A comparative study of laparoscopic microwave ablation with laparoscopic radiofrequency ablation for colorectal liver metastasis

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1 JBUON 2017; 22(): ISSN: , olie ISSN: ORIGINAL ARTICLE A comparative study of laparoscopic microwave ablatio with laparoscopic radiofrequecy ablatio for colorectal liver metastasis Bo Yag, Yuwei Li The Affiliated Hospital of Southwest Medical Uiversity, Luzhou , People s Republic of Chia Summary Purpose: Laparoscopic thermal ablatio is a commo alterative to surgical resectio for treatig colorectal liver metastasis, particularly for metastases located i difficult-to-reach regios. This study aimed to compare the short- ad logterm outcomes of laparoscopic radiofrequecy ablatio () ad laparoscopic microwave ablatio () used for treatig colorectal liver metastasis. Methods: Data from patiets with colorectal liver metastasis who had udergoe or from Jauary 2010 to Jauary 2016 were examied. Baselie data, postoperative 0-day complicatios, complete ablatio rates, local tumor progressio rates, ad disease-free (DFS) ad overall survival (OS) rates were compared betwee the two treatmet groups. Results: A total of 179 patiets with colorectal liver metastasis (71 with ad 108 with ) were treated via the laparoscopic approach. Major postoperative 0-day complicatio rates were 11.1% ad 12.7% i the ad groups, respectively (p=0.046). No perioperative or postoperative 0-day deaths occurred. Local tumor progressio (LTP) rates were 10.2% (11/108) ad 1.4% (1/71) i the ad groups (p=0.046), respectively. Fiveyear OS rates were 56% ad 58% (p=0.498) ad 5-year DFS rates were 41% ad 9% (p=0.557) i the ad groups, respectively. Coclusios: ad appear to be safe for treatig colorectal liver metastasis. The OS ad DFS rates were similar, although LTP rates were lower i the group tha i the group. Key words: colorectal liver metastasis, hepatectomy, laparoscopic radiofrequecy ablatio, laparoscopic microwave ablatio, survival Itroductio Treatmet optios for colorectal liver metastasis iclude radical hepatic resectio, thermal ablatio (by percutaeous, laparoscopic, or ope approach), ad chemotherapy [1-7]. Amog them, percutaeous RFA is oe of the most commoly used techiques for treatig colorectal liver metastases with small diameters [8-11]. Thus, percutaeous RFA ca be used to treat small tumors with lesser blood loss ad fewer postoperative complicatios tha those i radical hepatic resectio [8-11]. Oe limitatio of percutaeous RFA is that it caot be used to treat tumors larger tha cm i size or aroud earby blood vessels that may act as a heat sik [8-11]. Icomplete ablatios i these circumstaces may lead to high rates of LTP [8-11]. Surgeos have begu addressig these limitatios usig high-powered MWA systems, which utilize a electric field to heat tissues. Com- Correspodece to: Bo Yag, MD. The Affiliated Hospital of Southwest Medical Uiversity, Luzhou , People s Republic of Chia. Tel ad Fax: , boyagc@vip.126.com Received: 20/01/2017; Accepted: 07/02/2017

2 668 Microwave vs radiofrequecy ablatio i liver metastasis pared with RFA, this peetratig electric field i MWA ca create larger ablatio zoes ad heat tumor tissue to hotter temperatures [12-14]. Despite the beefits associated with percutaeous ablatio, few colorectal liver cacer cases are still ot ameable to a direct percutaeous approach because of the locatio of the odule, particularly if it is ear the capsule or the diaphragm [12-14]. A alterative method for treatig these odules is to utilize a laparoscopic approach, which allows the surgeo to grossly examie the tumor spread, detect a ew odule via itraoperative ultrasoud (IOUS), ad idetify safer isertio paths to treat tumors located i difficult-to-reach locatios. Laparoscopic treatmet strategies with MWA or RFA have oly recetly bee adopted to reduce complicatio rates [15-19]. Log-term cliical results from laparoscopic MWA treatmet of colorectal liver metastasis have ot yet bee characterized. This retrospective study aimed to compare laparoscopic MWA ad RFA i patiets with colorectal liver metastasis i terms of their respective techical success, postoperative 0-day complicatio rates, LTP rates, ad OS ad DFS rates. Methods This retrospective study complied with the teets of the Declaratio of Helsiki ad was approved by the local ethics committee. The eed for iformed coset from all patiets was waived because the study was retrospective. All patiets with colorectal liver metastasis who were treated with either or from Jauary 2010 to Jauary 2016 were icluded i this study. The idicatios for laparoscopic ablatio therapies ( or ) were as follows: a sigle lesio of 5 cm i diameter or 2 to lesios of cm i diameter uresectable because of the high risk of postoperative complicatios, without cirrhosis, ad/or superficial lesios adjacet to abdomial viscera or deeply seeded lesios that were ot ameable to percutaeous approaches. Patiets who uderwet radical hepatic resectio with ablatio therapy were excluded from this study. Preoperative assessmet icluded abdomial ultrasoud (US) ad computed tomography (CT) of the abdome to cofirm the diagosis ad locatio of colorectal liver metastasis. I selected cases wherei CT or US imagig was equivocal, magetic resoace imagig (MRI) of the abdome was utilized. All patiets uderwet IOUS for detectig a ew odule, which was ot discovered by preoperative examiatios. The techiques used for laparoscopic ablatio have bee reported elsewhere [20]. Postoperative morbidity ad mortality were defied as complicatios ad death, respectively, withi 0 days after laparoscopic ablatio. The Clavie Dido classificatio was used to grade complicatios as follows: Grade 1, oral medicatio or bedside medical care required; Grade 2, itraveous medical therapy required; Grade, radiologic, edoscopic, or operative itervetio required; Grade 4, chroic deficit or disability associated with the evet; ad Grade 5, death related to surgical complicatios. Major complicatios were classified as Grades 5, whereas mior complicatios were classified as Grades 1 ad 2 [21-25]. Abdomial US ad CT scas were performed at 1 ad moths after laparoscopic ablatio to evaluate treatmet respose. Subsequetly, the post-treatmet respose was evaluated by CT every 6 moths. Techical success was defied by the tumor lesio beig completely covered by the ablatio zoes at the 1-moth follow-up examiatios usig cotrast-ehaced imagig [26-29]. LTP was defied by the reappearace of tumor foci withi the edge of the ablatio zoe. Patiets who did ot exhibit a complete local respose after the first ablatio sessio immediately uderwet additioal ablatio sessios or chemotherapy. Patiets with itrahepatic or extrahepatic recurrece were treated with appropriate therapies followig the curret guidelies for colorectal liver metastasis [0-6]. OS rate was assessed from the day of RFA till the last follow-up or death due to ay cause. DFS rate was calculated from the day of RFA till the day of cacer recurrece or death due to ay cause. The follow-up period eded i November Statistics Data are preseted as meas ad stadard deviatios for variables that followed ormal distributio. For data followig o-ormal distributio, the results were expressed as medias ad rages. Survival rates were aalyzed usig the Kapla-Meier method ad log-rak test. Uivariate aalyses were performed to idetify progostic variables related to OS ad DFS. Uivariate variables with p values <0.10 were selected for iclusio i a multivariate Cox proportioal hazards regressio model. Adjusted hazard ratios ad the correspodig 95% cofidece itervals were calculated. P < 0.05 was cosidered statistically sigificat. SPSS 1.0 for Microsoft Widows versio (SPSS Ic., Chicago, IL, USA) was used for all statistical aalyses. Results A total of 179 patiets with colorectal liver metastasis treated via the laparoscopic approach were aalyzed (71 uderwet ad 108 ). The baselie characteristics of patiets allocated to or are described i Table 1. A sigificat differece i the maximum diameter of colorectal liver metastatic odules was observed betwee patiets treated with ad those treated with. The coversio rate to ope approach durig the laparoscopic access was 0%, ad o periop- JBUON 2017; 22(): 668

3 Microwave vs radiofrequecy ablatio i liver metastasis 669 Table 1. Compariso of cliical data betwee ad group Data Age (years), media (rage) Sex Male Female CEA pre ablatio (g/ml), media (rage) Primary tumor Colo cacer Rectal cacer (=71) (=108) p value 51 (9-71) 50 (42-72) (-49) 14 (2-9) Origial cacer stage I II ASA score I II Number of lesios 1 2 Maximum tumor size (cm), (rage) (1-5) 2 (1-4) Figure 1. Overall survival of patiets with colorectal liver metastasis udergoig laparoscopic microwave ablatio ad radiofrequecy ablatio (p=0.498). Table 2. Compariso of surgical outcomes ad complicatios betwee ad group Ablatio time (mi), (rage) Blood loss (ml), (rage) Legth of hospital stay (d), (rage) Patiets with complicatios Patiets with major complicatios Patiets with mior complicatios Perihepatic fluid collectio Uriary tract ifectio Pleural effusio (=71) (=108) p value 70 (0-100) 60 (40-110) (20-90) 50 (0-80) (5-19) 9 (4-18) Ascites 2 erative or postoperative 0-day deaths occurred. The overall morbidity rates were 12.7 ad 11.1% i the ad groups, respectively; however, this differece was ot sigificat. The severity of postoperative 0-day complicatios, as per Clavie Dido classificatio, was comparable betwee the two groups (Table 2) Figure 2. Disease-free survival of patiets with colorectal liver metastasis udergoig laparoscopic microwave ablatio ad radiofrequecy ablatio (p=0.557). The media follow-up period of all patiets was 9 moths. Techical success was achieved i 96% (68/71) of patiets treated with ad 95% (108/10) of patiets treated with. LTP rates were 10.2% (11/108) ad 1.4% (1/71) i the ad groups, respectively. A sigificatly higher LTP rate was observed i the group compared with the group (p=0.046). Five-year OS rates were 56 ad 58% ad 5-year DFS rates were 41 ad 9% i the ad groups, respectively (Figures 1 ad 2). The two groups demostrated similar rates JBUON 2017; 22(): 669

4 670 Microwave vs radiofrequecy ablatio i liver metastasis Table. Uivariate aalysis of overall survival Variables Five-year overall p value survival (%) Age, years < Geder Male Female Disease-free iterval, moths > ASA score Primary tumor Colo cacer Rectal cacer Origial cacer stage CEA, g/ml 10 >10 Maximum tumor size, cm 2 >2 Ablatio method Table 5. Uivariate aalysis of disease-free survival Variables Five-year overall p value survival (%) Age, years < Geder Male Female Disease-free iterval, moths > ASA score Primary tumor Colo cacer Rectal cacer Origial cacer stage CEA, g/ml 10 >10 Domiat tumor size, cm 2 >2 Ablatio method of OS (p=0.498) ad DFS (p=0.557). Uivariate ad multivariate aalyses idetified DFS ad origial pathological stage as factors with idepedet effects o OS (Tables ad 4). or did ot ifluece OS. Uivariate ad multivariate aalyses revealed that pathological stage ad CEA levels before ablatio had idepedet effects o DFS. or did ot ifluece DFS (Tables 5 ad 6). Discussio Laparoscopic approaches for thermal ablatio provide access to difficult-to-reach tumors, particularly if the tumors are located udereath the liver capsule or adjacet to the gallbladder or the diaphragm [15-20]. I this study, we compared the efficacy, icidece ad severity of postoperative 0-day complicatios, ad log-term survival outcomes betwee ad procedures. Our results demostrated that both laparoscopic approaches were associated with ear-complete techical success ad low postoperative 0-day complicatios, similar to previously reported results o percutaeous RFA for treatig colorectal liver metastasis [9-11]. No sigificat differeces were foud betwee ablatio groups i terms of recurrece, DFS, ad OS rates. However, our study revealed a lower icidece of LTP i the group tha i the group. With regard to the safety of both ad, the preset study foud o perioperative or postoperative 0-day mortality ad a low icidece of postoperative 0-day complicatio. These values are comparable to the safety profiles foud i previous studies o cliical ablatio [15-20]. Recet studies comparig RFA ad MWA also reported similar data for both techiques, with Table 4. Cox proportioal hazards model for overall survival Variables Hazard ratio (95% CI) p value Disease-free iterval > 24 versus 24 moths ( ) 0.02 Origial cacer stage versus ( ) 0.08 Domiat tumor size 2 cm versus >2 cm ( ) JBUON 2017; 22(): 670

5 Microwave vs radiofrequecy ablatio i liver metastasis 671 Table 6. Cox proportioal hazards model for disease-free survival Variables Hazard ratio (95% CI) p value CEA 10 g/ml versus >10 g/ml ( ) 0.00 Origial cacer stage versus Disease-free iterval > 24 versus 24 moths.098 ( ) 1.69 ( ) Domiat tumor size 2 cm versus >2 cm ( ) low complicatios rates [9-1]. Curret literature cocerig complete ablatio ad LTP rates of versus is cotroversial [7-40]. I our study, a lower icidece of LTP was observed i the group tha i the group. systems create larger margis ad overcome the heat-sik effect, blockig the vessels implicated i LTP. Log-term survival outcomes after for colorectal liver metastasis ca be improved by miimizig the risk of LTP. We foud that LTP was sigificatly higher i the group tha i the group, but both processes had similar OS ad DFS rates. Survival rates may have bee related to our protocol of immediate treatmet with repeat,, or chemotherapy after LTP detectio. Notably, oly 4 patiets had o follow-up treatmet. Our study desig has certai limitatios. The retrospective, ublided ature of our aalysis may have itroduced bias, especially as procedures were performed earlier i the study, whereas procedures were predomiatly performed later i the study. At our istitute, we prefer to use if the colorectal liver metastasis odule diameter is 2 cm ad for smaller odules. This preferece presets a potetial bias that could ifluece OS. However, overall recurreces were ot statistically differet, ad LTP rates i patiets treated with were higher tha those i patiets treated with -treated patiets, despite their smaller odules. As previously described, repeated treatmets received by patiets at recurrece could represet a potetial cofouder for iterpretig survival data. I summary, our study showed that laparoscopic ablatios with or are safe ad effective alteratives for patiets with colorectal liver metastases located i difficult-to-reach locatios. There was o mortality i either group, ad o differece i the postoperative complicatio rates. The LTP rates i patiets treated with were lower tha those i patiets treated with ; however, this fidig had little impact o OS ad DFS, which was similar betwee the two groups. A multiceter, prospective, radomized cotrolled trial i the future is warrated to cofirm these results. Ackowledgemets The authors would like to thak Eago for the Eglish laguage review. Coflict of iterests The authors declare o cofict of iterests. Refereces 1. Adres A, Metha G, Adam R et al. Surgical maagemet of patiets with colorectal cacer ad simultaeous liver ad lug metastases. Br J Surg 2015;102: Noré A, Eriksso HG, Olsso LI. Selectio for surgery ad survival of sychroous colorectal liver metastases; a atiowide study. Eur J Cacer 2016;5: Kuo IM, Huag SF, Chiag JM et al. Cliical features ad progosis i hepatectomy for colorectal cacer with cetrally located liver metastasis. World J Surg Ocol 2015;1: Parau A, Todor N, Vlad L. Determiats of survival after liver resectio for metastatic colorectal carcioma. J BUON 2015;20: Zhag CS, Zhag JL, Li XH et al. Is radiofrequecy ablatio equal to surgical re-resectio for recurret hepatocellular carcioma meetig the Mila criteria? A meta-aalysis. J BUON 2015;20: Zeg Y, Tia M. Laparoscopic versus ope hepatectomy for elderly patiets with liver metastases from colorectal cacer. J BUON 2016;21: Garbajs M, Popovic P. Cotrast-ehaced ultrasoud for assessmet of therapeutic respose after percutaeous radiofrequecy ablatio of small real tumors. J BUON 2016;21: JBUON 2017; 22(): 671

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