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J Gastrointest Surg. 2019 Jan 24. doi: 10.1007/s11605-019-04106-2. [Epub ahead of print]

Utility of Image Guidance in the Localization of Disappearing Colorectal Liver Metastases.

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Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, 1 Place Lucie & Raymond Aubrac, 63000, Clermont-Ferrand, France.
U1071 INSERM/University Clermont Auvergne, Clermont-Ferrand, France.
Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC, 27110, USA.
Department of Surgery, University of Pennsylvania, 2400 Spruce Street, Philadelphia, PA, 19104, USA.
Department of Biomedical Engineering, Vanderbilt University, 5901 Stevenson Center, Nashville, TN, 37235, USA.
Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.



Colorectal liver metastases that demonstrate a complete radiographic response during chemotherapy are increasingly common with advances in chemotherapy regimens and are described as disappearing liver metastases (DLMs). However, these DLMs often continue to harbor residual viable tumor. If these tumors are found in the operating room with ultrasound (US), they should be treated. The intraoperative sonographic visualization of these lesions, however, can be hindered by chemotherapy-associated liver parenchyma changes. The objective of this study was to evaluate the use of an intraoperative image guidance system, Explorer (Analogic Corporation, Peabody, MA), to aid surgeons in the identification of DLMs initially undetected by US alone.


In a single-arm prospective trial, patients with colorectal liver metastases undergoing liver resection and/or ablation with one or more DLMs during neoadjuvant chemotherapy were enrolled. Intraoperatively, DLMs were localized with conventional US. Any DLM not found by conventional US was re-evaluated with the image guidance system. The primary outcome was the proportion of sonographically occult DLMs subsequently located by image-guided US.


Between April 2016 and November 2017, 25 patients with 61 DLMs were enrolled. Thirty-eight DLMs (62%) in 14 patients (56%) were not identified with US alone. Six (16%) DLMs in five patients (36%) were subsequently located with assistance of the image guidance system. The image guidance changed the intraoperative surgical plan in four of these patients.


Image guidance can aid surgeons in the identification of initially sonographically occult DLMs and facilitate the complete surgical clearance of all sites of liver disease.


Image-guided surgery; Liver surgery; Navigated ultrasound; Surgical navigation; Tracked ultrasound


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