Unresectable colorectal cancer liver metastases treated by intraoperative radiofrequency ablation with or without resection (Br J Surg 2012; 99: 558–565)

Evrard and colleagues are the first to show prospectively that intraoperative radiofrequency ablation (RFA) combined with, or without liver resection is a valuable treatment option for patients with unresectable colorectal liver metastases (CRLM). This is highly relevant clinically as 40 per cent of patients with colorectal cancer develop CRLM and only a minority of these are treatable surgically despite aggressive preoperative chemotherapy. The study accrual was slow despite seven centres participating. Consequently, some centres included only a limited number of patients. Overall it took more than 5 years to include 52 patients. With the recognized importance of RFA expertise to achieve maximum tumour clearance, this could be worrying1. However, of ten patients who exhibited hepatic recurrence, only two showed relapse at the site of ablation. Unfortunately, the study does not provide enough clues to unravel the true merits of RFA for the treatment of CRLM. The surgical trauma of liver resection and the subsequent potentially tumour-boosting effects during regeneration of liver parenchyma could, at least theoretically, be prevented partially by using RFA. A randomized controlled trial comparing surgery with RFA for resectable CRLM was considered ethically tenuous by Curley in 20082. At that time he was right. However, the discussion should not stop there as the present study shows that 5-year overall survival rates of over 40 per cent can be achieved in patients with unresectable CRLM. In the meantime, it may be useful to define what should be achieved with respect to RFA technique, such as real-time imaging and standardization of ablation techniques, before such a trial could be conducted. The author declares no conflict of interest.