Karin Nielsen

Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted techniques to eliminate small unresectable colorectal liver metastases (CRLM). Although previous studies labelled thermal ablation inferior to surgical resection, the apparent selection bias when comparing patients with unresectable disease to surgical candidates, the superior safety profile, and the competitive overall survival results for the more recent reports mandate the setup of a randomized controlled trial. The objective of the COLLISION trial is to prove non-inferiority of thermal ablation compared to hepatic resection in patients with at least one resectable and ablatable CRLM and no extrahepatic disease. In this two-arm, single-blind multi-center phase-III clinical trial, six hundred and eighteen patients with at least one CRLM (≤3 cm) will be included to undergo either surgical resection or thermal ablation of appointed target lesion(s) (≤3 cm). Primary endpoint is OS (overall survival, intention-to-treat analysis). Main secondary endpoints are overall disease-free survival (DFS), time to progression (TTP), time to local progression (TTLP), primary and assisted technique efficacy (PTE, ATE), procedural morbidity and mortality, length of hospital stay, assessment of pain and quality of life (QoL), cost-effectiveness ratio (ICER) and quality-adjusted life years (QALY). If thermal ablation proves to be non-inferior in treating lesions ≤3 cm, a switch in treatment-method may lead to a reduction of the post-procedural morbidity and mortality, length of hospital stay and incremental costs without compromising oncological outcome for patients with CRLM. NCT03088150 , January 11th 2017.

Introduction Systemic chemotherapy is able to convert colorectal liver metastases (CRLM) that are initially unsuitable for local treatment into locally treatable disease. Surgical resection further improves survival in these patients. Our aim was to evaluate disease-free survival (DFS), overall survival, and morbidity for patients with CRLM treated with RFA following effective downstaging by chemotherapy, and to identify factors associated with recurrence and survival. Materials and methods Included patients had liver-dominant CRLM initially unsuitable for local treatment but eligible for RFA or RFA with resection after downstaging by systemic chemotherapy. Chemotherapeutic regimens consisted predominantly of CapOx, with or without bevacizumab. Follow-up was conducted with PET-CT or thoraco-pelvic CT. Results Fifty-one patients had a total of 325 CRLM (median = 7). Following chemotherapy, 183 lesions were still visible on CT (median = 3). Twenty-six patients were treated with RFA combined with resection. During surgery, 309 CRLM were retrieved on intraoperative ultrasound (median = 5). Median survival was 49 months and was associated with extrahepatic disease at time of presentation and recurrences after treatment. Estimated cumulative survival at 1, 3 and 4 years was 90, 63 and 45 %, respectively. Median DFS was 6 months. Twelve patients remained free of recurrence after a mean follow-up of 32.6 months. Conclusion RFA of CRLM after conversion chemotherapy provides potential local control and a good overall survival. To prevent undertreatment, the involvement of a multidisciplinary team in follow-up imaging and assessment of local treatment possibilities after palliative chemotherapy for liver-dominant CRLM should always be considered.

Irreversible electroporation (IRE) is a novel image-guided tumor ablation technique that has shown promise for the ablation of lesions in proximity to vital structures such as blood vessels and bile ducts. The primary aim of the COLDFIRE-2 trial is to investigate the efficacy of IRE for unresectable, centrally located colorectal liver metastases (CRLM). Secondary outcomes are safety, technical success, and the accuracy of contrast-enhanced (ce)CT and 18F-FDG PET-CT in the detection of local tumor progression (LTP). In this single-arm, multicenter phase II clinical trial, twenty-nine patients with 18F-FDG PET-avid CRLM ≤ 3,5 cm will be prospectively included to undergo IRE of the respective lesion. All lesions must be unresectable and unsuitable for thermal ablation due to vicinity of vital structures. Technical success is based on ceMRI one day post-IRE. All complications related to the IRE procedure are registered. Follow-up consists of 18F-FDG PET-CT and 4-phase liver CT at 3-monthly intervals during the first year of follow-up. Treatment efficacy is defined as the percentage of tumors successfully eradicated 12 months after the initial IRE procedure based on clinical follow-up using both imaging modalities, tumor marker and (if available) histopathology. To determine the accuracy of 18F-FDG PET-CT and ceCT, both imaging modalities will be individually scored by two reviewers that are blinded for the final oncologic outcome. To date, patients with a central CRLM unsuitable for resection or thermal ablation have no curative treatment option and are given palliative chemotherapy. For these patients, IRE may prove a life-saving treatment option. The results of the proposed trial may represent an important step towards the implementation of IRE for central liver tumors in the clinical setting. Trial registration number: NCT02082782 .

Irreversible electroporation (IRE) is a novel image-guided ablation technique that is rapidly gaining popularity in the treatment of malignant liver tumors located near large vessels or bile ducts. We describe a 28-year-old female patient with a 5 cm large, centrally located hepatocellular adenoma who wished to get pregnant. Regarding the risk of growth and rupture of the adenoma caused by hormonal changes during pregnancy, treatment of the tumor was advised prior to pregnancy. However, due to its central location, the tumor was considered unsuitable for resection and thermal ablation. Percutaneous CT-guided IRE was performed without complications and led to rapid and impressive tumor shrinkage. Subsequent pregnancy and delivery went uncomplicated. This case report suggests that the indication for IRE may extend to the treatment of benign liver tumors that cannot be treated safely otherwise.

Irreversible electroporation (IRE) is a novel image-guided ablation technique that is increasingly used to treat locally advanced pancreatic carcinoma (LAPC). We describe a 67-year-old male patient with a 5 cm stage III pancreatic tumor who was referred for IRE. Because the ventral approach for electrode placement was considered dangerous due to vicinity of the tumor to collateral vessels and duodenum, the dorsal approach was chosen. Under CT-guidance, six electrodes were advanced in the tumor, approaching paravertebrally alongside the aorta and inferior vena cava. Ablation was performed without complications. This case describes that when ventral electrode placement for pancreatic IRE is impaired, the dorsal approach could be considered alternatively.

Thermal ablation of colorectal liver metastases (CRLM) may result in local progression, which generally appear within a year of treatment. As the timely diagnosis of this progression allows potentially curative local treatment, an optimal follow-up imaging strategy is essential. PET-MRI is a one potential imaging modality, combining the advantages of PET and MRI. The aim of this study is evaluate fluorine-18 deoxyglucose positron emission tomography (FDG) PET-MRI as a modality for detection of local tumor progression during the first year following thermal ablation, as compared to the current standard, FDG PET-CT. The ability of FDG PET-MRI to detect new intrahepatic lesions, and the extent to which FDG PET-MRI alters clinical management, inter-observer variability and patient preference will also be included as secondary outcomes.

Irreversible electroporation (IRE) is a new, non-thermal image-guided tumour ablation technique. The repeated application of high-voltage electrical pulses causes pores to form in the cell membrane, so that cells lose their homeostatic properties, and die. The advantage of IRE over other local ablation techniques is that IRE selectively destroys cells, whilst the surrounding extracellular matrix structures remain intact. Therefore, the anatomic framework that gives vulnerable structures such as bile ducts, blood vessels, ureters and nerves their shape and strength is preserved during IRE, which allows for safe ablation of tumours near these vulnerable structures. Both in the Netherlands and worldwide, various clinical studies are being run on the safety and efficacy of IRE for centrally located hepatic and pancreatic tumours, which are unsuitable for the current local therapies (surgical resection, irradiation or thermal ablation) due to their anatomic location. Although the long-term results are as yet unknown, the future of IRE appears promising. IRE may prove a valuable tool to add in the multidisciplinary treatment of cancer.

Background: Diverticulitis is commonly diagnosed using ultrasound (US), followed by computed tomography (CT). Our aim was to determine the diagnostic accuracy of US compared with CT for patients with uncomplicated and complicated diverticulitis.Methods: We reviewed medical records of 232 patients admitted with diverticulitis via the emergency department between January 2009 and January 2011. Patients who had undergone US and a CT scan were identified and further analyzed.Results: A total of 123 patients underwent an US and a CT scan. In 78/94 patients with uncomplicated diverticulitis, results of US and CT scan were compatible (83 %); in 6 of the remaining 29 patients both modalities showed a complicated diverticulitis (21 %). US misdiagnosed 17 % of patients with uncomplicated diverticulitis and 79 % with complicated diverticulitis.Conclusions: US is insufficient for diagnosing a complicated diverticulitis. Missing a complicated diverticulitis can have important clinical implications, and if diverticulitis is suspected, we suggest obtaining a CT scan to confirm diagnosis and to exclude complications.

Repair of abdominal wall hernias with mesh is one of the most common procedures in general surgery. The introduction of hernia repair with mesh has lowered recurrence rates and shifted the focus to quality of life after surgery, raising the need for a specific tool measuring quality of life. The Carolinas Comfort Scale (CCS) is a questionnaire designed specifically for patients having hernia repair with mesh. The aim of this study is to validate the Dutch CCS and to compare it to the generic short form-36 (SF-36). The CCS questionnaire was translated into Dutch. Patients undergoing mesh hernia repair between April 2010 and December 2011 completed the CCS, the SF-36 and four questions comparing these two questionnaires in the first week after surgery. After 3 weeks, the CCS was repeated. Correlations between the two surveys were calculated using the Spearman’s rank correlation test with a 95 % confidence interval to determine validity. The response rate was 60.3 % (100/168). The CCS showed excellent reliability with a Cronbach’s α of 0.948. Significant correlation existed between the CCS and the domains physical functioning, bodily pain, role-physical, vitality and social functioning of the SF-36. Seventy-nine percent of the patients preferred the CCS to the SF-36, and 83 % considered the CCS a better reflection of their quality of life after hernia repair with mesh. The Dutch CCS appears a valid and clinically relevant tool for assessing quality of life after repair of abdominal wall hernia with mesh.