Elsevier

Gynecologic Oncology

Volume 111, Issue 2, November 2008, Pages 202-207
Gynecologic Oncology

Image-guided percutaneous cryotherapy for the management of gynecologic cancer metastases

https://doi.org/10.1016/j.ygyno.2008.08.003Get rights and content

Abstract

Objective

To report the clinical response to image-guided percutaneous cryotherapy (IPC) for the palliative management of localized metastases in patients with gynecologic malignancies.

Methods

Institutional review board approval and patient consent were obtained. Gynecologic oncology patients were identified from our institution's cryotherapy database from August 2003 to August 2007. Cryotherapy was performed with 2.4 mm diameter probes (Endocare, Irvine, CA) with ultrasound or computerized tomography (CT) guidance under conscious sedation and local anesthesia. Follow-up was conducted by imaging studies and clinical encounters, using Response Evaluation Criteria in Solid Tumors (RECIST criteria).

Results

Twenty-eight ablation sessions were performed for 41 metastatic foci in 15 patients with gynecologic malignancies. Twelve patients had prior chemotherapy and 5 patients had prior radiation. Median follow-up was 317.5 days (range 95–1189). Median post-procedure pain score: 3/10 (range 0–5). Mean initial tumor size was 2.6 cm in maximal diameter. Median reduction in tumor diameter at 1 month was 21.4% (range 2–67.4%), at 3 months was 43.6% (range 16–80.4%), at 6 months was 54.7% (range (16.6–88.9%) and at 9 months was 58.2% (range 32–88.9%). Ten patients received concurrent chemotherapy, 8 had progression of disease at other sites and 2 had stable disease, while the cryotherapy site improved. One of 5 patients who had cryotherapy in the previously irradiated zone had recurrence. A liver capsule hematoma developed as an immediate complication in one patient and an enterocutaneous fistula developed in another.

Conclusion

IPC is a well-tolerated, effective tool for local control of isolated metastatic foci as a single-modality treatment and for local control of symptomatic metastases in select patients undergoing systemic therapy for the management of gynecologic malignancies.

Introduction

Cryotherapy has been used to treat cancer metastases as well as primary tumors since the 1960's. Though complication rates were unacceptable initially, recent advances in cryobiology and technology have allowed for the advancement of this therapy with minimally invasive methods and a safer approach.

In particular, using multiple smaller cryoprobes and image guidance allows the operator to sculpt the ice formation so it is tailored to each individual lesion [1], [2], [3]. The lower sedation requirements than heat-based ablations [e.g., radiofrequency (RF)] broadens options for patients of advanced age and/or co-morbidities. Cellular damage caused by cryotherapy is by direct injury due to ice crystal formation and cell microcirculatory failure [5]. In addition, some studies have shown that apoptosis is induced by the therapy particularly in the periphery of the treated zone which may impact a tumor's sensitivity to adjuvant therapy [5].

At our institution, cryotherapy has been used to manage recurrent painful metastases and isolated metastases in a variety of gynecologic cancers that were refractory to conventional therapy. We report our initial experience with image-guided percutaneous cryotherapy (IPC) for the palliative management of localized metastases in a series of patients with recurrent gynecologic malignancies.

Section snippets

Patients

Using the gynecologic oncology as well as the interventional radiology databases, gynecologic oncology patients treated with IPC between August 2003 and August 2007, were retrospectively identified. Clinical information was abstracted from cryotherapy procedure records and patients' electronic medical records. All cryotherapy procedures were performed and data collected under an Institutional Review Board (IRB) approved protocol and in compliance with the Health Insurance Portability and

Results

Twenty-eight ablation procedures were performed in 15 patients with gynecologic malignancies, covering the treatment of 41 metastatic foci. Repeat ablations were performed in 6 patients for developing multi-focal tumors that were different from the original ablated tumors. Three of these patients had primary ovarian tumors whereby 2 of these patients each had 5 ablation procedures for new abdominal foci while the third had 3 procedures for recurrent subcutaneous and skin metastases. Two other

Discussion

Patients who present with painful metastatic foci or with isolated metastases have a number of local treatment options, including surgical resection, radiofrequency ablation, radiation and cryotherapy. Surgical resection is associated with a 5-year survival of 38% in patients with colorectal cancer liver metastases, and is thus the current treatment of choice if the patient is an operative candidate. Success depends on margin status, the ability to leave enough normal tissue behind, the absence

Conflict of interest statement

PJL has served as a consultant and partial research sponsor of Endocare, Inc and as a cofounder of Cryodynamics, LLC. All other authors have no conflicts of interest to declare.

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