Case Report
Modified Preoperative Computed TomographicGuided Localization of Colorectal Liver Metastases With Metallic Clips—Technical Note Chiang J. Tyng, Luiz Henrique O. Schiavon, Felipe J.F. Coimbra, Paula N.V. Barbosa, Almir G.V. Bitencourt, Maria Fernanda A. Almeida, Ana Carolina S.A. Schiavon, Alessandro L. Diniz, Marcos D. Guimaraes, Rubens Chojniak Clinical Practice Points Neoadjuvant chemotherapy has been increasingly
used before resection of colorectal liver metastases. However, chemotherapy can lead to the disappearance of small lesions or render them difficult to detect intraoperatively because of changes in their characteristics or modifications to the hepatic parenchyma. Complete resection of all previous sites of metastases is of utmost importance owing to the high rate of local recurrence, even in the scenario of a radiologically complete response. Thus, marking these lesions before the beginning of chemotherapy can facilitate their identification after treatment, enabling proper surgical resection. We have described a modified technique to identify liver metastases that might disappear after
chemotherapy in 3 patients in whom metal clips were used to preoperatively mark metastatic liver lesions using CT guidance. After determining the topography of each lesion and the best access route, metal clips were placed inside each lesion, using the coaxial needle as a positioning tool. During surgery, the metal clips were identified using intraoperative ultrasonography. Metallic clip placement was achieved in all patients, without major complications, and all lesions were easily identified and resected. Preoperative localization with metal clips is a simple, useful, and inexpensive method to avoid difficulties in identifying small liver lesions that can disappear during preoperative chemotherapy.
Clinical Colorectal Cancer, Vol. 14, No. 2, 123-7 ª 2015 Elsevier Inc. All rights reserved. Keywords: Chemotherapy, Computed tomography, Interventional radiology, Liver neoplasms, Surgery
Introduction Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for two thirds of deaths from this disease. The treatment options for this clinical entity include chemotherapy, surgical resection, ablative techniques, and, more recently, a combination of these modalities.1,2 Neoadjuvant chemotherapy has been increasingly used before the resection of metastatic liver lesions. This treatment can convert A. C. Camargo Cancer Center, São Paulo, SP, Brazil Submitted: Oct 4, 2014; Revised: Dec 17, 2014; Accepted: Dec 19, 2014; Epub: Dec 31, 2014 Address for correspondence: Almir G. V. Bitencourt, PhD, A. C. Camargo Cancer Center, R. Prof. Antonio Prudente, 211, São Paulo, SP 09015-010, Brazil E-mail contact: [email protected]
1533-0028/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clcc.2014.12.008
unresectable disease to resectable.3 However, the complete pathologic response rate has been low, even when a complete radiologic response has been achieved. Also, all previous metastatic sites require resection owing to the high rate of local recurrence.4 Surgical resection of lesions that have not been adequately characterized on imaging examinations after chemotherapy can lead to inadequate treatment, with under- or overestimation of the amount of parenchymal resection required. Chemotherapy can lead to the disappearance of small lesions or render them difficult to detect intraoperatively because of changes in their characteristics or in the hepatic parenchyma.5 Thus, marking these lesions before the beginning of chemotherapy could facilitate their identification after treatment, enabling proper surgical resection and ensuring complete disease removal.6
Clinical Colorectal Cancer June 2015
- 123
Preoperative CT-Guided Localization of Liver Metastasis The present report describes 3 patients with colorectal adenocarcinoma in whom metal clips were used to preoperatively mark the metastatic liver lesions under computed tomographic (CT) guidance before the beginning of chemotherapy.
the metal clips were identified using intraoperative ultrasonography. An 18-gauge core needle biopsy was performed before placement of the clips, and the pathologic findings confirmed metastatic colorectal adenocarcinoma in all patients.
Materials and Methods
Results
All 3 patients were selected after discussion at the multidisciplinary meeting, which included oncologists, surgeons, radiologists, and interventional radiologists. After evaluating the previous imaging studies, nonenhanced CT was performed to plan the clip placement. Patient positioning varied according to the best access for each lesion. When the lesion was not visible on the nonenhanced images, we used intravenous nonionic iodinated contrast to achieve better characterization of the lesions. The procedures were performed with the patient under conscious sedation and local anesthesia (2% lidocaine without vasoconstrictor). The patients freely signed an informed consent form before the procedure. After determining the topography of each lesion and the best access route, we introduced a 17-gauge coaxial needle in its center under CT guidance. Two manually straightened Mckenzie-Diener silver clips (Christian Diener GmbH & Co. KG, Tuttlingen, Germany) were placed inside each lesion, using the coaxial needle as a positioning tool. Next, the coaxial needle was withdrawn, and we performed a CT follow-up study to confirm the clips’ locations and identify the occurrence of any complication, such as hemorrhage or pneumothorax. Another CT examination was performed after the cessation of chemotherapy to evaluate the therapeutic response, confirm the location of the clips, and plan the surgery. At surgery,
A 60-year-old man presented with a history of colorectal adenocarcinoma and liver metastases during follow-up at our institution. Positron emission tomography-CT showed 2 metabolically active liver lesions in segments VIII (subcapsular, larger diameter of 40 mm) and IV (deep, larger diameter of 16 mm). After discussing the case at a multidisciplinary meeting, it was decided to perform systemic treatment and posterior resection of the liver lesions. Because of the dimension and depth of the lesion in segment IV, we placed metal clips inside this nodule under CT guidance to facilitate its location during surgery (Figure 1A, 1B). No complications related to this procedure occurred. The patient then underwent chemotherapy. The CT examination performed 4 months later, after cessation of chemotherapy, showed that the size of the previously marked lesion had been reduced, indicating a partial radiologic response according to the Response Evaluation Criteria in Solid Tumors (RECIST). The patient underwent surgery, in which the subcapsular lesion in segment VIII was enucleated and the deep lesion in segment IV was resected after identification of the metal clips using intraoperative ultrasonography (Figure 1C, 1D). The specimens were sent for histologic analysis, which showed tubular adenocarcinoma
Patient 1
Figure 1 Use of Metal Clips to Mark a Liver Nodule in Segment IV Using Computed Tomographic (CT) Guidance. (A) Coaxial Needle Positioning and Insertion of Metal Clips Inside the Lesion. (B) CT Performed After Chemotherapy, Showing the Location of the Metal Clips for Surgical Planning. (C) Intraoperative Ultrasound Scan Showing a Poorly Defined Hypoechogenic Lesion With Metal Clips Inside. (D) Surgical Sample Showing a Metal Clip Inside the Liver Nodule
124
-
Clinical Colorectal Cancer June 2015
Chiang J. Tyng et al metastasis, with viable tumor cells in 80% of the sample and the surgical margins clear of neoplasm.
mucin pools and the absence of residual neoplasm, compatible with a complete pathologic response.
Patient 2
Patient 3
A 70-year-old man presented with a diagnosis of colorectal adenocarcinoma, which had been treated surgically at another institution. The staging CT scan showed a liver nodule measuring nearly 15 mm in its larger diameter, suspicious of metastasis, in segment VIII (Figure 2A). After discussing the case at a multidisciplinary meeting, it was decided to perform chemotherapy before resecting the liver nodule. Because of the lesion’s dimensions, metal clips were placed in the nodule under CT guidance before chemotherapy was started (Figure 2B). CT examination performed shortly after the procedure showed a small pneumothorax; however, subsequent follow-up examinations showed no evolution of this condition, and specific treatment was not needed. No major complications occurred. The patient received systemic treatment. A CT examination performed 3 months later, after cessation of chemotherapy, showed no evidence of the nodule in the area marked by the clips (Figure 2C), indicating a complete radiologic response according to the RECIST. The patient then underwent surgery. After identifying the metal clip using intraoperative ultrasonography, the area in segment VIII was resected (Figure 2D). The surgical specimen was sent for histologic analysis, which showed the presence of acellular
A 72-year-old man with metastatic rectal carcinoma presented with liver lesions suggestive of metastasis on the staging examinations. The larger lesion was located in segment II and III and measured 46 mm. However, smaller lesions were seen in segments IV and VI, measuring 12 mm. After the multidisciplinary meeting, the patient was scheduled to undergo chemotherapy before resection of the lesions. Owing to the small size of some of the nodules, CT-guided clip marking was performed before the start of chemotherapy (Figure 3). After placement of each metal clip, a gelatin sponge (GelFoam, Pfizer, New York, NY) was introduced with iodinated contrast in the needle path to aid local hemostasis. No procedure-related complications occurred. After 3 months of systemic treatment, the patient underwent surgical treatment of the liver lesions with left lateral segmentectomy and resection of all segment VI. At surgery, after identification of the metal clip in segment IV using intraoperative ultrasonography, radiofrequency ablation was performed on the previously marked nodule. Pathologic examination of the specimen after resection of segment VI showed a metallic clip within the fully necrotic nodule corresponding to the area of previous cancer with a complete response to treatment.
Figure 2 Use of Metal Clips to Mark a Liver Nodule in Segment VIII Using Computed Tomographic (CT) Guidance. (A) ContrastEnhanced CT Image Obtained Before Clip Placement Showing a Hypovascular Nodule in Segment VIII (Arrow). (B) Coaxial Needle Positioning and Insertion of Metal Clips Inside the Lesion. (C) CT Scan Performed After Chemotherapy Showing the Location of the Metal Clips for Surgical Planning. (D) Postoperative Follow-Up CT Image Showing Proper Resection of the Lesion
Clinical Colorectal Cancer June 2015
- 125
Preoperative CT-Guided Localization of Liver Metastasis Figure 3 Use of Metal Clips to Mark a Liver Nodules in Segments IV and VI Using Computed Tomographic (CT) Guidance. (A) Coaxial Needle Positioned and Metal Clips Inserted Into the Lesion in Segment VI. (B) Metal Clips Inserted Into the Lesion and Gelatin Sponge With Iodinated Contrast in the Needle Path. (C) Coaxial Needle Positioned and Metal Clips Inserted Into the Lesion in Segment IV. (D) Metal Clips Inserted Into the Lesion and Gelatin Sponge With Iodinated Contrast in the Needle Path
Discussion
126
-
The intraoperative location of liver metastases after chemotherapy can be challenging, increasing the operative time, morbidity, and risk of leaving behind active disease. Chemotherapy can change the imaging appearance of the metastatic liver lesions, with some evolving to necrosis and presenting as hyperechogenic or with cystic components and others showing a complete radiologic response.5 Chemotherapy can also change the hepatic parenchyma, potentially leading to steatosis, steatohepatitis, or sinusoidal dilation, with consequent changes in the radiologic characteristics, making the detection of small lesions difficult.7 No consensus has yet been reached for which liver lesions should be considered for preoperative localization, and each case must be assessed individually. In our institution, the clip marking technique is indicated for selected patients with small colorectal liver metastases, usually < 2 cm, who will receive systemic treatment before surgery. The clip marking technique is especially indicated in the setting of multiple and bilobar hepatic lesions, those not amenable to primary resection, with some lesions expected to shrink but other small ones to disappear, leading to the risk of incomplete oncologic resection in the near future surgical procedure. Another specific indication is a deep small lesion that is expected to be difficult to find using conventional intraoperative ultrasonography that requires extensive loss of normal parenchyma and will result in an insufficient remnant liver at volumetry. In these cases, preoperative localization can lead to single-stage parenchyma-sparing surgery without the need to use liver hypertrophy techniques, such as portal vein embolization or 2-stage surgery. In contrast, large and subcapsular nodules will be more easily identified during surgery, even after chemotherapy, and thus do not need to be marked. Additionally,
Clinical Colorectal Cancer June 2015
multiple or large lesions included in the initial surgical liver tissue to be resected will not need to be marked. Some investigators have described the use of microcoils to preoperatively mark metastatic liver lesions.8-10 The advantages of microcoils include the ability to use small-caliber (18-22 gauge) coaxial needles and a theoretically lower risk of their dislocation in the hepatic parenchyma. However, these devices are expensive and not readily available in many centers around the world. The main purpose of preoperative marking with metal clips is to facilitate intraoperative lesion identification in an easy, inexpensive, and safe manner. This technique does not interfere with frozen section analysis or histologic examination, and it has been used successfully to preoperatively mark pulmonary ground-glass opacities.11 One potential disadvantage of the metal clips is streak artifacts, which can impair the evaluation of the residual lesion in those cases with a good therapeutic response. However, in the present cases, the patients were scheduled to undergo surgery regardless of a complete or partial treatment response found on the imaging studies. Another theoretical risk is the dislocation of the clip from the lesion site, which is unlikely, because the liver is a solid organ. The potential complications associated with this procedure are the same as those for other percutaneous liver interventions, such as biopsy, drainage, and ablation, and include pain, bleeding, and infection.12 Although no complications were observed in our cases, larger samples should be evaluated to better assess these risks.
Conclusion Preoperative localization could be important in the management of liver metastasis in patients who will receive chemotherapy before surgery to avoid disappearing metastatic sites and to facilitate parenchymal-sparing resection. Our initial experience has shown
Chiang J. Tyng et al that this technique is safe, easy, and precise, although additional studies focusing on its effectiveness and possible side effects are needed.
References 1. Coimbra FJ, Pires TC, Costa Junior WL, Diniz AL, Ribeiro HS. Advances in surgical treatment of colorectal liver metastases. Rev Assoc Med Bras 2011; 57: 220-7. 2. Ribeiro HS, Stevanato-Filho PR, Costa WL Jr, Diniz AL, Herman P, Coimbra FJ. Prognostic factors for survival in patients with colorectal liver metastases: experience of a single Brazilian cancer center. Arq Gastroenterol 2012; 49:266-72. 3. Adam R, Wicherts DA, De Haas RJ, et al. Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J Clin Oncol 2009; 27: 1829-35. 4. Adam R, Wicherts DA, De Haas RJ, et al. Complete pathologic response after preoperative chemotherapy for colorectal liver metastases: myth or reality? J Clin Oncol 2008; 26:1635-41. 5. Robinson PJA. The effects of cancer chemotherapy on liver imaging. Eur Radiol 2009; 19:1752-62.
6. Baron LF, Baron PL, Ackerman SJ, Durden DD, Pope TL. Sonographically guided clip placement facilitates localization of breast cancer after neoadjuvant chemotherapy. AJR Am J Roentgenol 2000; 174:539-40. 7. Zorzi D, Laurent A, Pawlik TM, Lauwers GY, Vauthey JN, Abdalla EK. Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases. Br J Surg 2007; 94:274-86. 8. Alonso Casado O, González Moreno S, Encinas García S, Rojo Sebastián A, Olavarría Delgado A. Hepatic metastasis marking before neoadjuvant chemotherapy for their subsequent location and resection using non-anatomical hepatectomy. Cir Esp 2013; 91:687-9. 9. Zalinski S, Abdalla EK, Mahvash A, Vauthey J-N. A marking technique for intraoperative localization of small liver metastases before systemic chemotherapy. Ann Surg Oncol 2009; 16:1208-11. 10. Kornprat P, Schöllnast H, Cerwenka H, Werkgartner G, Bernhardt G, Mischinger HJ. Management of colorectal liver metastases after complete response to neoadjuvant chemotherapy: a case of computer tomography-guided wire marking of the liver tumor. Int J Colorectal Dis 2009; 24:125-6. 11. Tyng CJ, Baranauskas MVB, Bitencourt AGV, et al. Preoperative computed tomography-guided localization of ground-glass opacities with metallic clip. Ann Thorac Surg 2013; 96:1087-9. 12. Shankar S, van Sonnenberg E, Silverman SG, Tuncali K. Interventional radiology procedures in the liver: biopsy, drainage, and ablation. Clin Liver Dis 2002; 6: 91-118.
Clinical Colorectal Cancer June 2015
- 127
Modified Preoperative Computed TomographicGuided Localization of Colorectal Liver Metastases With Metallic Clips—Technical Note Chiang J. Tyng, Luiz Henrique O. Schiavon, Felipe J.F. Coimbra, Paula N.V. Barbosa, Almir G.V. Bitencourt, Maria Fernanda A. Almeida, Ana Carolina S.A. Schiavon, Alessandro L. Diniz, Marcos D. Guimaraes, Rubens Chojniak Clinical Practice Points Neoadjuvant chemotherapy has been increasingly
used before resection of colorectal liver metastases. However, chemotherapy can lead to the disappearance of small lesions or render them difficult to detect intraoperatively because of changes in their characteristics or modifications to the hepatic parenchyma. Complete resection of all previous sites of metastases is of utmost importance owing to the high rate of local recurrence, even in the scenario of a radiologically complete response. Thus, marking these lesions before the beginning of chemotherapy can facilitate their identification after treatment, enabling proper surgical resection. We have described a modified technique to identify liver metastases that might disappear after
chemotherapy in 3 patients in whom metal clips were used to preoperatively mark metastatic liver lesions using CT guidance. After determining the topography of each lesion and the best access route, metal clips were placed inside each lesion, using the coaxial needle as a positioning tool. During surgery, the metal clips were identified using intraoperative ultrasonography. Metallic clip placement was achieved in all patients, without major complications, and all lesions were easily identified and resected. Preoperative localization with metal clips is a simple, useful, and inexpensive method to avoid difficulties in identifying small liver lesions that can disappear during preoperative chemotherapy.
Clinical Colorectal Cancer, Vol. 14, No. 2, 123-7 ª 2015 Elsevier Inc. All rights reserved. Keywords: Chemotherapy, Computed tomography, Interventional radiology, Liver neoplasms, Surgery
Introduction Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for two thirds of deaths from this disease. The treatment options for this clinical entity include chemotherapy, surgical resection, ablative techniques, and, more recently, a combination of these modalities.1,2 Neoadjuvant chemotherapy has been increasingly used before the resection of metastatic liver lesions. This treatment can convert A. C. Camargo Cancer Center, São Paulo, SP, Brazil Submitted: Oct 4, 2014; Revised: Dec 17, 2014; Accepted: Dec 19, 2014; Epub: Dec 31, 2014 Address for correspondence: Almir G. V. Bitencourt, PhD, A. C. Camargo Cancer Center, R. Prof. Antonio Prudente, 211, São Paulo, SP 09015-010, Brazil E-mail contact: [email protected]
1533-0028/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clcc.2014.12.008
unresectable disease to resectable.3 However, the complete pathologic response rate has been low, even when a complete radiologic response has been achieved. Also, all previous metastatic sites require resection owing to the high rate of local recurrence.4 Surgical resection of lesions that have not been adequately characterized on imaging examinations after chemotherapy can lead to inadequate treatment, with under- or overestimation of the amount of parenchymal resection required. Chemotherapy can lead to the disappearance of small lesions or render them difficult to detect intraoperatively because of changes in their characteristics or in the hepatic parenchyma.5 Thus, marking these lesions before the beginning of chemotherapy could facilitate their identification after treatment, enabling proper surgical resection and ensuring complete disease removal.6
Clinical Colorectal Cancer June 2015
- 123
Preoperative CT-Guided Localization of Liver Metastasis The present report describes 3 patients with colorectal adenocarcinoma in whom metal clips were used to preoperatively mark the metastatic liver lesions under computed tomographic (CT) guidance before the beginning of chemotherapy.
the metal clips were identified using intraoperative ultrasonography. An 18-gauge core needle biopsy was performed before placement of the clips, and the pathologic findings confirmed metastatic colorectal adenocarcinoma in all patients.
Materials and Methods
Results
All 3 patients were selected after discussion at the multidisciplinary meeting, which included oncologists, surgeons, radiologists, and interventional radiologists. After evaluating the previous imaging studies, nonenhanced CT was performed to plan the clip placement. Patient positioning varied according to the best access for each lesion. When the lesion was not visible on the nonenhanced images, we used intravenous nonionic iodinated contrast to achieve better characterization of the lesions. The procedures were performed with the patient under conscious sedation and local anesthesia (2% lidocaine without vasoconstrictor). The patients freely signed an informed consent form before the procedure. After determining the topography of each lesion and the best access route, we introduced a 17-gauge coaxial needle in its center under CT guidance. Two manually straightened Mckenzie-Diener silver clips (Christian Diener GmbH & Co. KG, Tuttlingen, Germany) were placed inside each lesion, using the coaxial needle as a positioning tool. Next, the coaxial needle was withdrawn, and we performed a CT follow-up study to confirm the clips’ locations and identify the occurrence of any complication, such as hemorrhage or pneumothorax. Another CT examination was performed after the cessation of chemotherapy to evaluate the therapeutic response, confirm the location of the clips, and plan the surgery. At surgery,
A 60-year-old man presented with a history of colorectal adenocarcinoma and liver metastases during follow-up at our institution. Positron emission tomography-CT showed 2 metabolically active liver lesions in segments VIII (subcapsular, larger diameter of 40 mm) and IV (deep, larger diameter of 16 mm). After discussing the case at a multidisciplinary meeting, it was decided to perform systemic treatment and posterior resection of the liver lesions. Because of the dimension and depth of the lesion in segment IV, we placed metal clips inside this nodule under CT guidance to facilitate its location during surgery (Figure 1A, 1B). No complications related to this procedure occurred. The patient then underwent chemotherapy. The CT examination performed 4 months later, after cessation of chemotherapy, showed that the size of the previously marked lesion had been reduced, indicating a partial radiologic response according to the Response Evaluation Criteria in Solid Tumors (RECIST). The patient underwent surgery, in which the subcapsular lesion in segment VIII was enucleated and the deep lesion in segment IV was resected after identification of the metal clips using intraoperative ultrasonography (Figure 1C, 1D). The specimens were sent for histologic analysis, which showed tubular adenocarcinoma
Patient 1
Figure 1 Use of Metal Clips to Mark a Liver Nodule in Segment IV Using Computed Tomographic (CT) Guidance. (A) Coaxial Needle Positioning and Insertion of Metal Clips Inside the Lesion. (B) CT Performed After Chemotherapy, Showing the Location of the Metal Clips for Surgical Planning. (C) Intraoperative Ultrasound Scan Showing a Poorly Defined Hypoechogenic Lesion With Metal Clips Inside. (D) Surgical Sample Showing a Metal Clip Inside the Liver Nodule
124
-
Clinical Colorectal Cancer June 2015
Chiang J. Tyng et al metastasis, with viable tumor cells in 80% of the sample and the surgical margins clear of neoplasm.
mucin pools and the absence of residual neoplasm, compatible with a complete pathologic response.
Patient 2
Patient 3
A 70-year-old man presented with a diagnosis of colorectal adenocarcinoma, which had been treated surgically at another institution. The staging CT scan showed a liver nodule measuring nearly 15 mm in its larger diameter, suspicious of metastasis, in segment VIII (Figure 2A). After discussing the case at a multidisciplinary meeting, it was decided to perform chemotherapy before resecting the liver nodule. Because of the lesion’s dimensions, metal clips were placed in the nodule under CT guidance before chemotherapy was started (Figure 2B). CT examination performed shortly after the procedure showed a small pneumothorax; however, subsequent follow-up examinations showed no evolution of this condition, and specific treatment was not needed. No major complications occurred. The patient received systemic treatment. A CT examination performed 3 months later, after cessation of chemotherapy, showed no evidence of the nodule in the area marked by the clips (Figure 2C), indicating a complete radiologic response according to the RECIST. The patient then underwent surgery. After identifying the metal clip using intraoperative ultrasonography, the area in segment VIII was resected (Figure 2D). The surgical specimen was sent for histologic analysis, which showed the presence of acellular
A 72-year-old man with metastatic rectal carcinoma presented with liver lesions suggestive of metastasis on the staging examinations. The larger lesion was located in segment II and III and measured 46 mm. However, smaller lesions were seen in segments IV and VI, measuring 12 mm. After the multidisciplinary meeting, the patient was scheduled to undergo chemotherapy before resection of the lesions. Owing to the small size of some of the nodules, CT-guided clip marking was performed before the start of chemotherapy (Figure 3). After placement of each metal clip, a gelatin sponge (GelFoam, Pfizer, New York, NY) was introduced with iodinated contrast in the needle path to aid local hemostasis. No procedure-related complications occurred. After 3 months of systemic treatment, the patient underwent surgical treatment of the liver lesions with left lateral segmentectomy and resection of all segment VI. At surgery, after identification of the metal clip in segment IV using intraoperative ultrasonography, radiofrequency ablation was performed on the previously marked nodule. Pathologic examination of the specimen after resection of segment VI showed a metallic clip within the fully necrotic nodule corresponding to the area of previous cancer with a complete response to treatment.
Figure 2 Use of Metal Clips to Mark a Liver Nodule in Segment VIII Using Computed Tomographic (CT) Guidance. (A) ContrastEnhanced CT Image Obtained Before Clip Placement Showing a Hypovascular Nodule in Segment VIII (Arrow). (B) Coaxial Needle Positioning and Insertion of Metal Clips Inside the Lesion. (C) CT Scan Performed After Chemotherapy Showing the Location of the Metal Clips for Surgical Planning. (D) Postoperative Follow-Up CT Image Showing Proper Resection of the Lesion
Clinical Colorectal Cancer June 2015
- 125
Preoperative CT-Guided Localization of Liver Metastasis Figure 3 Use of Metal Clips to Mark a Liver Nodules in Segments IV and VI Using Computed Tomographic (CT) Guidance. (A) Coaxial Needle Positioned and Metal Clips Inserted Into the Lesion in Segment VI. (B) Metal Clips Inserted Into the Lesion and Gelatin Sponge With Iodinated Contrast in the Needle Path. (C) Coaxial Needle Positioned and Metal Clips Inserted Into the Lesion in Segment IV. (D) Metal Clips Inserted Into the Lesion and Gelatin Sponge With Iodinated Contrast in the Needle Path
Discussion
126
-
The intraoperative location of liver metastases after chemotherapy can be challenging, increasing the operative time, morbidity, and risk of leaving behind active disease. Chemotherapy can change the imaging appearance of the metastatic liver lesions, with some evolving to necrosis and presenting as hyperechogenic or with cystic components and others showing a complete radiologic response.5 Chemotherapy can also change the hepatic parenchyma, potentially leading to steatosis, steatohepatitis, or sinusoidal dilation, with consequent changes in the radiologic characteristics, making the detection of small lesions difficult.7 No consensus has yet been reached for which liver lesions should be considered for preoperative localization, and each case must be assessed individually. In our institution, the clip marking technique is indicated for selected patients with small colorectal liver metastases, usually < 2 cm, who will receive systemic treatment before surgery. The clip marking technique is especially indicated in the setting of multiple and bilobar hepatic lesions, those not amenable to primary resection, with some lesions expected to shrink but other small ones to disappear, leading to the risk of incomplete oncologic resection in the near future surgical procedure. Another specific indication is a deep small lesion that is expected to be difficult to find using conventional intraoperative ultrasonography that requires extensive loss of normal parenchyma and will result in an insufficient remnant liver at volumetry. In these cases, preoperative localization can lead to single-stage parenchyma-sparing surgery without the need to use liver hypertrophy techniques, such as portal vein embolization or 2-stage surgery. In contrast, large and subcapsular nodules will be more easily identified during surgery, even after chemotherapy, and thus do not need to be marked. Additionally,
Clinical Colorectal Cancer June 2015
multiple or large lesions included in the initial surgical liver tissue to be resected will not need to be marked. Some investigators have described the use of microcoils to preoperatively mark metastatic liver lesions.8-10 The advantages of microcoils include the ability to use small-caliber (18-22 gauge) coaxial needles and a theoretically lower risk of their dislocation in the hepatic parenchyma. However, these devices are expensive and not readily available in many centers around the world. The main purpose of preoperative marking with metal clips is to facilitate intraoperative lesion identification in an easy, inexpensive, and safe manner. This technique does not interfere with frozen section analysis or histologic examination, and it has been used successfully to preoperatively mark pulmonary ground-glass opacities.11 One potential disadvantage of the metal clips is streak artifacts, which can impair the evaluation of the residual lesion in those cases with a good therapeutic response. However, in the present cases, the patients were scheduled to undergo surgery regardless of a complete or partial treatment response found on the imaging studies. Another theoretical risk is the dislocation of the clip from the lesion site, which is unlikely, because the liver is a solid organ. The potential complications associated with this procedure are the same as those for other percutaneous liver interventions, such as biopsy, drainage, and ablation, and include pain, bleeding, and infection.12 Although no complications were observed in our cases, larger samples should be evaluated to better assess these risks.
Conclusion Preoperative localization could be important in the management of liver metastasis in patients who will receive chemotherapy before surgery to avoid disappearing metastatic sites and to facilitate parenchymal-sparing resection. Our initial experience has shown
Chiang J. Tyng et al that this technique is safe, easy, and precise, although additional studies focusing on its effectiveness and possible side effects are needed.
References 1. Coimbra FJ, Pires TC, Costa Junior WL, Diniz AL, Ribeiro HS. Advances in surgical treatment of colorectal liver metastases. Rev Assoc Med Bras 2011; 57: 220-7. 2. Ribeiro HS, Stevanato-Filho PR, Costa WL Jr, Diniz AL, Herman P, Coimbra FJ. Prognostic factors for survival in patients with colorectal liver metastases: experience of a single Brazilian cancer center. Arq Gastroenterol 2012; 49:266-72. 3. Adam R, Wicherts DA, De Haas RJ, et al. Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J Clin Oncol 2009; 27: 1829-35. 4. Adam R, Wicherts DA, De Haas RJ, et al. Complete pathologic response after preoperative chemotherapy for colorectal liver metastases: myth or reality? J Clin Oncol 2008; 26:1635-41. 5. Robinson PJA. The effects of cancer chemotherapy on liver imaging. Eur Radiol 2009; 19:1752-62.
6. Baron LF, Baron PL, Ackerman SJ, Durden DD, Pope TL. Sonographically guided clip placement facilitates localization of breast cancer after neoadjuvant chemotherapy. AJR Am J Roentgenol 2000; 174:539-40. 7. Zorzi D, Laurent A, Pawlik TM, Lauwers GY, Vauthey JN, Abdalla EK. Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases. Br J Surg 2007; 94:274-86. 8. Alonso Casado O, González Moreno S, Encinas García S, Rojo Sebastián A, Olavarría Delgado A. Hepatic metastasis marking before neoadjuvant chemotherapy for their subsequent location and resection using non-anatomical hepatectomy. Cir Esp 2013; 91:687-9. 9. Zalinski S, Abdalla EK, Mahvash A, Vauthey J-N. A marking technique for intraoperative localization of small liver metastases before systemic chemotherapy. Ann Surg Oncol 2009; 16:1208-11. 10. Kornprat P, Schöllnast H, Cerwenka H, Werkgartner G, Bernhardt G, Mischinger HJ. Management of colorectal liver metastases after complete response to neoadjuvant chemotherapy: a case of computer tomography-guided wire marking of the liver tumor. Int J Colorectal Dis 2009; 24:125-6. 11. Tyng CJ, Baranauskas MVB, Bitencourt AGV, et al. Preoperative computed tomography-guided localization of ground-glass opacities with metallic clip. Ann Thorac Surg 2013; 96:1087-9. 12. Shankar S, van Sonnenberg E, Silverman SG, Tuncali K. Interventional radiology procedures in the liver: biopsy, drainage, and ablation. Clin Liver Dis 2002; 6: 91-118.
Clinical Colorectal Cancer June 2015
- 127
