Combination of Liver Resection with Methods of Local Thermal destruction in the Treatment of Metastases of Colorectal Cancer in the Liver

Colorectal cancer (CRC) is a common and lethal disease. CRC incidence and mortality rates vary markedly around the world. Globally, CRC is the third most commonly diagnosed cancer in males and the second in females, with 1.8 million new cases and almost 861,000 deaths in 2018 according to the World Health Organization GLOBOCAN database [1]. Current researches suggest that over 86 percent of patients diagnosed under the age of 50 are symptomatic at diagnosis, and despite this, they have a more advanced stage at diagnosis and poorer outcomes [2,3]. Liver metastases of CRC are diagnosed synchronously with colorectal cancer in 25% of patients [3,4]. Over 23% of them also present extrahepatic metastases. Nearly a half of the remaining patients develop metachronous liver metastases within 3 years following bowel resection [3,4]. For patients with colorectal cancer liver metastases, liver resection is currently the only treatment with a curative intent and chance to prolong life [3,5]. Radical surgery is the “gold” standard in the treatment of metastatic tumors of the liver, allowing to achieve 37-45% 5-year survival, with a combined effect (surgical treatment and Abstract Relevance: Colorectal cancer (CRC) is one of the most common of the detection among malignant tumors. More than 80% of patients with metastases of the CRC to the liver are unsuitable for radical surgical treatment. It is this category of patients that shows the application of local thermal destruction methods.

Unfortunately, only 10-25% of patients with colorectal liver metastases are justified to radical surgical treatment [4]. Metastatic tumors in the remaining patients are considered unresectable, mainly due to their dissemination in both liver lobes, presence of extrahepatic metastases or the inability to preserve an adequate future liver remnant volume. Without specific treatment, the life expectancy of these patients is 5-11 months [4,5]. In such patients, palliative treatment is implemented, such as chemotherapy and thermal ablation of metastases. It is this category of patient's different method of local control could be applying such as cryoablation, radiofrequency, microwave and laser thermal ablation [6]. The development of cryosurgery techniques in the USSR in the 80s of the last centuries began with the study of cryotherapy in the liver and pancreas in an experiment that was later introduced into the clinic [7]. Cryo methods are widely used in the treatment of cancer [8].
Authors recommend the use of cryo destruction (cryoablation) as a palliative method for metastatic liver cancer in order to relieve pain, as well as to reduce the growth rate of neoplasms in locally advanced tumors, increase life expectancy (from 5-11 months with-out surgery to 14-18 months after surgical treatment) [9]. Cryo destruction not only leads to local destruction of the tumor, but also stimulates the immune response, improves the quality of life of patients [7,9,11].
The first reports about the effect of radiofrequency energy on living tissues with their heating and the formation of coagulation necrosis belong to the last decade of the XIX century [4]. However, the practical application of RFA in the treatment of focal neoplasms of the liver has its history since the first half of the 90s of the 20th century [11]. In a multicenter randomized study for 15 years, the justification of the use of cryo destruction in patients with colorectal cancer metastases in the liver has been shown [4]. Long-term results were comparable with other methods of local destruction (Table 1)

Materials and Methods
Since  All patients subsequently underwent adjuvant chemotherapy, supplemented with regional chemoembolization in 9 cases.

Results
Postoperative complications developed in 15 (37.5%) of patients. According the classification of Clavien-Dindo, the complications we noted in stages can be divided as follows (Table 2).
In the postoperative period intra-abdominal bleeding -1(4.2%) case; renal and hepatic failure led to the development of the syndrome of multiple organ failure and then to death on the 47th day after the intervention (liver resection+ Cryo + RFA) -1(4.2%). Pain after the procedure: complete pain disappearance after the procedure observed in 40%, significant pain reduction -in 20% of pa-  (Figures 2 & 3). We have performed a retrospective study to assess the outcomes of patients receiving local thermal destruction -RFA, cryo destruction and combination for colorectal cancer metastases. We compared them against an age-sex matched group who had a similar treatment profile. V stage Renal and hepatic failure led to the development of the syndrome of multiple organ failure and then to death on the 47th day after the intervention (liver resection+ Cryo+RFA) (4,2%).