Abstract
Background
With improved preoperative cross-sectional imaging, the added clinical value of intraoperative ultrasonography (IOUS) in the detection of colorectal liver metastases (CRLM) is unclear. Specifically, the ability of IOUS to detect additional liver metastases during surgery and its relationship between clinical and lesion specific ultrasonographic characteristics remains ill-defined. The purpose of the current study was to determine the association of clinical parameters and tumor echogenicity with the ability of IOUS to detect occult CRLM.
Materials and Methods
A total of 213 patients undergoing surgical exploration and IOUS for CRLM between 1998 and 2009 were included in the study. All patients underwent preoperative multidetector computed tomography (CT) imaging and lesion detection was compared with those identified by IOUS. In addition, early (<6 months) intrahepatic recurrence was used as a surrogate for residual disease (e.g., metastases that were undetected on initial IOUS). The influence of various characteristics on the rate in which additional metastases were detected and the rate of early intrahepatic recurrence was examined.
Results
Overall, IOUS detected additional liver metastases in 10% of patients (n = 22). Detection of additional metastases was significantly higher in patients with multiple (≥4) tumors (P < 0.001) and hypoechoic tumors (P = 0.007). Of 153 patients undergoing resection only, 17 (11%) had an early intrahepatic recurrence. This was more common in patients with isoechoic metastases during IOUS (P = 0.03).
Conclusions
Even with the use of modern cross-sectional preoperative imaging, IOUS detects additional liver metastases in 10% of patients. In addition, the sensitivity of IOUS for detecting occult CRLM is highly dependent on the number and echogenicity of detected tumors.
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References
Scheele J, Stangl R, Altendorf-Hofmann A. Hepatic metastases from colorectal carcinoma: impact of surgical resection on the natural history. Br J Surg. 1990;77:1241–6.
Choti MA, Sitzmann JV, Tiburi MF, Sumetchotimetha W, Rangsin R, Schulick RD, et al. Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg. 2002;235:759–66.
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg. 1999;230:309–18; discussion 318–21.
Rees M, Tekkis PP, Welsh FK, O’Rourke T, John TG. Evaluation of long-term survival after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929 patients. Ann Surg. 2008;247:125–35.
Rifkin MD, Rosato FE, Branch HM, Foster J, Yang SL, Barbot DJ, et al. Intraoperative ultrasound of the liver. An important adjunctive tool for decision making in the operating room. Ann Surg. 1987;205:466–72.
Machi J, Isomoto H, Yamashita Y, Kurohiji T, Shirouzu K, Kakegawa T. Intraoperative ultrasonography in screening for liver metastases from colorectal cancer: comparative accuracy with traditional procedures. Surgery. 1987;101:678–84.
Clarke MP, Kane RA, Steele G, Jr., Hamilton ES, Ravikumar TS, Onik G, et al. Prospective comparison of preoperative imaging and intraoperative ultrasonography in the detection of liver tumors. Surgery. 1989;106:849–55.
Rydzewski B, Dehdashti F, Gordon BA, Teefey SA, Strasberg SM, Siegel BA. Usefulness of intraoperative sonography for revealing hepatic metastases from colorectal cancer in patients selected for surgery after undergoing FDG PET. AJR Am J Roentgenol. 2002;178:353–8.
Tamandl D, Herberger B, Gruenberger B, Schoppmann SF, Puhalla H, Schindl M, et al. Adequate preoperative staging rarely leads to a change of intraoperative strategy in patients undergoing surgery for colorectal cancer liver metastases. Surgery. 2008;143:648–57.
Choti MA, Kaloma F, de Oliveira ML, Nour S, Garrett-Mayer ES, Sheth S, Pawlik TM. Patient variability in intraoperative ultrasonographic characteristics of colorectal liver metastases. Arch Surg. 2008;143:29–34;discussion 35.
Leen E, Angerson WJ, O’Gorman P, Cooke TG, McArdle CS. Intraoperative ultrasound in colorectal cancer patients undergoing apparently curative surgery: correlation with two year follow-up. Clin Radiol. 1996;51:157–9.
Nomura K, Kadoya M, Ueda K, Fujinaga Y, Miwa S, Miyagawa S. Detection of hepatic metastases from colorectal carcinoma: comparison of histopathologic features of anatomically resected liver with results of preoperative imaging. J Clin Gastroenterol. 2007;41:789–95.
Joyce DL, Wahl RL, Patel PV, Schulick RD, Gearhart SL, Choti MA. Preoperative positron emission tomography to evaluate potentially resectable hepatic colorectal metastases. Arch Surg. 2006;141:1220–6; discussion 1227.
Conlon R, Jacobs M, Dasgupta D, Lodge JP. The value of intraoperative ultrasound during hepatic resection compared with improved preoperative magnetic resonance imaging. Eur J Ultrasound. 2003;16:211–6.
Wildi SM, Gubler C, Hany T, Petrowsky H, Clavien PA, Jochum W, et al. Intraoperative sonography in patients with colorectal cancer and resectable liver metastases on preoperative FDG-PET-CT. J Clin Ultrasound. 2008;36:20–6.
Mazzoni G, Napoli A, Mandetta S, Miccini M, Cassini D, Gregori M, et al. Intra-operative ultrasound for detection of liver metastases from colorectal cancer. Liver Int. 2008;28:88–94.
Donadon M, Botea F, Del Fabbro D, Palmisano A, Montorsi M, Torzilli G. The surgical policy predicts the impact of contrast enhanced intraoperative ultrasound for colorectal liver metastases. Eur J Radiol. 2008;67:177–8.
Adam R, Delvart V, Pascal G, Valeanu A, Castaing D, Azoulay D, et al. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg. 2004; 240:644–57;discussion 657–8.
Folprecht G, Grothey A, Alberts S, Raab HR, Kohne CH. Neoadjuvant treatment of unresectable colorectal liver metastases: correlation between tumour response and resection rates. Ann Oncol. 2005;16:1311–9.
Leonard GD, Brenner B, Kemeny NE. Neoadjuvant chemotherapy before liver resection for patients with unresectable liver metastases from colorectal carcinoma. J Clin Oncol. 2005;23:2038–48.
Nuzzo G, Giuliante F, Ardito F, Vellone M, Pozzo C, Cassano A, et al. Liver resection for primarily unresectable colorectal metastases downsized by chemotherapy. J Gastrointest Surg. 2007;11:318–24.
Rubbia-Brandt L, Giostra E, Brezault C, Roth AD, Andres A, Audard V, et al. Importance of histological tumor response assessment in predicting the outcome in patients with colorectal liver metastases treated with neo-adjuvant chemotherapy followed by liver surgery. Ann Oncol. 2007;18:299–304.
Nordlinger B, Sorbye H, Glimelius B, Poston GJ, Schlag PM, Rougier P, et al. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet. 2008; 371:1007–16.
Auer RC, White RR, Kemeny NE, Schwartz LH, Shia J, Blumgart LH, et al. Predictors of a true complete response among disappearing liver metastases from colorectal cancer after chemotherapy. Cancer. 2010;116:1502–9.
Tanaka K, Takakura H, Takeda K, Matsuo K, Nagano Y, Endo I. Importance of complete pathologic response to prehepatectomy chemotherapy in treating colorectal cancer metastases. Ann Surg. 2009;250:935–42.
Benoist S, Brouquet A, Penna C, Julie C, El Hajjam M, Chagnon S, et al. Complete response of colorectal liver metastases after chemotherapy: does it mean cure? J Clin Oncol. 2006;24:3939–45.
Pawlik TM, Olino K, Gleisner AL, Torbenson M, Schulick R, Choti MA. Preoperative chemotherapy for colorectal liver metastases: impact on hepatic histology and postoperative outcome. J Gastrointest Surg. 2007;11:860–8.
Vauthey JN, Pawlik TM, Ribero D, Wu TT, Zorzi D, Hoff PM, et al. Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol. 2006;24:2065–72.
Robinson PJ. The effects of cancer chemotherapy on liver imaging. Eur Radiol. 2009;19:1752–62.
VanVledder MG, Torbenson MS, Pawlik TM, Boctor EM, Hamper UM, Olino K, et al. The impact of hepatic steatosis on echogenicity of hepatic colorectal metastases on intraoperative ultrasonography. Arch Surg. in press.
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van Vledder, M.G., Pawlik, T.M., Munireddy, S. et al. Factors Determining the Sensitivity of Intraoperative Ultrasonography in Detecting Colorectal Liver Metastases in the Modern Era. Ann Surg Oncol 17, 2756–2763 (2010). https://doi.org/10.1245/s10434-010-1108-y
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DOI: https://doi.org/10.1245/s10434-010-1108-y