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Liver Metastases: Neoadjuvant Downsizing with Transarterial Chemoembolization before Laser-Induced Thermotherapy¹

¹ From the Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany. Received October 11, 2002; revision requested December 26; final revision received May 11, 2003; accepted June 9. Address correspondence to T.J.V. (e-mail: t.vogl@em.uni.frankfurt.de).

View larger version (181K): [in a new window]   Figure 1a. Images obtained in a 52-year-old man with bilobar colorectal liver metastases. (a) Unenhanced transverse gradient-echo T1-weighted MR image (140/12; flip angle, 80°) shows a 65 x 45-mm target lesion (arrows) in segment VI with irregular borders before treatment. (b) Unenhanced transverse CT scan obtained after the third course of TACE during application of the laser catheters (arrowheads) shows residual tumor lesions, with attenuating area (arrow) caused by retention of iodized oil. (c) Unenhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) with residual lesion (arrow). Laser catheter (arrowhead) was placed laterally during application to achieve complete ablation. During the procedure, four catheters were applied. (d) Gadopentetate dimeglumine-enhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) obtained 24 hours after LITT shows demarcation of the volume of the induced necrosis (arrowheads). Note the sharp delineation of the border of the induced lesion.

View larger version (184K): [in a new window]   Figure 1b. Images obtained in a 52-year-old man with bilobar colorectal liver metastases. (a) Unenhanced transverse gradient-echo T1-weighted MR image (140/12; flip angle, 80°) shows a 65 x 45-mm target lesion (arrows) in segment VI with irregular borders before treatment. (b) Unenhanced transverse CT scan obtained after the third course of TACE during application of the laser catheters (arrowheads) shows residual tumor lesions, with attenuating area (arrow) caused by retention of iodized oil. (c) Unenhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) with residual lesion (arrow). Laser catheter (arrowhead) was placed laterally during application to achieve complete ablation. During the procedure, four catheters were applied. (d) Gadopentetate dimeglumine-enhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) obtained 24 hours after LITT shows demarcation of the volume of the induced necrosis (arrowheads). Note the sharp delineation of the border of the induced lesion.

View larger version (195K): [in a new window]   Figure 1c. Images obtained in a 52-year-old man with bilobar colorectal liver metastases. (a) Unenhanced transverse gradient-echo T1-weighted MR image (140/12; flip angle, 80°) shows a 65 x 45-mm target lesion (arrows) in segment VI with irregular borders before treatment. (b) Unenhanced transverse CT scan obtained after the third course of TACE during application of the laser catheters (arrowheads) shows residual tumor lesions, with attenuating area (arrow) caused by retention of iodized oil. (c) Unenhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) with residual lesion (arrow). Laser catheter (arrowhead) was placed laterally during application to achieve complete ablation. During the procedure, four catheters were applied. (d) Gadopentetate dimeglumine-enhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) obtained 24 hours after LITT shows demarcation of the volume of the induced necrosis (arrowheads). Note the sharp delineation of the border of the induced lesion.

View larger version (203K): [in a new window]   Figure 1d. Images obtained in a 52-year-old man with bilobar colorectal liver metastases. (a) Unenhanced transverse gradient-echo T1-weighted MR image (140/12; flip angle, 80°) shows a 65 x 45-mm target lesion (arrows) in segment VI with irregular borders before treatment. (b) Unenhanced transverse CT scan obtained after the third course of TACE during application of the laser catheters (arrowheads) shows residual tumor lesions, with attenuating area (arrow) caused by retention of iodized oil. (c) Unenhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) with residual lesion (arrow). Laser catheter (arrowhead) was placed laterally during application to achieve complete ablation. During the procedure, four catheters were applied. (d) Gadopentetate dimeglumine-enhanced transverse T1-weighted gradient-echo MR image (140/12; flip angle, 80°) obtained 24 hours after LITT shows demarcation of the volume of the induced necrosis (arrowheads). Note the sharp delineation of the border of the induced lesion.

View larger version (25K): [in a new window]   Figure 2. Flow chart of neoadjuvant study.

View larger version (24K): [in a new window]   Figure 3. Graph shows survival data of patients (n = 287) with liver metastases of various primary tumors treated with TACE (solid line) and of patients (n = 82) treated with combined treatment protocol, that is, TACE followed by LITT (dashed line). Mean survival of the patients treated with TACE was 17.0 months, and that for those treated with the combined protocol was 24.9 months.

View larger version (159K): [in a new window]   Figure 4a. Images obtained in a 62-year-old woman with newly developed liver metastases of colorectal carcinoma. (a) Transverse gradient-echo T1-weighted MR image (135/6; flip angle, 80°) shows a large liver metastasis (arrows) in segment VI. In the coronal orientation, the lesion was 55 mm in diameter. (b) Frontal angiogram obtained during the first course of TACE reveals the hypervascularity of the target metastasis (arrowheads) and the additional target lesions (arrows) that were not shown in a. (c) Unenhanced transverse gradient-echo MR image (140/12; flip angle, 80°) obtained after the third course of TACE shows a 50% decrease in tumor volume (arrows). (d) Unenhanced transverse CT scan obtained after the third course of TACE during the application of the laser catheters (arrowheads) shows residual tumor lesions with attenuating area (arrow) caused by retention of iodized oil. (e) Contrast-enhanced transverse MR image (135/6; flip angle, 80°) obtained 24 hours after LITT demonstrates ablated volume (arrowheads), characterized by a low signal intensity area surrounded by a hyperintense rim. Area of necrosis is larger than original lesions.

View larger version (201K): [in a new window]   Figure 4b. Images obtained in a 62-year-old woman with newly developed liver metastases of colorectal carcinoma. (a) Transverse gradient-echo T1-weighted MR image (135/6; flip angle, 80°) shows a large liver metastasis (arrows) in segment VI. In the coronal orientation, the lesion was 55 mm in diameter. (b) Frontal angiogram obtained during the first course of TACE reveals the hypervascularity of the target metastasis (arrowheads) and the additional target lesions (arrows) that were not shown in a. (c) Unenhanced transverse gradient-echo MR image (140/12; flip angle, 80°) obtained after the third course of TACE shows a 50% decrease in tumor volume (arrows). (d) Unenhanced transverse CT scan obtained after the third course of TACE during the application of the laser catheters (arrowheads) shows residual tumor lesions with attenuating area (arrow) caused by retention of iodized oil. (e) Contrast-enhanced transverse MR image (135/6; flip angle, 80°) obtained 24 hours after LITT demonstrates ablated volume (arrowheads), characterized by a low signal intensity area surrounded by a hyperintense rim. Area of necrosis is larger than original lesions.

View larger version (166K): [in a new window]   Figure 4c. Images obtained in a 62-year-old woman with newly developed liver metastases of colorectal carcinoma. (a) Transverse gradient-echo T1-weighted MR image (135/6; flip angle, 80°) shows a large liver metastasis (arrows) in segment VI. In the coronal orientation, the lesion was 55 mm in diameter. (b) Frontal angiogram obtained during the first course of TACE reveals the hypervascularity of the target metastasis (arrowheads) and the additional target lesions (arrows) that were not shown in a. (c) Unenhanced transverse gradient-echo MR image (140/12; flip angle, 80°) obtained after the third course of TACE shows a 50% decrease in tumor volume (arrows). (d) Unenhanced transverse CT scan obtained after the third course of TACE during the application of the laser catheters (arrowheads) shows residual tumor lesions with attenuating area (arrow) caused by retention of iodized oil. (e) Contrast-enhanced transverse MR image (135/6; flip angle, 80°) obtained 24 hours after LITT demonstrates ablated volume (arrowheads), characterized by a low signal intensity area surrounded by a hyperintense rim. Area of necrosis is larger than original lesions.

View larger version (174K): [in a new window]   Figure 4d. Images obtained in a 62-year-old woman with newly developed liver metastases of colorectal carcinoma. (a) Transverse gradient-echo T1-weighted MR image (135/6; flip angle, 80°) shows a large liver metastasis (arrows) in segment VI. In the coronal orientation, the lesion was 55 mm in diameter. (b) Frontal angiogram obtained during the first course of TACE reveals the hypervascularity of the target metastasis (arrowheads) and the additional target lesions (arrows) that were not shown in a. (c) Unenhanced transverse gradient-echo MR image (140/12; flip angle, 80°) obtained after the third course of TACE shows a 50% decrease in tumor volume (arrows). (d) Unenhanced transverse CT scan obtained after the third course of TACE during the application of the laser catheters (arrowheads) shows residual tumor lesions with attenuating area (arrow) caused by retention of iodized oil. (e) Contrast-enhanced transverse MR image (135/6; flip angle, 80°) obtained 24 hours after LITT demonstrates ablated volume (arrowheads), characterized by a low signal intensity area surrounded by a hyperintense rim. Area of necrosis is larger than original lesions.

View larger version (166K): [in a new window]   Figure 4e. Images obtained in a 62-year-old woman with newly developed liver metastases of colorectal carcinoma. (a) Transverse gradient-echo T1-weighted MR image (135/6; flip angle, 80°) shows a large liver metastasis (arrows) in segment VI. In the coronal orientation, the lesion was 55 mm in diameter. (b) Frontal angiogram obtained during the first course of TACE reveals the hypervascularity of the target metastasis (arrowheads) and the additional target lesions (arrows) that were not shown in a. (c) Unenhanced transverse gradient-echo MR image (140/12; flip angle, 80°) obtained after the third course of TACE shows a 50% decrease in tumor volume (arrows). (d) Unenhanced transverse CT scan obtained after the third course of TACE during the application of the laser catheters (arrowheads) shows residual tumor lesions with attenuating area (arrow) caused by retention of iodized oil. (e) Contrast-enhanced transverse MR image (135/6; flip angle, 80°) obtained 24 hours after LITT demonstrates ablated volume (arrowheads), characterized by a low signal intensity area surrounded by a hyperintense rim. Area of necrosis is larger than original lesions.