SUMMARY

Liver cryosurgery for primary or methastatic cancer requires the insertion of thin needles - the cryoprobes - inside the tumor under CT or ultrasound guide. Cryosurgery has recently been revamped as an effective technique (4) to become comparable to radiofrequency and microwaves, when not even preferable (9). Compared to other methods that use heat, cryosurgery can be performed without general anesthesia, under local anesthesia and can be applied even near the large vessels, the hepatic dome or near the chest wall (1), (3), (6), (11), (14).

GENERAL INFORMATION

The liver is the largest gland in the human body, and it has both endocrine and exocrine functions. Located beneath the diaphragm, on the right side of the body, it is adjacent to the stomach and the transverse colon. It also produces bile to emulsify fats, and it is also responsible for metabolising carbohydrates and proteins, and more. 

This gland is responsible for many other functions such as metabolising lipids, destroying haemoglobin and several toxic substances, converting ammonia into urea and it works as a deposit for substances such as iron and copper. 

Benign tumorous forms that are most often encountered in the liver are adenomas and angiomas; hepatocellular carcinoma is on the other hand the expression of malignant forms, together with metastasis caused by other so-called primitive tumours.

Diagnosis

Tumorous disease is usually discovered by ultrasound, CAT, or NMR scans, often in normal investigations for other cancerous pathologies; in fact liver cancer is generally asymptomatic in the initial stages.

The various tumorous stages of this organ determine its operability or inoperability, since several other complaints, such as cirrhosis of the liver undermine its functionality, and this prejudices the possibility of partial removal. 

Therapy

Technological developments in general and several studies performed on hepatocellular carcinoma or hepatocarcinoma (HCC) have widened the perspectives for treatment techniques that can be used in several situations. One recent publication (October 2016) stated it could advise either partial resection of the organ or cyroablation based on biological markers present in the blood7. Ignoring the limited cases os transplants, cryosurgery has been reconsidered as a plausible technique to the point of being comparable to radiofrequency in terms of effectiveness4, or even preferable to radiofrequency or microwave treatment 9. Compared with other systems that use heat, cryosurgery does not need deep anaesthesia, and can be applied close to major vessels, at the dome of the liver or close to the thoracic wall1,3,6,11,14.

Studies performed in many centres scattered across the globe demonstrate that cryosurgery

  • Is effective as a palliative (it reduces the pain caused by the cancer) in unapproachable cases 5;
  • It is effective in cases of advanced hepatocarcinoma6,13;
  • It works in synergy with chemotherapy when applied to metastasis on the liver8;
  • It has improved local control compared with microwaves and radiofrequencies9,10,13,14, it is possible to see the growth of the ice ball by means of CAT, it can be used close to major vessels and it has a pain relieving effect; no further appreciable differences subsist from other techniques in terms of mortality and of the progression of the disease and complications14;

Cryosurgery may be applied in the liver by introducing fine needles under local anaesthetic, with or without sedation2. These fine needles are called cryoprobes and enable ultra-low temperatures to be generated in the tumour (down to -180°C), which kill the tumour cells in a controlled, rapid and efficient manner. Patients can be discharged in 24 hrs. More than one tumour can be attacked and destroyed in a single session. 

  1. Multicenter randomized controlled trial of percutaneous cryoablation versus radiofrequency ablation in hepatocellular carcinoma.
    Wang C1, Wang HYang WHu KXie HHu KQBai WDong ZLu YZeng ZLou MWang HGao XChang XAn LQu JLi JYang Y.
    Hepatology. 2015 May;61(5):1579-90. doi: 10.1002/hep.27548. Epub 2015 Mar 20.
  2. Advances in clinical application of cryoablation therapy for hepatocellular carcinoma and metastatic liver tumor.
    Hu KQ1.
    J Clin Gastroenterol. 2014 Nov-Dec;48(10):830-6. doi: 10.1097/MCG.0000000000000201.
  3. Comparison of percutaneous cryoablation with microwave ablation in a porcine liver model.
    Niu L1, Li J2, Zeng J2, Zhou L2, Wang S3, Zhou X2, Sheng L4, Chen J5, Xu K1.
    Cryobiology. 2014 Apr;68(2):194-9. doi: 10.1016/j.cryobiol.2014.01.005. Epub 2014 Jan 29.
  4. Cryoablation Versus Radiofrequency Ablation for Hepatic Malignancies: A Systematic Review and Literature-Based Analysis.
    Wu S1, Hou JDing YWu FHu YJiang QMao PYang Y.
    Medicine (Baltimore). 2015 Dec;94(49):e2252. doi: 10.1097/MD.0000000000002252.
  5. Alleviating the pain of unresectable hepatic tumors by percutaneous cryoablation: Experience in 73 patients.
    Xin'an L1, Jianying Z2, Lizhi N3, Fei Y4, Xiaohua W1, Jibing C5, Jialiang L3, Kecheng X2.
    Cryobiology. 2013 Oct 25. pii: S0011-2240(13)00392-1. doi: 10.1016/j.cryobiol.2013.10.005.
  6. Analysis of therapeutic effectiveness and prognostic factor on argon-helium cryoablation combined with transcatheter arterial chemoembolization for the treatment of advanced hepatocellular carcinoma.
    Huang C1, Zhuang W1, Feng H1, Guo H1, Tang Y1, Chen H1, Huang Y1.
    J Cancer Res Ther. 2016 Dec;12(Supplement):C148-C152. doi: 10.4103/0973-1482.200605.
  7. Circulating tumour cells as biomarkers for evaluating cryosurgery on unresectable hepatocellular carcinoma.
    Shi J1, Li Y2, Liang S2, Zeng J2, Liu G2, Mu F2, Li H2, Chen J2, Lin M2, Sheng S3, Zhang H3, Liu T1, Niu L2.
    Oncol Rep. 2016 Oct;36(4):1845-51. doi: 10.3892/or.2016.5050. Epub 2016 Aug 25.
  8. Cryoablation plus chemotherapy in colorectal cancer patients with liver metastases.
    Li Z1, Fu YLi QYan FZhao JDong XZhang Y.
    Tumour Biol. 2014 Nov;35(11):10841-8. doi: 10.1007/s13277-014-2374-2. Epub 2014 Aug 1.
  9. Cryoablation provides superior local control of primary hepatocellular carcinomas of >2 cm compared with radiofrequency ablation and microwave coagulation therapy: an underestimated tool in the toolbox.
    Ei S1, Hibi TTanabe MItano OShinoda MKitago MAbe YYagi HOkabayashi KSugiyama DWakabayashi GKitagawa Y.
    Ann Surg Oncol. 2015 Apr;22(4):1294-300. doi: 10.1245/s10434-014-4114-7. Epub 2014 Oct 7.
  10. Cryoablation Versus Radiofrequency Ablation for Hepatic Malignancies: A Systematic Review and Literature-Based Analysis.
    Wu S1, Hou JDing YWu FHu YJiang QMao PYang Y.
    Medicine (Baltimore). 2015 Dec;94(49):e2252. doi: 10.1097/MD.0000000000002252.
  11. Percutaneous Tumor Ablation Tools: Microwave, Radiofrequency, or Cryoablation—What Should You Use and Why?
    J. Louis Hinshaw, MD,  Meghan G. Lubner, MD, Timothy J. Ziemlewicz, MD, Fred T. Lee, Jr, MD, and Christopher L. Brace, PhD
    Radiographics. September-October 2014; 34(5): 1344–1362.
  12. Percutaneous cryoablation of ovarian cancer metastasis to the liver: initial experience in 13 patients.
    Gao W1, Guo ZZhang XWang YZhang WYang XYu H.
    Int J Gynecol Cancer. 2015 Jun;25(5):802-8. doi: 10.1097/IGC.0000000000000420.
  13. Percutaneous ablative treatments of hepatocellular carcinoma.
    Gian Ludovico Rapaccini M.D., PH.D
    Hepatology, March 2015, DOI: 10.1002/hep.27615
  14. Percutaneous cryoablation for hepatocellular carcinoma.
    Song KD1.
    Clin Mol Hepatol. 2016 Dec;22(4):509-515. doi: 10.3350/cmh.2016.0079.
  15. Immunological response induced by cryoablation against murine H22 hepatoma cell line in vivo.
    Yang X, Li X, Guo Z, Si T, Yu H, Xing W. Cryobiology. 2018 Feb;80:114-118. doi: 10.1016/j.cryobiol.2017.11.005. Epub 2017 Nov 13.