高雄長庚 大腸直腸外科 吳昆霖 盧建璋, 陳鴻華, 李克釗, 胡萬祥, 張家駱, 蔡鎧隆, 林岳民, 鄭功全 台灣外科醫學會107年度聯合學術演講會 Prognostic Factors of Radiofrequency Ablation Therapy for Liver Metastases from Colorectal Cancer 高雄長庚 大腸直腸外科 吳昆霖 盧建璋, 陳鴻華, 李克釗, 胡萬祥, 張家駱, 蔡鎧隆, 林岳民, 鄭功全

Introduction Majority of CRC related deaths attributed to metastatic disease. Liver is the most common site of distal metastasis. Surgical resection of liver metastasis from CRC produce long- term survival Only 10~20% P’t are candidate at the time of presentation.

Radiofrequency ablation(RFA) achieve higher complete necrosis of metastatic lesions then other local ablative technique. Promising tool to expand criteria of resectability or treatment strategy for post hepatectomy. Limited data on recurrences and survival after RFA for CRC liver metastasis.

Materials and Methods Single tertiary center, retrospective study, 2008/06~2013/12 colorectal cancer with liver metastasis patient. Exclusion criteria: Tumor with vascular invasion or coagulopathy(Plt<50K/uL or INR>1.5)

All p’t received chemotherapy in pre- or post- RFA stage. Percutaneous or intraOP RFA combine with hepatectomy Primary technical success absence of target tumor contrast enhancement on CT scan 1 month after treatment.

Results 52 p’t (34 Men/ 18 Women) Mean age: 62.5 years. Main tumor median size: 2.5cm Detection of liver metastasis: synchronous: 25; metachronous: 27 Percutaneous: 33; intraOP RFA plus hepatectomy: 19 Median follow-up time: 24 months

No procedure related deaths. Primary technical success: 45/52 (87%) Tumor number: Solitary:14 2-3 tumors: 15 > 3 tumors: 23

  Primary success+ (n=45) Primary success- (n=7) p-value Age (years) 61.9 ± 12.0 67.0 ± 13.3 0.308 Male / Female 28 / 17 6 / 1 0.399 Body mass index (kg/m2) 24.0 ± 3.6 23.6 ± 2.6 0.807 Type 2 diabetes mellitus (%) 15 / 30 3 / 4 0.682 Synchronous / Metachronous 22 / 23 1 CEA >=10 /< 10 ng/ml 21 / 23 4 / 3 0.703 Main RFA tumor >3 /<3 cm 8 / 37 5 / 2 0.008 Tumor number <=3 / >3 1 / 6 0.035 RFA / RFA plus resection 29 / 16 0.697

Local recurrence free survival

New tumor recurrence free survival

Overall survival OS at 1,2,and 3 year after RFA: 87%, 61, and 46%. 9/19(47%) deaths related with liver tumor prograssion

Multivariate analysis   Hazard ratio 95% CI p-value Survival Age < 60 years 2.825 1.032-7.752 0.043 CEA > 10 ng/ml 6.456 1.522-27.39 0.005 Local recurrence-free Primary success 7.489 2.192-25.59 0.001 New recurrence-free Tumor number <=3 3.220 1.462-7.093 0.004

Discussion

In literature, Surgical resection v. s In literature, Surgical resection v.s. RFA in therapeutic success surgical group have better result with 3-y survival 55~82% than 22~53% in RFA. Local recurrent rate of percutaneous and open RFA ranged from 9~42% and 5~14% In our study, the outcomes were not different in RFA alone and intraOP RFA plus resection  suggest our percutaneous RFA still achieve good primary success rate, and as a effective alternative for unresectable liver lesions.

Factors associated with local recurrence were reported as large lesion size, close to large vessels, inadequate treatment margin  our study: primary treatment success Intrahepatic new recurrence after RFA was around 44% in literature. In our study, multinodularity metastasis with total tumor number > 3 could predict higher incidence of new recurrence. high risk of unrecognize “micro-metastasis” at diagnosis

Previous study indicate poor predictors for undergoing resection liver metastasis from CRC Positive margin Extrahepatic disease Primary Nodal positive Disease free interval <12 months >1 hepatic tumors Largest tumor > 5cm CEA > 200ng/mL Ann surg 1999; 230:309-318

In our study, young age (<60 years) (HR 2 In our study, young age (<60 years) (HR 2.82) and high CEA level (>10 ng/ml) (HR 6.456) were independent factors with poor overall survival Relationship of young age and poor survival remains unclear poor tumor biology or delayed diagnosis? some study indicate opposite opinion  further large-scale prospective studies are still mandatory to clarify these issues.

Conclusion Our study shows RFA is an effective and safe treatment modality for colorectal liver metastases. In some patients, combined resection and intraOP RFA can increase the possibility of curative therapy. Young age and high CEA level predict poor outcomes after RFA for colorectal liver metastases.