructed defecation syndrome: Initial experience.

OBJECTIVE: To evaluate the role of dynamic MR defecography before rectal filling in detecting occult anterior compartment prolapse in patients with obstructed defecation. METHODS: This prospective study was approved by the ethics committee. Seventy six females with obstructed defecation underwent dynamic MR defecography before and after rectal filling. Pre-rectal and post-rectal filling sequences were interpreted separately by two radiologists on two different settings with a time interval of one week. Statistical analysis was performed using Wilcoxon's-matched-pairs signed rank test and t-test for matched pairs; differences were considered statistically significant at p<0.05. RESULTS: Fifty eight females of 76 showed additional anterior compartment derangement, with 27 diagnosed only in pre-rectal filling sequence (27/58=46.55%). Following rectal filling detected cystocele in 27 patients was not identified in 14 cases and downgraded in 13. Similarly, detected uterine prolapse in 17 patients was not visualized in 14 patients and downgraded in 3. Furthermore, rectocele was identified in 7 cases before gel enema, additional 32 detected after rectal filling. Significant statistical difference in the detection of both cystocele (p=0.0001) and uterine prolapse (p=0.0013) was identified in the non-filled sequence. CONCLUSION: Pelvic floor imaging before rectal filling is significantly better for detection of anterior compartment prolapse.

How Effective Are Percutaneous Liver-Directed Therapies in Patients with Non-Colorectal Liver Metastases?

BACKGROUND: The purpose of this review is to demonstrate the clinical indications, technical developments, and outcome of liver-directed therapies in interventional oncology of non-colorectal liver metastases. METHODS: Liver-directed therapies are classified into vascular transarterial techniques such as chemoperfusion (TACP), chemoembolization (TACE), radioembolization (selective internal radiation therapy (SIRT)), and chemosaturation, as well as thermal ablation techniques like microwave ablation (MWA), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT), cryotherapy, and irreversible electroporation (IRE). The authors searched the database PubMed using the following terms: 'image-guided tumor ablation', 'thermal ablation therapies', 'liver metastases of uveal melanoma', 'neuroendocrine carcinoma', 'breast cancer', and 'non-colorectal liver metastases'. RESULTS: Various combinations of the above-mentioned therapy protocols are possible. In neuroendocrine carcinomas, oligonodular liver metastases are treated successfully via thermal ablation like RFA, LITT, or MWA, and diffuse involvement via TACE or SIRT. Although liver involvement in breast cancer is a systemic disease, non-responding nodular metastases can be controlled via RFA or LITT. In ocular or cutaneous melanoma, thermal ablation is rarely considered as an interventional treatment option, as opposed to TACE, SIRT, or chemosaturation. Rarely liver-directed therapies are used in pancreatic cancer, most likely due to problems such as biliary digestive communications after surgery and the risk of infections. Rare indications for thermal ablation are liver metastases of other primary cancers like non-small cell lung, gastric, and ovarian cancer. CONCLUSION: Interventional oncological techniques play a role in patients with liver-dominant metastases.

Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management.

BACKGROUND: To evaluate the effectiveness of lymphography as a minimally invasive treatment option of lymphatic leakage in terms of local control and to investigate which parameters influence the success rate. METHOD: This retrospective study protocol was approved by the ethic committee. Patient history, imaging data, therapeutic options and follow-up were recorded and retrospectively analyzed. Between June 1998 and February 2013, 71 patients (m:w = 42:29, mean age, 52.4; range 42­75 years) with lymphatic leakage in form of lymphatic fistulas (n = 37), lymphocele (n = 11), chylothorax (n = 13) and chylous ascites (n = 10)underwent lymphography. Sixty-four patients (90.1%) underwent successful lymphography while lymphography failed in 7 cases. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage and to the volume of the applied iodized oil. RESULT: Signs of leakage or contrast extravasation were directly detected in 64 patients. Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients when the lymphatic drainage volume was less than 200 mL/day (n = 33). Even when lymphatic drainage was higher than 200 mL/day (n = 31),therapeutic lymphography was still successful in 58.1% of the patients. CONCLUSION: Lymphography is an effective, minimally invasive method in the detection and treatment of lymphatic leakage. The volume of lymphatic drainage per day is a significant predictor of the therapeutic success rate.

Neoadjuvant TACE before laser induced thermotherapy (LITT) in the treatment of non-colorectal non-breast cancer liver metastases: feasibility and survival rates.

PURPOSE: To evaluate safety, feasibility and overall survival rates for transarterial chemoembolization (TACE) alone or combined with MR-guided laser-induced-thermotherapy (LITT) in liver metastases of non-colorectal and non-breast cancer origin. METHODS AND MATERIALS: Included were patients with unresectable non-colorectal non-breast cancer liver metastases with progression under systemic chemotherapy. Excluded were patients with Karnofsky score ≤ 70, respiratory, renal and cardiovascular failure, and general TACE contraindications. TACE using Mitomycin alone, Mitomycin-Gemcitabine or Mitomycin-Gemcitabine-Cisplatin was performed to all patients. After TACE 146 metastases were ablated with MR-guided LITT. To be eligible for LITT metastases should be < 5 cm in size and ≤ 5 in number. Tumor response was evaluated using MRI according to RECIST. Survival was evaluated using Kaplan-Meier analysis. RESULTS: A total of 110 patients (mean age 59.2 years) with 371 metastases received TACE (mean 5.4 sessions/patient, n=110) with 76 (69%) receiving LITT (mean 1.6 session/patient) afterwards. TACE resulted in a mean decrease of mean maximum diameter of 52% ± 26.6 and volume change of -68.5% ± 22.9 in the 25 patients (23%) with partial response. Stable disease (n=59, 54%). Progressive disease (n=26, 23%). The RECIST outcome after LITT showed complete response (n=13, 17%), partial response (n=1, 1%), stable situation (n=41, 54%) and progressive disease (n=21, 28%). The mean time to progression (TTP) was 8.6 months. Median survival of all patients was 21.1 months. CONCLUSION: TACE with different protocols alone and in combination with LITT is a feasible palliative treatment option resulting in a median survival of 21.1 months for unresectable liver metastases of non-colorectal and non-breast cancer origin.

Thermal ablation of liver metastases from colorectal cancer: radiofrequency, microwave and laser ablation therapies.

Surgery is currently considered the treatment of choice for patients with colorectal cancer liver metastases (CRLM) when resectable. The majority of these patients can also benefit from systemic chemotherapy. Recently, local or regional therapies such as thermal ablations have been used with acceptable outcomes. We searched the medical literature to identify studies and reviews relevant to radiofrequency (RF) ablation, microwave (MW) ablation and laser-induced thermotherapy (LITT) in terms of local progression, survival indexes and major complications in patients with CRLM. Reviewed literature showed a local progression rate between 2.8 and 29.7 % of RF-ablated liver lesions at 12-49 months follow-up, 2.7-12.5 % of MW ablated lesions at 5-19 months follow-up and 5.2 % of lesions treated with LITT at 6-month follow-up. Major complications were observed in 4-33 % of patients treated with RF ablation, 0-19 % of patients treated with MW ablation and 0.1-3.5 % of lesions treated with LITT. Although not significantly different, the mean of 1-, 3- and 5-year survival rates for RF-, MW- and laser ablated lesions was (92.6, 44.7, 31.1 %), (79, 38.6, 21 %) and (94.2, 61.5, 29.2 %), respectively. The median survival in these methods was 33.2, 29.5 and 33.7 months, respectively. Thermal ablation may be an appropriate alternative in patients with CRLM who have inoperable liver lesions or have operable lesions as an adjunct to resection. However, further competitive evaluation should clarify the efficacy and priority of these therapies in patients with colorectal cancer liver metastases.

Colorectal cancer liver metastases: long-term survival and progression-free survival after thermal ablation using magnetic resonance-guided laser-induced interstitial thermotherapy in 594 patients: analysis of prognostic factors.

PURPOSE: The purpose of this study was the evaluation of prognostic factors for long-term survival and progression-free survival (PFS) after treatment of colorectal cancer (CRC) liver metastases with magnetic resonance-guided laser-induced interstital thermotherapy (LITT). PATIENTS AND METHODS: We included 594 patients (mean age, 61.2 years) with CRC liver metastases who were treated with LITT. The statistical analysis of the long-term survival and PFS were based on the Kaplan-Meier method. The Cox regression model tested different parameters that could be of prognostic value. The tested prognostic factors were the following: sex, age, the location of primary tumor, the number of metastases, the maximal diameter and total volume of metastases and necroses, the quotient of total volumes of metastases and necroses, the time of appearance of liver metastases and location in the liver, the TNM classification of CRC, extrahepatic metastases, and neoadjuvant treatments. RESULTS: The median survival was 25 months starting from the date of the first LITT. The 1-, 2-, 3-, 4-, and 5-year survival rates were 78%, 50.1%, 28%, 16.4%, and 7.8%, respectively. The median PFS was 13 months. The 1-, 2-, 3-, 4-, and 5-year PFS rates were 51.3%, 35.4%, 30.7%, 25.4%, and 22.3%, respectively. The number of metastases and their maximal diameter were the most important prognostic factors for both long-term survival and PFS. Long-term survival was also highly influenced by the initial involvement of the lymph nodes. CONCLUSIONS: For patients treated with LITT for CRC liver metastases, the number and size of metastases, together with the initial lymph node status, are significant prognostic factors for long-term survival.

Evaluation of MRI T1-based treatment monitoring during laser-induced thermotherapy of liver metastases for necrotic size prediction.

PURPOSE: The aim of this study was to evaluate the accuracy of real-time magnetic resonance imaging (MRI) T1-based treatment monitoring for predicting volume of lesions induced by laser-induced thermotherapy (LITT) of liver metastases. MATERIALS AND METHODS: This prospective study was approved by the institutional review board and informed consent from all included patients was obtained. In 151 patients, 237 liver metastases were ablated during 372 LITT procedures. 1.5 T MRI treatment monitoring was performed based on longitudinal relaxation time (T1) using fast low-angle shot (FLASH) sequences. Patients underwent additional contrast-enhanced MRI directly after LITT, 24 h after the procedure and during follow-up at 3, 6 and 12 months. The amount of energy necessary to induce a defined necrotic area was investigated within the various liver segments. RESULTS: The total amount of energy applied during LITT varied from 6.12-225.32 kJ (mean 48.96 kJ). Ablation in liver segments 5 (2.12 kJ/cm(3)) and 8 (2.16 kJ/cm(3)) required the highest energy. The overall pre-ablative metastasis volume ranged from 0.5-51.94 cm(3) (mean 1.99 cm(3), SD 25.49 cm(3)) while the volume measured in the last available T1 image varied from 0.78-120 cm(3) (mean 26.25 cm(3), SD 25.66 cm(3)). Volumes measured via MRI T1-based treatment monitoring showed a stronger correlation with necrosis 24 h after LITT (r = 0.933, p < 0.001) than contrast-enhanced MRI directly after the procedure (r = 0.888, p < 0.001). CONCLUSIONS: Real-time MRI T1-based treatment monitoring during LITT of liver metastases allows for precise estimation of the resulting lesion volume and improves control of the energy necessary during ablation.

Thermal ablation therapies in patients with breast cancer liver metastases: a review.

BACKGROUND: The liver is involved in about half of patients with metastatic breast cancer. Unfortunately systemic chemotherapy as the treatment of choice is limited. Due to multifocality and/or insufficient remnant liver volume, the majority of liver metastases are also unresectable. Currently, thermal ablations are used in these patients with acceptable impact. METHODS: We reviewed studies on radiofrequency ablation (RFA), laser-induced thermotherapy (LITT) and microwave ablation (MWA) regarding local tumour response, progression and survival indexes in patients with breast cancer liver metastases (BCLM). RESULTS: The reviewed literature showed positive response rates of 63 % to 97 % in RF-ablated lesions, 98.2 % in LITT-treated lesions and 34.5-62.5 % in MW-ablated lesions. Median survival was 10.9-60 months using RFA, 51-54 months after LITT and 41.8 months using MWA. Five-year survival rates were 27-30 %, 35 % and 29 %, respectively. Local tumour progression ranged from 13.5 % to 58 % using RFA, 2.9 % with LITT and 9.6 % with MWA. CONCLUSION: The reviewed literature demonstrated that ablation therapies either as single therapy or combined with other locoregional therapies are a good alternative as an adjunction to resection in patients with resectable lesions or with positive response using chemotherapy. However, multicentre randomised studies should be conducted to obtain further evidence of the benefits of these treatments in patients with BCLM.

MR-based thermometry of laser induced thermotherapy: temperature accuracy and temporal resolution in vitro at 0.2 and 1.5 T magnetic field strengths.

PURPOSE: To evaluate MR-thermometry using fast MR sequences for laser induced interstitial thermotherapy (LITT) at 0.2 and 1.5 T systems. METHODS & MATERIALS: In-vitro experiments were performed using Agarose gel mixture and lobes of porcine liver. MR-thermometry was performed by means of longitudinal relaxation time (T1) and proton resonance frequency shift (PRF) methods under acquisition of amplitude and phase shift images. Four different sequences were used for T1 thermometry: A gradient-echo (GRE), a True Fast Imaging with Steady Precession (TRUFI), a Saturation Recovery Turbo-FLASH (SRTF), and an Inversion Recovery Turbo-FLASH (IRTF) sequence (FLASH-Fast Low Angle Shot). PRF was measured with four sequences: Two fast-spoiled GRE sequences (one as WIP sequence), a Turbo-FLASH (TFL) sequence (WIP sequence), and a multiecho-TrueFISP sequence. Temperature was controlled and verified using a fiber-optic Luxtron device. The temperature was correlated with the MR measurement. RESULTS: All sequences showed a good linear correlation R(2) = 0.97-0.99 between the measured temperature and the MR-thermometry measurements. The only exception was the TRUFI sequence in the Agarose phantom that showed a non-linear calibration curve R(2) = 0.39-0.67. At 1.5 T, the Agarose experiments revealed similar temperature accuracies of 4-6°C for all sequences excluding TRUFI. During experiments with the liver, the PRF sequences showed better performance than the T1, with accuracies of 5-12°C, contrary to the T1 sequences at 14-18°C. The accuracy of the Siemens PRF-FLASH sequence was 5.1°C. At 0.2 T, the Agarose experiments provided the highest accuracy of 3.3°C for PRF measurement. At the liver experiments the T1 sequences SRTF and FLASH revealed the best accuracies at 6.4 and 7.0°C. CONCLUSION: The accuracy and speed of MR temperature measurements are sufficient for controlling the temperature-based tumor destruction. For 0.2 T systems SRTF and FLASH sequences are recommended. For 1.5 T systems SRTF and FLASH are the most accurate.

Repeated chemoembolization followed by laser-induced thermotherapy for liver metastasis of breast cancer.

OBJECTIVE: The purpose of this study was to evaluate local tumor control and survival after use of a downstaging protocol of repeated transarterial chemoembolization (TACE) with two chemotherapeutic combinations followed by laser-induced thermotherapy in the care of patients with liver metastasis of breast cancer. SUBJECTS AND METHODS: This prospective study included 161 patients with liver metastasis of breast cancer origin. TACE (mean, 3.5 [SD, 1.3] sessions per patient; range, 1-9 sessions) was performed as downstaging treatment to achieve the size and number of metastatic lesions that met the requirements for laser-induced thermotherapy (diameter < 5 cm, number ≤ 5). The TACE protocol was performed with either mitomycin C alone (n = 53) or mitomycin C in combination with gemcitabine (n = 108). RESULTS: In response to TACE overall, the mean reduction in diameter based on the longest diameter of the target lesions was 27%. The difference between diameter reduction in the mitomycin C group and that in the mitomycin C-gemcitabine group was not statistically significant (p = 0.65). The mean survival time of all patients was 32.5 months, calculation starting from the first TACE treatment. The mean local tumor control period calculated as of completion of therapy was 13 months, and the mean time to progression was 8 months. In the mitomycin-gemcitabine group, mean time to progression was 10.7 months, and in the mitomycin group it was 6.9 months (p = 0.5). CONCLUSION: TACE can be used for sufficient downstaging of liver metastatic lesions of breast cancer to allow laser-induced thermotherapy. A combination of mitomycin C and gemcitabine seems to improve the reduction achieved with TACE.

Radiofrequency, microwave and laser ablation of pulmonary neoplasms: clinical studies and technical considerations--review article.

Image-guided thermal ablation therapy has received significant attention for the treatment of many focal primary and metastatic pulmonary neoplasms. This interest has been associated with progressive advances in energy development, approach, technical application and adjuvant therapeutic combinations to improve the outcome results concerning local tumor control, survival rate and symptoms relief. This review provides clinical outline of percutaneous thermal ablation of lung neoplasms using radiofrequency, microwave and laser techniques regarding their principles, theoretical background, devices and techniques, technical problems and recent protocols. Advantages, limitations and technical considerations of each method will be illustrated to provide a practical guideline.

Activation of tumor-specific T lymphocytes after laser-induced thermotherapy in patients with colorectal liver metastases.

PURPOSE: To asses if laser-induced thermotherapy (LITT) induces a specific cytotoxic T cell response in patients treated with LITT for colorectal cancer liver metastases. METHODS: Eleven patients with liver metastases of colorectal cancer underwent LITT. Blood was sampled before and after LITT. Peripheral T cell activation was assessed by an interferon gamma (IFNg) secretion assay and flow cytometry. Test antigens were autologous liver and tumor lysate obtained from each patient by biopsy. T cells were stained for CD3/CD4/CD8 and IFNg to detect activated T cells. The ratio of IFNg positive to IFNg negative T cells was determined as the stimulation index (SI). To assess cytolytic activity, T cells were co-incubated with human colorectal cancer cells (CaCo) and cytosolic adenylate kinase release was measured by a luciferase assay. RESULTS: IFNg secretion assay: before LITT SI was 12.73 (+/-4.83) for CD3+, 4.36 (+/-3.32) for CD4+ and 3.64 (+/-1.77) for CD8+ T cells against autologous tumor tissue. Four weeks after LITT SI had increased to 92.09 (+/-12.04) for CD3+ (P < 0.001), 42.92 (+/-16.68) for CD4+ (P < 0.001) and 47.54 (+/-15.68) for CD8+ T cells (P < 0.001) against autologous tumor tissue. No increased SI was observed with normal liver tissue at any time point. Cytotoxicity assay: before LITT activity against the respective cancer cells was low, with RLU = 1,493 (+/-1,954.68), whereas after LITT cytolytic activity had increased to RLU = 7,260 [+/-3,929.76 (P < 0.001)]. CONCLUSION: Patients with liver metastases of colorectal cancer show a tumor-specific cytotoxic T cell stimulation and a significantly increased cytolytic activity of CD3+, CD4+ and CD8+ T cells after LITT against an allogenic tumor (CaCo cell line).

Liver metastases of neuroendocrine carcinomas: interventional treatment via transarterial embolization, chemoembolization and thermal ablation.

UNLABELLED: The aim of this review article is to provide a practical clinical guideline for indication, technical aspects, protocol guideline and strategies for the interventional treatment of liver metastases from neuroendocrine tumors and focusing on the results of various protocols of management. The response to therapy, in the published articles, is calculated on the basis of the following clinical parameters; including symptomatic response (SR), biologic response (BR), morphological response (MR), progress free survival (PFS), and survival periods (SP). Transarterial chemoembolization (TACE) has been associated with SR rates of 60-95%, BR of 50-90%, MR of 33-80%, SR of 20-80 months, and a 5-year survival of between 50% and 65%. PFS was also between 18 and 24 months. In the transarterial embolization (TAE) group, SR was similar to the TACE group, MR was 32% and 82%, survival was between 18 and 88 months with a survival rate of 40-67%, and BR was between 50% and 69%. Radiofrequency ablation (RFA), either percutaneous or during surgery, has been associated with SR of 71-95% for a mean duration of 8-10 months, BR of 65%, and mean SP of 1.6 years after ablation. The mean survival following surgical resection for operable cases is 4.26 years+/-S.D.: 1.1. CONCLUSION: The interventional protocols for the management of liver metastases from neuroendocrine tumors: for oligonodular liver metastatic deposits, local resection or RFA and/or LITT is recommended, while in multinodular diseases with higher tumor load, TACE or TAE is recommended.