Intraoperative modality of treatment for peritoneal carcinomatosis: use of hyperthermic interperitoneal chemoperfusion.

The use of hyperthermia as an adjunct to chemotherapy in the treatment of peritoneal carcinomatosis is a promising technique for patients who otherwise have a poor prognosis for survival. We, herein, report an overview and description of our technique for the safe conduct of this treatment. Included in these data are a total of 71 patients who underwent an intraoperative treatment with Mitomycin C at temperatures of 41-42 degrees C for a 90- to 120-min time period. The treatment protocol, perfusion system description, technical considerations, and potential complications are also included. The prognosis for intraabdominal carcinomatosis is poor with conventional treatments and modalities. We believe that the use of this technique offers a very positive clinical alternative for patients undergoing treatment for laparoscopic palliation of malignant ascites and/or surgical debulking for intraoperative treatment and prevention of metastasis.

Prospective evaluation of office-based parotid ultrasound.

BACKGROUND: Differentiation of parotid neoplasms from extraparotid upper cervical lesions is difficult by physical examination. The purpose of this report is to identify the role of office-based parotid ultrasound (US) in the evaluation of periauricular masses. METHODS: A prospective database including the results of physical examination, office-based US, and the corresponding pathology was reviewed. Soft-tissue US was performed with a 7.5-mHz parallel probe with biplanar imaging. RESULTS: Thirty-eight patients were evaluated over a 28-month period (mean age. 45 years; range, 23-78 years). US demonstrated a mass within the substance of the parotid (n = 23, 61%), outside the parotid (n = 11, 29%), or diffuse parotitis (n = 4, 10%). Intraparotid masses were preauricular (n = 14), postauricular (n = 5), or upper cervical (n = 4) and were solid (n = 22) or cystic (n = 1). Patients with solid intraparotid masses underwent superficial (n = 20) or total parotidectomy (n = 2). Benign (n = 19) and malignant (n = 3) solid parotid nodules had similar US features of hypoechogenicity with posterior enhancement. Indistinct margins were noted in 3 of 3 malignant lesions as well as 15 of 19 benign nodules (P = .9). Extraparotid masses were confirmed to be nodal disease on the basis of observation with resolution (n = 3), fine-needle aspiration (n = 6), or surgical removal (n = 2) (mean follow-up, 6 months). CONCLUSIONS: Surgical office-based parotid US can delineate the location of periauricular mass lesions relative to the parotid gland. Benign and malignant lesions have a similar sonographic appearance.

Gene therapy for head and neck cancers.

Despite advances in surgery, radiotherapy, and chemotherapy, survival of patients with squamous cell carcinoma of the head and neck has not significantly improved over the past 30 years. Locally recurrent or refractory disease is particularly difficult to treat. Repeat surgical resection and/or radiotherapy are often not possible, and long-term results for salvage chemotherapy are poor. Recent advances in gene therapy have been applied to recurrent squamous cell carcinoma of the head and neck. Many of these techniques are now in clinical trials and have shown some efficacy. This article discusses the techniques employed in gene therapy and summarizes the ongoing protocols that are currently being evaluated in clinical trials.

A prospective phase II trial of ONYX-015 adenovirus and chemotherapy in recurrent squamous cell carcinoma of the head and neck (the Baylor experience).

BACKGROUND: The E1-b attenuated adenovirus, ONYX-015 (Onyx Pharmaceuticals, Richmond, CA), has demonstrated antitumoral activity in patients with recurrent squamous cell carcinoma of the head and neck. This study evaluated the effects of intratumoral ONYX-015 injection combined with systemic chemotherapy. METHODS: Inclusion criteria included: (1) recurrent squamous cell carcinoma of the head and neck, not surgically salvageable, (2) target tumor amenable to direct injection, and (3) no prior chemotherapy for recurrent disease. Patients received ONYX-015 (10(10) plaque-forming units) intratumorally for 5 days, cisplatin (80 mg/m2) on day 1, and 5-fluorouracil (800-1000 mg/m2) on days 1-5. This cycle was repeated every 3 weeks. Serial physical examination and computed tomography were used to assess tumor size and treatment response. RESULTS: Fourteen patients were enrolled, and nine patients were evaluable for response at the time of enrollment. The mean age of the evaluable patients was 60.8 years (range, 46-71 years). Mean maximum tumor diameter was 4.8 cm (range, 1.9-10.5 cm). Treatment-related toxicity included nausea (n = 7, 77.8%), vomiting (n = 5, 55.6%), mucositis (n = 5, 55.6%), pain at the injection site (n = 5, 55.6%), constipation (n = 4, 44.4%), and fatigue (n = 4, 44.4%). Locoregional tumor control was obtained in all nine patients (100%) (mean observation time, 157 days). Complete clinical response was seen in three patients (33.3%), partial response was seen in three patients (33.3%), minor response was seen in one patient (11.1%), and two patients (22.2%) had stable disease. Median time to local progression of disease has not been reached (range, 35-356 days). CONCLUSIONS: ONYX-015 adenovirus plus systemic cisplatin and 5-fluorouracil provides antitumor activity and local tumor control in patients with recurrent squamous cell carcinoma of the head and neck. This novel treatment approach offers hope for patients with limited treatment alternatives and provides the foundation for a phase III clinical trial.

Diagnostic evaluation of hepatocellular carcinoma in a cirrhotic liver.

Hepatocellular carcinoma (HCC) is one of the world's most common cancers. It is closely associated with cirrhosis, especially that due to viral hepatitis. The incidences of viral hepatitis and HCC are rising steadily in the United States. When symptomatic, HCC is usually unresectable and associated with a median survival of less than 6 months. Nodular lesions of undetermined malignant potential are often found in cirrhotic, explanted livers. There appears to be a continuum of increasing malignant potential from regenerating nodules to dysplastic nodules and to HCC. Pathologic differentiation of high-grade dysplastic nodules from HCC is often difficult. Early diagnosis offers the best potential for curative intervention. Screening of high-risk patient populations using serum alpha-fetoprotein and ultrasound has been attempted but is hindered by low sensitivity and specificity. The multinodularity and vascular flow anomalies of the cirrhotic liver complicate imaging. However, recent advances in magnetic resonance imaging technology allow for more accurate examination of the liver. We review the current status of hepatic imaging techniques and the results of screening a high-risk population for HCC.

Hepatic imaging with iron oxide magnetic resonance imaging.

The management of hepatic tumors presents a challenging problem. The natural history of primary and metastatic liver lesions portends a poor prognosis. However, surgical resection and newer ablative techniques have had a great impact on cure rates. Unfortunately, the majority of newly diagnosed patients have surgically unresectable disease. Advances in hepatic imaging have improved the preoperative evaluation of malignant lesions and greatly assisted in selecting patients for surgical resection or other interventions. Currently, a number of modalities are available for the evaluation of hepatic tumors. This article provides an overview of some of the modalities currently in use, examines the role of iron oxide magnetic resonance imaging (MRI), and relates experience with its use at Baylor University Medical Center.

Should locally excised T1 rectal cancer receive adjuvant chemoradiation?

BACKGROUND: Local excision of low-lying adenocarcinoma of the rectum is increasingly utilized, but the benefit of adjuvant treatment in T1 lesions with otherwise favorable pathology remains controversial. METHODS: A retrospective review was performed on patients who underwent local excision of invasive rectal cancer with curative intent from 1991 to 1999. RESULTS: Forty-eight patients were treated with local surgical excision. Twenty-seven T1 lesions were identified, 10 received postoperative chemoradiation, and no local recurrences were identified. Seventeen T1 patients did not receive adjuvant treatment and local recurrence occurred in 4 patients (24%). In all cases of local recurrence, the lesions had been excised to negative margins, none were poorly differentiated, and none exhibited vascular or lymphatic invasion. CONCLUSION: These data suggest a trend toward improved local control with adjuvant therapy after local excision of T1 rectal cancer. This is an important consideration in patients with negative surgical margins and favorable pathology who are traditionally not treated.

Association of an abnormal pancreaticobiliary junction with biliary tract cancers.

Recent international reports have suggested that an abnormal pancreatic and bile duct junction can influence the degree of pancreatic fluid regurgitation, resulting in an increased incidence of biliary tract malignancy. To confirm these reports, we retrospectively examined the anatomic relation at the pancreaticobiliary junction in all patients diagnosed with cholangiocarcinoma or gallbladder cancer at Baylor University Medical Center (BUMC) over a 10-year period. From 1989 to 1998, 82 patients with bile duct cancer were treated at BUMC. Adequate visualization of the pancreaticobiliary junction was accomplished in 29 patients (35%). Among these patients, an abnormal junction, with a common channel length of 8 to >15 mm, was noted in 13 patients (45%). Thus, this study confirms previous reports regarding the high incidence of an abnormal pancreaticobiliary junction in patients with bile duct cancer. A prospective effort to examine this anatomy and the length of the common channel should be encouraged to identify a potential high-risk group.

The effect of surgical office-based thyroid ultrasound on clinical decision making.

An important diagnostic tool for the evaluation of thyroid disease, thyroid ultrasound has recently become available for use in surgical offices. The purpose of this report is to determine the lesional sensitivity of office-based thyroid ultrasound and its impact on clinical decision making. Surgical office-based thyroid ultrasound was performed on 49 consecutive patients who presented with thyroid disease. Indications for sonography included a solitary palpable nodule (n = 32), multiple palpable nodules (n = 3), diffuse enlargement (n = 5), or other hormonal or radiologic abnormalities (n = 9). Thyroid ultrasound demonstrated 104 lesions compared with 38 lesions found on physical examination (P < 0.0001). In the subpopulation who underwent scintigraphy (n = 10), 24 nodules were identified by ultrasound and only 10 nodules were identified by scan (P < 0.01). Overall, office-based thyroid ultrasound impacted the clinical management of 40 patients (80%): in 16 patients, thyroid ultrasound was the only modality that demonstrated a multinodular condition, thus contributing to a decision to avoid surgery; 19 patients had ultrasound-guided fine-needle aspiration of vaguely palpable or nonpalpable lesions; and 5 patients underwent ultrasound-guided cyst aspiration and follow-up. Office-based thyroid ultrasound performed by surgeons is a highly accurate imaging modality that identified significantly more lesions than physical examination or scintigraphy. Clinical management was affected through the identification of a multinodular process or through facilitation of accurate image-guided biopsy.

Hepatic tumor imaging using iron oxide MRI: comparison with computed tomography, clinical impact, and cost analysis.

BACKGROUND: The surgical management of hepatic tumors has traditionally relied on preoperative contrast-enhanced computed tomography (CECT) in combination with intraoperative ultrasonography (IOUS). Unfortunately, the ability to detect and characterize hepatic tumors by using CECT is limited, and IOUS frequently reveals additional disease that alters the operative approach. Recent advances in hepatic magnetic resonance imaging (MRI) may improve preoperative tumor detection and characterization; however, little is known about how MRI compares with CECT or about the clinical impact and cost considerations of liver MRI. METHODS: A retrospective chart review was performed to compare iron oxide (Feridex [Fe])-MRI with CECT in the preoperative imaging of hepatic neoplasms, as well as to determine the clinical impact and overall healthcare costs associated with Fe-MRI. RESULTS: Of approximately 1000 patients who underwent abdominal MRI at a single institution during a 20-month period, 57 were identified who underwent Fe-MRI evaluation of the liver. Indications for imaging included suspected metastases (n = 43), an indeterminate hepatic mass (n = 9), or primary hepatic cancer (n = 5). Overall, Fe-MRI identified a total of 157 lesions (mean, 2.75 per patient; range, 0-14). CECT was performed in 50 patients, of whom 35 had primary or metastatic cancer. Fe-MRI identified more lesions than CT (n = 136 vs. 77; P = .016), and the average size of lesion detected by Fe-MRI was significantly smaller than that by CECT (2.5 vs. 3.4 cm; P = .018). Comparison of CECT and Fe-MRI findings with IOUS and pathological specimens showed a significant difference in sensitivity (MRI, 86%; CECT, 58%; P<.001), and IOUS changed the operative approach in only 5% of those imaged with Fe-MRI. Overall, Fe-MRI altered the clinical management in 67% of patients imaged (n = 38 of 57), which corresponded to an overall net cost savings of $108,368 ($1,901 per patient). CONCLUSIONS: Fe-MRI is a powerful imaging technique, with greater hepatic tumor detection sensitivity than CECT. Moreover, it is an economically feasible imaging method that will alter the clinical management in most patients imaged.

An orthotopic in vivo model of human pancreatic cancer.

BACKGROUND: Pancreatic cancer is a highly lethal disease that frequently presents in advanced stages. For most patients, treatment with great clinical efficacy does not exist. Relevant in vivo models to test novel therapies are highly desirable. METHODS: The human pancreatic ductal adenocarcinoma cell line Panc-1 was injected intraperitoneally into SCID mice. The pattern of the resulting peripancreatic as well as metastatic disease was examined. Survival experiments after chemotherapy with gemcitabine or doxorubicin, and after immunotherapy with p53-specific cytotoxic T lymphocytes were performed. RESULTS: All animals developed isolated pancreatic tumor implants within 48 hours after injection. After the formation of invasive pancreatic tumor nodules, peripancreatic and portal adenopathy developed, causing biliary obstruction. All tumor-bearing animals died of disease within 5 to 12 weeks. Survival after gemcitabine treatment and after p53-CTL injection was significantly prolonged, with some animals remaining tumor-free. Doxorubicin treatment did not yield extended survival, but led to significant toxicity. CONCLUSION: Intraperitoneal injection of Panc-1 cells into SCID mice produces a quasi-orthotopic tumor development model that shares many characteristics with human pancreatic cancer. The ease of cell injection, avoidance of cumbersome surgical intervention with its resulting mortality, and the reliable development of obstructive jaundice as a dependent comorbid factor render this a useful model for in vivo testing of novel therapeutic approaches to pancreatic cancer. Our initial therapeutic studies demonstrate that in vitro antitumor efficacy against Panc-1 cancer cells does not necessarily predict the in vivo response, highlighting the preclinical experimental value of this model.

Radiation safety with breast sentinel node biopsy.

BACKGROUND: Sentinel lymph node biopsy with Technetium 99m sulfur colloid (Tc99m) is an evolving technique that offers the potential for improved staging of breast cancer with decreased morbidity. However, the use of radioactive materials in the operating room generates significant concern about radiation exposure. The purpose of this study was to evaluate radiation exposure to operating room personnel, pathologist, and equipment from specimens during breast sentinel lymph node biopsy. METHODS: Twenty patients were injected with 0.7 to 1.1 mCi of Tc99m sulfur colloid 1.5 to 3 hours before sentinel lymph node biopsy. A calibrated Geiger counter was used to measure dose rates from the breast injection site before skin incision (n = 20), lumpectomy specimens (n = 8), and sentinel nodes (n = 20) at distances of 3, 30, and 300 cm. This represented exposure to the surgeon's hands, surgeon's torso, and scrub nurse, respectively. Exposure to the pathologist's hands and torso was represented as dose-rate measurements from lumpectomy and nodal specimens. The operative instruments, trash receptacles, suction canisters, pathology slides, and cryostat machines were measured at 3 cm at the conclusion of each procedure. Specimens or equipment emitting radiation doses equal to background levels (0.04 mRem/h) were exempt from special handling and disposal. RESULTS: The highest exposure rate was to the surgeon's hands from the breast injection site before skin incision (34.25 mRem/h). Exposure to the surgeon's torso measured 1.33 mRem/h, and exposure to the scrub nurse's torso measured 0.15 mRem/h from the injection site. Exposure to the pathologist's hands was 18.62 and 0.06 mRem/h from the lumpectomy specimen and sentinel node, respectively. Exposure to the pathologist's torso measured 0.34 and 0.04 mRem/h from the lumpectomy specimen and sentinel node, respectively. One hundred percent of lumpectomy specimens measured above the exempt level. Thirty-two of 46 (70%) sentinel lymph nodes emitted radiation equal to the exempt background level. Seventeen of 20 trash receptacles (85%) and 4 of 12 (33%) suction canisters measured equal to background levels. All operative instruments, pathology slides, and cryostat machines were equal to background levels. CONCLUSIONS: Radiation exposure to operating room personnel, pathologists, and operative equipment during a breast sentinel node biopsy using Tc99m is minimal. A primary surgeon can perform 2,190 hours, a scrub nurse 33,333 hours, and a pathologist 14,705 hours of procedural work before surpassing Occupational Safety and Health Administration limits. Operative instruments, pathology slides, and cryostat machines do not require special handling. All lumpectomy specimens should be stored for decontamination until the dose rate equals background levels. Intraoperative dose-rate monitoring allows selective decontamination of nodal specimens, trash receptacles, and suction canisters, which decreases disposal time and cost.

The role of computed tomography in the diagnosis of acute appendicitis.

BACKGROUND: Routine contrast-enhanced computed tomography (CECT) has been described as an accurate diagnostic imaging modality in patients with acute appendicitis. However, most patients with acute appendicitis can be diagnosed by clinical findings and physical exam alone. The role of CECT in patients suspected of having appendicitis but with equivocal clinical exams remains ill defined. METHODS: One hundred and seven consecutive patients who were thought to have appendicitis but with equivocal clinical findings and/or physical exams were imaged by CECT over a 12-month period. Oral and intravenous contrast-enhanced, spiral abdominal and pelvic images were obtained using 7-mm cuts. CECT images were interpreted by a board-certified radiologist. Main outcome measures included CECT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in the diagnosis of acute appendicitis, comparing CECT with ultrasound, and determining the impact of CECT on the clinical management of this patient population. RESULTS: A group of 107 patients consisting of 44 males (41%) and 63 females (59%) with a median age of 33 years (range 13 to 89 years) were imaged with CECT to evaluate suspected appendicitis. Of the 107 CECTs performed, 11 false-positive and 3 false-negative readings were identified, resulting in a sensitivity of 92%, specificity of 85%, PPV of 75%, NPV of 95%, and an overall accuracy of 90%. Forty-three patients were imaged with ultrasound and CECT, and CECT had significantly better sensitivity and accuracy (30% versus 92% and 69% versus 88%, P<0.01). With regard to clinical management, 100% (36/36) of patients with appendicitis, and 4.2% (3/71) of patients without appendicitis underwent appendectomy. Therefore, the overall negative appendectomy rate was 7.6% (3/39). CONCLUSIONS: CECT is a useful diagnostic imaging modality for patients suspected of having acute appendicitis but with equivocal clinical findings and/or physical exams. CECT is more sensitive and accurate than ultrasound and is particularly useful in excluding the diagnosis of appendicitis in those without disease.

Cryotherapy for liver tumors.

The curative management of primary and metastatic liver tumors has traditionally relied on surgical resection. Unfortunately, fewer than 10% of newly diagnosed patients have tumors that are considered to be surgically resectable. Limitations that often preclude a safe surgical resection include bilobar or centrally located tumors, insufficient hepatic reserve, cirrhosis, and/or associated comorbid medical conditions. For individuals with unresectable hepatic tumors, the treatment options are few, and the prognosis is uniformly poor. However, cryosurgery is a promising therapeutic alternative for these patients. This rapidly emerging technology allows for image-guided in situ tumor eradication using subzero temperatures, while selectively sparing most normal hepatic tissue. Tumor death occurs by direct cellular freezing and indirectly through vascular thrombosis and tissue anoxia. Accumulating data suggest that cryosurgery is a safe, effective treatment option for patients who would otherwise fair quite poorly, and that it may achieve long-term survival rates similar to those observed with formal surgical resection. This article summarizes the role cryosurgery may play in the management of patients with surgically unresectable primary and metastatic liver tumors.

Targeting p53 for adoptive T-cell immunotherapy.

p53 gene mutations occur in most human cancers and result in an altered protein product that accumulates within the cell. Although the observed endogenous human CTL response to p53 is weak, high-affinity, human p53-specific CTLs have been generated from HLA A2.1 transgenic mice immunized with human CTL epitope peptides. In this study, we examine the ability of HLA A2.1-restricted and human p53-specific CTLs from HLA A2.1 transgenic mice to suppress the growth of p53-overexpressing human tumors in severe combined immunodeficient (SCID) mice. In vitro, murine p53(149-157)-specific CTLs selectively lysed the p53-overexpressing pancreatic carcinoma cell line Panc-1 but did not recognize HLA A2.1- tumor cells or HLA A2.1+ normal human fibroblasts. Furthermore, in vivo, the growth of established human tumor xenografts in SCID mice was significantly reduced and survival was prolonged after the administration of p53-specific CTLs but not after the administration of control CTLs or PBS alone. Following treatment with p53(149-157)-specific CTLs, regressing Panc-1 tumors were infiltrated by the CD8+ CTLs, as demonstrated by immunohistochemistry. These findings suggest that p53(149-157)-specific and HLA A2.1-restricted murine CTLs suppress the growth of established Panc-1 tumors following adoptive transfer into SCID hosts and prolong their survival.

Visceral varicella-zoster after bone marrow transplantation: report of a case series and review of the literature.

OBJECTIVES: Infection with varicella-zoster virus after bone marrow transplantation (BMT) is a common cause of morbidity and mortality. Visceral involvement with varicella-zoster may be incorrectly ascribed to graft-versus-host disease, resulting in delayed diagnosis and misguided therapy. METHODS: A 4-yr retrospective chart review was performed to determine the presenting symptoms and clinical outcome of visceral varicella-zoster virus infection in BMT recipients. RESULTS: Ten BMT recipients who subsequently developed visceral varicella-zoster virus infection were identified. The mean age at diagnosis was 40 yr (range 27-56 yr). Primary hematological malignancies were leukemia (N = 7), myelodysplasia (N = 2), and myelofibrosis (N = 1). Bone marrow transplants in affected patients were autologous (N = 2), related allogeneic (N = 5), or matched unrelated allogeneic (N = 3). The mean time interval from BMT to symptomatic visceral varicella-zoster virus infection was 153 days (range 60-280 days). Presenting symptoms included abdominal pain in all patients, nausea (60%), fever > 38 degrees C (60%), vomiting (50%), pneumonitis (50%), skin rash (40%), and diarrhea (30%). All patients had moderately or profoundly elevated aminotransferases and most had elevated pancreatic enzymes (80%). The mean time interval from the development of abdominal pain to the characteristic skin rash and then diagnosis was 6 and 7 days, respectively (range 4-10 and 4-14 days). Active graft-versus-host disease had previously been documented in five of the eight allogeneic BMT recipients. Immunosuppressive medications were increased at the onset of the abdominal pain in seven of these eight patients for suspected exacerbation of graft-versus-host disease. After recognition of varicella infection, antiviral therapy was promptly initiated; despite this, mortality was still 50%. CONCLUSIONS: Visceral involvement with varicella-zoster virus infection can occur as a late complication after both allogeneic and autologous BMT. In these cases, symptoms of severe abdominal pain with associated nausea, vomiting, and diarrhea and elevated liver and pancreatic enzymes preceded the vesicular skin eruption and were confused with graft-versus-host disease. With the increasing application of high-dose chemotherapy followed by stem cell rescue for both hematological and solid tumors, clinicians should be aware of this potentially treatable and often lethal complication.

An HLA-restricted, p53 specific immune response from HLA transgenic p53 knockout mice.

BACKGROUND: p53 is over-expressed in most human malignancies and is therefore an attractive target for immunotherapy. Unfortunately, a human cytotoxic T cell response to p53 is difficult to generate. p53 knockout transgenic mice may provide a model to circumvent immunologic tolerance to p53 and develop high-affinity p53-specific cytotoxic T lymphocytes (CTL). METHODS: p53 knockout, HLA A2.1 transgenic mice were generated and immunized with the immunodominant wild-type p53 nonamer peptide epitope p53149-157. Two weeks later splenocytes were harvested and stimulated in vitro with acid-treated, p53 peptide-pulsed syngeneic blast cells. Cultures were restimulated weekly with acid-treated, p53 peptide-pulsed Jurkat cells transfected with the HLA A2.1 gene. Peptide-specific cytotoxic activity was measured by chromium release assay, and the resulting CD8+ effectors were cloned via limiting dilution. RESULTS: P53 peptide-specific CTL were generated against p53149-157. Clones generated from the p53149-157 cell line demonstrated high affinity and specificity for p53149-157 when presented by HLA A2.1+ antigen-presenting cells. The p53149-157 CTL killed only cells overexpressing p53 cells that were HLA A2.1+ and did not kill cells with normal levels of p53 expression or those that were HLA A2.1-. CONCLUSION: HLA transgenic mice not previously exposed to the p53 protein provide a useful model for generating high-affinity p53-specific CTL.

Cryosurgical ablation of hepatic tumors.

BACKGROUND: Cryosurgical ablation of hepatic tumors relies on nonspecific tissue necrosis due to freezing as well as microvascular thrombosis. Patients with selected primary and metastatic hepatic malignancies who are not candidates for surgical resection are afforded potentially curative benefit using this technique. METHODS: Forty patients underwent cryosurgery for hepatic malignancy related to colorectal metastasis (n = 27), hepatocellular carcinoma (n = 8), metastatic breast (n = 2), metastatic neuroendocrine (n = 2), and metastatic ovarian carcinoma (n = 1). Intraoperative ultrasound (IOUS) was used in all patients to help locate the tumor and guide the cryosurgical trocar to the lesions. RESULTS: Indications for cryosurgical ablation included bilobar and centrally located disease, poor medical risk, insufficient hepatic reserve, and involved margin after wedge resection. Major complications included hepatic parenchyma cracking requiring transfusion in 5 patients, 1 postoperative biliary stenosis, and 1 inferior vena cava injury. There were 3 postoperative deaths from non-hepatic-related events. Based on Kaplan-Meier analysis the estimated overall survival for patients with hepatocellular carcinoma (60% at 18 months) was compared with patients with colorectal metastases (30% at 18 months). Nine patients (23%) are currently free of disease with an average follow-up of 17.7 months. The pattern of failure was identified at the site of cryosurgical ablation in 2 of 88 lesions. CONCLUSIONS: Cryosurgical ablation of selected hepatic malignancies is a safe and viable treatment for patients not amenable to surgical resection.