Perioperative complications in patients undergoing major liver resection with or without neoadjuvant chemotherapy

Locally advanced mid/low rectal cancer with synchronous liver metastases

BACKGROUND

Management of patients with T3/4 and/or N+ mid/low rectal cancer with synchronous liver metastases is not codified. The aim of this study was to analyze outcomes of our approach which consists of neoadjuvant chemotherapy or chemoradiotherapy, according to liver disease extension, followed by simultaneous rectal and liver resection.

METHODS

Between 2000 and 2009, 354 patients underwent hepatectomy for synchronous metastases. Thirty-six consecutive patients who underwent rectal and liver resection for metastatic T3/4 and/or N+ mid/low rectal cancer were analyzed.

RESULTS

Liver metastases were multiple in 27 patients, bilobar in 22, and >5 cm in six. Up-front treatment was chemotherapy in 15 patients, chemoradiotherapy in seven, chemotherapy followed by chemoradiotherapy in six, and surgery in eight (five symptomatic tumors). After chemotherapy alone (median number of cycles = 6), primary tumor response was observed in 11 patients (three complete responses). After chemoradiotherapy, only one patient had liver disease progression. Eighty-nine percent of patients underwent simultaneous rectal and hepatic resection. Mortality and morbidity rates were 2.8% (one pulmonary embolism) and 36%, respectively. After a mean follow-up of 39 months, 5-year overall and disease-free survival were 59.3 and 39.6%, respectively. Twenty-one patients had recurrence, including three pelvic recurrences (8.3%). No pelvic recurrence occurred among patients who correctly completed treatment strategy. All patients who received neoadjuvant chemoradiotherapy were alive and disease-free; 5-year overall and disease-free survival of patients receiving neoadjuvant chemotherapy were 59.3 and 25%, respectively.

CONCLUSIONS

For patients with metastatic T3/4 and/or N+ mid/low rectal cancer, the present strategy was safe and effective. Good disease control was achieved by neoadjuvant treatments, low morbidity rates were associated with simultaneous resection, and excellent long-term outcomes with low local relapse rate were obtained.

Neoadjuvant and adjuvant therapy in relation to surgery for colorectal liver metastases

Liver resection is associated with prolonged survival in patients with colorectal liver metastases. At diagnosis, 15-20% of patients have resectable colorectal liver metastases whereas other patients have too advanced disease to enable surgical treatment and receive chemotherapy. In patients undergoing resection of colorectal liver metastases, disease relapse occurs in up to 70%. Therefore, a combined approach including preoperative or postoperative chemotherapy or both has been tested to improve outcome after surgery. In patients with unresectable colorectal liver metastases, chemotherapy is initially the sole treatment option. The considerable improvement of the efficacy of anticancer agents has contributed to increase the response rate in patients with advanced colorectal cancer. In case of major response to chemotherapy, surgery with curative intent can be offered to patients with initially unresectable liver metastases.

Effect of neoadjuvant chemotherapy in hepatic steatosis

Chemotherapy drugs often produce side effects in the liver. In recent years, there has been speculation about the ability to produce hepatic steatosis in patients treated with 5-fluorouracil and oxaliplatin. This prospective study examines whether these drugs can produce steatosis in patients with neoadjuvant treatment who were operated on for liver tumors.

PURPOSE

Our objective was to assess the effect of neoadjuvant chemotherapy (NAC) on the development of hepatic steatosis in the healthy liver.

PATIENTS AND METHODS

This was a prospective study based on 32 patients divided into two groups. The presence of steatosis was assessed using a histological score (Kleiner classification) and a biochemical method (Folch method) for patients from both groups.

RESULTS

A total of 14 patients (44%) had hepatic steatosis and half of these were in each group. The steatosis was moderate to severe (grades 2-3) in 4 patients (13%), 2 in each group. The mean levels of triglycerides in the liver were 33.38 and 29.94 mg/g in group I and group II, respectively, with the difference not being statistically significant.

CONCLUSIONS

Almost half of the patients treated with NAC for liver neoplasia developed steatosis. Nevertheless, NAC does not seem to increase the risk of hepatic steatosis.

Influence of preoperative chemotherapy on the intraoperative and postoperative course of liver resection for colorectal cancer metastases

BACKGROUND

Liver resection is a possibly curative treatment for colorectal cancer (CRC) liver metastases. Preoperative chemotherapy may make initially irresectable tumors resectable. The aim of this study was to compare perioperative course and short-term mortality after liver resection for CRC metastases between patients who were and were not treated with preoperative chemotherapy.

METHODS

Patients who had undergone liver resection for CRC metastases were included. A total of 97 patients treated with preoperative chemotherapy (group A) were compared with 136 who were not (group B). Intraoperative bleeding, operating time, complications, duration of stay, and mortality were compared using Pearson's χ(2) test, Fisher's exact test, and the Mann-Whitney U-test.

RESULTS

Mean intraoperative bleeding, duration of stay, and operating time were not significantly different. Complications occurred in 62.9% and 63.2% in groups A and B, respectively. The 30- and 90-day mortality rates were zero in group A, comparable to 1.5% in group B.

CONCLUSIONS

There were no significant differences in the perioperative course or postoperative mortality when comparing CRC patients with or without chemotherapy prior to liver resection. Consequently, this study suggests that preoperative chemotherapy before liver resection for CRC metastases does not negatively influence perioperative outcome and can therefore be applied if "downstaging" is indicated.

The management of solitary colorectal liver metastases

Surgical resection of solitary colorectal liver metastases is associated with long-term survival. Radiofrequency ablation used as the primary treatment option of solitary resectable colorectal liver metastases is associated with an increased risk of local recurrence that generally leads to worse survival compared to resection. In contrast with treatment of other hepatic malignancies, radiofrequency ablation is not equivalent to resection for colorectal liver metastases and should not be used as an alternative but limited to inoperable patients. Although overall survival rate after resection can be up to 71% at 5 years, the majority of patients develop recurrence. Preoperative chemotherapy contributes to decrease the risk of recurrence after resection of colorectal liver metastases. In patients with advanced solitary colorectal liver metastasis initially non suitable for resection, chemotherapy and portal vein embolization contribute to increase the number of surgical candidates whereas radiofrequency is rarely an option.

Perioperative management of liver resection surgery

Advances in liver resection surgery have lead to reductions in both mortality and morbidity. However morbidity remains high so effective multidisciplinary teamwork is essential to optimise the perioperative care of this patient group. In this article we review the current literature on the perioperative management of patients undergoing liver resection surgery.

Liver resection for colorectal cancer metastases involving the caudate lobe

BACKGROUND

Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer-involved resection margins of over 50 per cent being reported following caudate lobe resection.

METHODS

Outcomes of consecutive liver resections for colorectal metastases involving the caudate lobe between 1996 and 2009 were reviewed retrospectively, and compared with those after liver surgery without caudate resection.

RESULTS

Twenty-five patients underwent caudate and 432 non-caudate liver resection. Caudate resection was commonly performed as part of extended resection. There were no differences in operative complications (24 versus 21·1 per cent; P = 0·727) or blood loss (median 300 versus 250 ml; P = 0·234). The operating time was longer for caudate resection (median 283 versus 227 min; P = 0·024). Tumour size was larger in the caudate group (median 40 versus 27 mm; P = 0·018). Resection margins were smaller when the caudate lobe was involved by tumour, than in resections including tumour-free caudate or non-caudate resection; however, there was no difference in the proportion of completely excised tumours between caudate and non-caudate resections (96 versus 96·1 per cent; P = 0·990). One-year overall survival rates were 90 and 89·3 per cent respectively (P = 0·960), with 1-year recurrence-free survival rates of 62 and 71·2 per cent (P = 0·340).

CONCLUSION

Caudate lobe surgery for colorectal cancer liver metastases does not increase the incidence of resection margin involvement, although when the caudate lobe contains metastases the margins are significantly closer than in other resections.

Dietary glycine protects from chemotherapy-induced hepatotoxicity

Hepatotoxic side effects of neoadjuvant chemotherapy for colorectal liver metastases increase perioperative morbidity and mortality. Glycine protects liver from injury in various animal models. Thus, this study was designed to assess its effect on liver after chemotherapy. Sprague-Dawley rats (200-220 g) were fed a synthetic diet containing 5% glycine for 5 days. Subsequently, chemotherapy (FOLFIRI: irinotecan, folinic acid and fluorouracil, or FOLFOX: oxaliplatin, folinic acid and fluorouracil) was administered at standard doses. Transaminases, histology, immunohistochemistry and in vivo microscopy were used to index liver injury, to monitor intrahepatic microperfusion and activation of Kupffer cells. Glycine significantly decreased transaminases after chemotherapy to 25-50% of control values (p < 0.05). Microvesicular steatosis was significantly reduced from 18.5 ± 3.4 and 57.1 ± 8.6% in controls to 9.5 ± 1.8 and 37.7 ± 4.4% after FOLFIRI and FOLFOX, respectively. Furthermore, phagocytosis of latex beads was reduced by about 50%, while leukocyte adherence in central and midzonal subacinar zones decreased to 60-80% after glycine (p < 0.05). Glycine significantly reduced expression of inducible nitric oxide synthase after chemotherapy, while hepatic microcirculation was increased (p < 0.05). This study shows for the first time that glycine reduces chemotherapy-induced liver injury. The underlying mechanisms most likely include Kupffer cells and an improved intrahepatic microperfusion.

The timing of chemotherapy and surgery for the treatment of colorectal liver metastases

Combining surgery and chemotherapy in the treatment of patients with colorectal hepatic metastases is increasingly becoming the standard of care. However, controversy remains regarding the juxtapositioning of chemotherapy and surgery, the duration of chemotherapy, and particularly, the use of preoperative chemotherapy in the treatment of patients with initially resectable metastases. The arguments for and against the different approaches presented are based on the data published in the medical literature and on the data presented at the most recent major oncology meetings, coupled with the personal experience of the authors. For patients with liver metastases that are resectable at presentation, perioperative chemotherapy has become the standard treatment in many institutions, with the recommendation that surgery is performed after a maximum of 6 cycles of systemic therapy. In the case of patients with initially unresectable liver metastases receiving preoperative systemic therapy, patients should be carefully monitored and surgery performed as soon as the metastases become resectable. All patients should, where possible, be treated by a multidisciplinary team. Going forward, it needs to be established whether more intensive treatment (ie, perioperative versus postoperative systemic therapy) is merited for the treatment of patients with initially resectable disease, and what the precise contribution of new therapeutic agents in these settings is, based on new prospective randomized trial data.

Surgical strategy of colorectal liver metastases treatment depending on clinical and pathological response to neoadjuvant chemo- and target therapy

Napjainkban az előrehaladott colorectalis carcinoma mindennapos onkológiai kihívásként jelenik meg a kezelőorvos számára. Az utóbbi években bevezetett protokolloknak köszönhetően jelentős terápiás előrelépésnek lehetünk tanúi. A neoadjuváns kemoterápia biológiai válaszmódosítókkal történt kiegészítése nagymértékben növelte a terápiára adott klinikai választ a májmetasztázisos betegek körében. Az ezredfordulót követően egyre gyakrabban találkozunk a májáttétek teljes eltűnésének jelenségével. A májáttétek sebészetével foglalkozó irodalom egyértelmű és világos különbséget tesz a klinikai és patológiai válasz között, ugyanakkor a két válasz között lévő összefüggés pontos kritériumait is rögzítette. A colorectalis carcinoma májmetasztázisainak komplex kezelésében a teljes patológiai válasz jelenti a végső célt.Célok és módszerek:Jelen kutatás 2009. január 1.–2010 augusztus 31. közötti időszakban, 39 betegben vizsgálta a klinikai és patológiai választ. A májreszekciós műtétet neoadjuváns kemo- és targetterápia előzte meg.Eredmények:Teljes patológiai válasz két betegben (5,71%), major patológiai válasz (necrosis >50%) 12 betegben, minor patológiai válasz (necrosis <50%) 22 betegben alakult ki, míg 3 betegben egyáltalán nem volt necrosis.Következtetések:A colorectalis carcinoma májmetasztázisainak neoadjuváns és célzott terápiás kezelése során a patológiai válasz elérésére kell törekedni. Jelenleg a patológiai választ tartjuk a legfontosabb prognosztikus faktornak, amely az R0 reszekciót követő hosszú távú túlélést döntően és alapvetően határozza meg. Ellentmondásos a májmetasztázisok teljes eltűnésének megítélése, mivel műtéttechnikailag ez igen nehéz helyzet elé állítja az operatőrt. Ebben az értelemben az áttétek teljes eltűnése nemkívánatos mellékhatás, amely miatt a stratégia azt kívánja, hogy májmetasztázisos beteg ne legyen „túlkezelve”, amíg az áttét/áttétek teljesen eltűnnek, hanem a multidiszciplináris onkoteam hozza meg időben a döntést a májműtét indikációját illetően a még lokalizálható metasztázis/metasztázisok eltávolítására. Orv. Hetil., 2010,47,1956–1960.

Regenerative nodular hyperplasia of the liver related to chemotherapy: impact on outcome of liver surgery for colorectal metastases

Background

Regenerative nodular hyperplasia (RNH) represents the end-stage of vascular lesions of the liver induced by chemotherapy. The goal was to evaluate its incidence and impact on the outcome of patients resected for colorectal liver metastases (CLM).

Methods

Patients who underwent hepatectomy for CLM after six cycles or more of first-line chemotherapy, between January 1990 and November 2006, were included. Detailed histopathologic analysis of the nontumoral liver was performed according to a standard format.

Results

From a cohort of 856 resected patients at our institution, 771 (90%) received preoperative chemotherapy. Of these, 146 fulfilled the selection criteria and were included: 24 (16%) received 5-fluorouracil (5-FU) and leucovorin (LV) alone, 92 (63%) had 5-FU/LV and oxaliplatin, 18 (12%) had 5-FU/LV and irinotecan, and 12 (8%) were treated by 5-FU/LV, oxaliplatin, and irinotecan. RNH occurred in 22 of 146 patients (15%). Twenty of these patients (91%) received oxaliplatin, of whom six (30%) had chronomodulated therapy. Patients treated by oxaliplatin more often had RNH compared with oxaliplatin-naïve patients (22 vs. 4%). Although operative mortality was nil, the presence of RNH was associated with increased postoperative hepatic morbidity (50 vs. 29%). Elevated preoperative gamma-glutamyltransferase (GGT) (>80 U/L; >1N) and total bilirubin levels (>15 μmol/L; >1N) were independent predictors of RNH.

Conclusions

Patients with CLM who receive preoperative oxaliplatin have an increased risk of RNH and associated postoperative morbidity. Increased serum GGT and bilirubin are useful markers to predict the presence of RNH.

Role of surgery in colorectal liver metastases: Too early or too late?

As colorectal cancer and colorectal liver metastases become a serious public health problem, new treatment modalities are needed in order to achieve better results. In the last decade there has been very important progress in oncology, with new and more effective chemotherapeutic agents administered alone or in combination improving the resectability rate in up to 40% of patients with colorectal liver metastases. Advances in interventional radiology, in particular, with the use of portal vein embolization and radiofrequency thermal ablation are new strategies allowing major liver resections and treatment of small liver metastases or early recurrences. Surgery, however, remains the gold standard strategy with intention to treat. In this review article we will describe the advanced role of surgery in the multidisciplinary approach to colorectal liver metastases, and the clinical problems the liver surgeon has to deal with, such as the resectability of the metastases, the presence of bilobar liver lesions and extrahepatic disease, the impact of chemotherapy in already resectable liver metastases, the problem of vanishing metastases after chemotherapy and the dilemma of staged or combined liver and colon operations and which organ first in the clinical scenario of synchronous colorectal liver metastases.

Chemotherapy-associated liver injury: impact on surgical management of colorectal cancer liver metastases

Chemotherapy is integral to the management of patients with advanced colorectal cancer liver metastases. Due to their improved efficacy, modern regimens can sometimes convert unresectable disease to a resectable state. As chemotherapy is often administered prior to hepatic resection, adverse effects on the liver are increasingly being recognized. Investigators have identified a wide spectrum of effects on the underlying liver parenchyma, ranging from mild forms of steatosis to severe steatohepatitis and sinusoidal obstruction syndrome. As the histopathologic definitions of these changes evolve, studies have identified specific patterns of hepatic injury related to the various chemotherapeutic agents. The impact of these changes on perioperative outcome after partial hepatectomy remains controversial. Timing and duration of chemotherapy may play a key role and account for discrepancies in outcomes seen among studies. In this review, we provide an overview of the spectrum of chemotherapy-associated liver injury and discuss its relevance to perioperative management of patients undergoing hepatic resection of colorectal cancer liver metastases.

Chemotherapy-associated hepatotoxicity: how concerned should we be?

Modern oncosurgical strategies are producing dramatic response rates and remarkable long-term survival rates for patients with hepatic colorectal cancer metastases. However, the increasing delivery of preoperative systemic chemotherapy to patients has coincided with recognition of possible chemotherapy-associated injury to the nontumoral liver. Although multiple groups have described gross changes in the appearance of the liver following systemic chemotherapy, the exact histopathologic lesions have not been clearly defined. A review of the literature on the topic indicates that host factors (e.g., diabetes mellitus and obesity) may be responsible for the development of liver injury as much as the drugs being delivered. With a lack of published evidence indicating that chemotherapy-associated liver injury results in adverse outcomes, several groups have recently questioned the clinical significance of this entity. This review describes the current understanding of this topic and seeks to answer the question of whether chemotherapy-associated liver injury actually impacts outcomes.

Evolution of laparoscopic left lateral sectionectomy without the Pringle maneuver: through resection of benign and malignant tumors to living liver donation

Background

Laparoscopic left lateral sectionectomy (LLS) has gained popularity in its use for benign and malignant tumors. This report describes the evolution of the authors’ experience using laparoscopic LLS for different indications including living liver donation.

Methods

Between January 2004 and January 2009, 37 consecutive patients underwent laparoscopic LLS for benign, primary, and metastatic liver diseases, and for one case of living liver donation. Resection of malignant tumors was indicated for 19 (51%) of the 37 patients.

Results

All but three patients (deceased due to metastatic cancer disease) are alive and well after a median follow-up period of 20 months (range, 8–46 months). Liver cell adenomas (72%) were the main indication among benign tumors, and colorectal liver metastases (84%) were the first indication of malignancy. One case of live liver donation was performed. Whereas 16 patients (43%) had undergone a previous abdominal surgery, 3 patients (8%) had LLS combined with bowel resection. The median operation time was of 195 min (range, 115–300 min), and the median blood loss was of 50 ml (range, 0–500 ml). Mild to severe steatosis was noted in 7 patients (19%) and aspecific portal inflammation in 11 patients (30%). A median free margin of 5 mm (range, 5–27 mm) was achieved for all cancer patients. The overall recurrence rate for colorectal liver metastases was of 44% (7 patients), but none recurred at the surgical margin. No conversion to laparotomy was recorded, and the overall morbidity rate was 8.1% (1 grade 1 and 2 grade 2 complications). The median hospital stay was 6 days (range, 2–10 days).

Conclusions

Laparoscopic LLS without portal clamping can be performed safely for cases of benign and malignant liver disease with minimal blood loss and overall morbidity, free resection margins, and a favorable outcome. As the ultimate step of the learning curve, laparoscopic LLS could be routinely proposed, potentially increasing the donor pool for living-related liver transplantation.

[Hepatotoxicity of metastatic colorectal cancer chemotherapy: systematic review]

AIM

Hepatic toxicity of chemotherapy for colorectal cancer and its complications after hepatic metastasis surgery are unclear. Studies reporting hepatic lesions after chemotherapy for colorectal cancer and published before July 2009 have been identified by searching the Medline database. Data concerning these hepatic lesions and outcome after surgery are resumed in this review.

RESULTS

Studies concerning the link between hepatic steatosis and chemotherapy have contradictory results but steatosis is clearly associated to an increase of postoperative morbidity. Steatohepatitis, especially due to irinotecan, is associated with increased postoperative mortality. Sinusoidal obstruction syndrome, a severe form of vascular hepatic lesion, associated to oxaliplatin, seems to be linked with an increase of postoperative morbidity, but not mortality. Bevacizumab would not increase, when used in combination with oxaliplatin, the rate of postoperative complications. Some studies suggest a decrease of vascular hepatic lesions when bevacizumab is administered with chemotherapy. The literature concerning hepatic toxicity of anti-EGF-R antibody is freak.

CONCLUSION

The fact that irinotecan may be linked to an increased risk of hepatic failure and postoperative death, which is not the case of oxaliplatine, must be taken in consideration in the choice of the preoperative chemotherapy before resection of hepatic metastasis of colorectal cancer.

Targeted molecular therapies (cetuximab and bevacizumab) do not induce additional hepatotoxicity: preliminary results of a case-control study

AIMS

To analyse the effects of the preoperative targeted molecular therapy (cetuximab (cetu) or bevacizumab (beva)) on non-tumorous liver parenchyma, and the clinical and biological outcome after liver resection for colorectal liver metastases (CLM).

METHODS

Between January 2005 and December 2007, 36 patients receiving preoperatively cetu (n = 15) or beva (n = 21) were, respectively, matched to a control group of patients who did not receive targeted molecular therapy. They were matched on the basis of age, gender, body mass index, extent of hepatectomy, and type and number of neoadjuvant chemotherapy. Liver function tests, postoperative outcome and histopathology of the resected liver were compared.

RESULTS

There was no mortality. Postoperative morbidity and perioperative bleeding rates were similar in both groups. In the beva group, liver function tests showed higher serum bilirubin level on postoperative day (POD) 1 (p = 0.001) and POD 3 (p = 0.01), higher serum aspartate aminotransferase on POD 1 (p = 0.004), and lower prothrombin time on POD 5 (p = 0.02). In both groups, cetu and beva, the postoperative peaks of gamma-glutamyl transpeptidase and alkaline phosphatase were statistically higher than in the control groups. Interestingly, the prevalence of sinusoidal injury and fibrosis was lower in patients receiving cetu (p = 0.04), while the prevalence of steatohepatitis was lower in patients receiving beva (p = 0.04).

CONCLUSION

The addition of beva or cetu to the neoadjuvant chemotherapy regimens does not appear to increase the morbidity rates after hepatectomy for CLM. The pathological examination did not show additional injury to the non-tumorous liver parenchyma.

[Does bevacizumab have a protective effect on hepatotoxicity induced by chemotherapy?]

Although the prognosis of patients with colorectal liver metastases (CLM) has improved dramatically with oxaliplatin and irinotecan, the enthusiasm for the preoperative use of these cytotoxic agents is being tempered by concerns about their impact on the nontumoral liver parenchyma. Bevacizumab, an anti-angiogenic agent that specifically targets the vascular endothelial growth factor, exerts an antitumor effect by inhibiting the development of the vascular network that is promoted by the tumor and mandatory for its growth. Yet angiogenesis is also a physiologic event contributing to wound healing and tissue regeneration. To date, it is well documented that the use of bevacizumab in combination with cytotoxic agents greatly improves pathologic response. Also well described is the protective effect of bevacizumab against sinusoidal injuries induced by oxaliplatin-based chemotherapy. Up to now, no side effects related to the perioperative use of bevacizumab have been reported in the setting of liver resection for CLM, and bevacizumab was shown not to impair liver regeneration following portal vein embolization. The clinical consequences of the protective effect of bevacizumab against sinusoidal injuries are hard to evaluate as patient selection and preparation have improved and these improvements contribute greatly to the favorable outcomes following liver resection for CLM. Indeed, patient safety in the setting of hepatic resection for CLM mainly depends on a careful preoperative evaluation of liver volumes and a limited use of cytotoxic agents followed by a delay of at least 5 weeks before the surgery.

Impact of preoperative bevacizumab on complications after resection of colorectal liver metastases: case-matched control study

BACKGROUND

Chemotherapy may increase postoperative morbidity and mortality after liver surgery. Especially bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF), could have a detrimental effect. To assess the impact of neoadjuvant bevacizumab on clinical outcome after hepatectomy for colorectal liver metastases (CRLMs) this case-matched control study was initiated.

METHODS

The multicentric data collection was performed in the Swiss HPB Center of the University Hospital Zurich (CH), the Department of Digestive Surgery and Transplantation Strasbourg (F), and the Division of Hepato-biliary-pancreatic surgery of "Josep Tureta" Hospital Girona (E). Consecutive patients operated onbetween July 2005 and December 2007 due to CRLMs who received neoadjuvant chemotherapy were assessed. Patients were divided in two groups: group A had neoadjuvant chemotherapy with bevacicumab, and group B had it without bevacizumab.

RESULTS

No differences in overall morbidity (56 vs. 40% in the bevacizumab and control groups, respectively, p = 0.23) or mortality could be documented. Similarly, the incidence of severe postoperative complications was not statistically different between the bevacizumab and control groups (31 and 18%, respectively, p = 0.31). Wound complications were comparable (11% in the bevacizumab group compared and 9% in the control group, p = 1.00). However, bevacizumab was associated with a significantly decreased incidence of postoperative hepatic insufficiency (7 vs. 20%, p = 0.03).

CONCLUSIONS

No impact on the incidence or severity of complications by bevacizumab could be shown. Bevacizumab may even reduce the incidence of liver failure after liver surgery.

Recovery of liver function after the cessation of preoperative chemotherapy for colorectal liver metastasis

BACKGROUND

Preoperative chemotherapy containing oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) causes histological liver injury and increases postoperative morbidity and mortality in patients with colorectal liver metastasis (CRLM). However, information on the aggravation of liver function and its reversibility is scarce.

METHODS

A total of 55 patients who underwent a hepatectomy after receiving FOLFOX and/or FOLFIRI were included in the present study. Indocyanine green tests were repeatedly performed before hepatectomy for monitoring the change of hepatic functional reserve.

RESULTS

A significant decrement in the ICG R15 value was observed at 2-4 weeks (12.9%, P = .04), 4-8 weeks (11.4%, P = .01), and 8 or more weeks (11.1%, P = .006) after the last chemotherapy, compared with results documented within 2 weeks (16.8%). However, no significant change was observed among the values obtained at 2-4 weeks, 4-8 weeks, and 8 or more weeks. The individual ICG R15 values at the beginning and end of the cessation period also improved from 17.7% to 11.6% (P = .001). Histological liver injury was associated with larger amounts of operative blood loss but not with morbidity. Neither liver failure nor mortality occurred in the present series.

CONCLUSIONS

The hepatic functional reserve, represented by the ICG R15 value, improves during the period after chemotherapy cessation. The present study suggests that chemotherapy cessation for at least 2-4 weeks enables an improvement in the hepatic functional reserve, especially among patients with an abnormal ICG R15 value (> 10%) who have received 6 or more cycles of FOLFOX and/or FOLFIRI.

Perioperative chemotherapy with bevacizumab and liver resection for colorectal cancer liver metastasis

BACKGROUND

Surgery remains the only curative option for patients with colorectal cancer liver metastases (CRLM). Perioperative chemotherapeutic strategies have become increasingly popular in the treatment of CRLM. Although the role of bevacizumab (Bev) in this setting remains unclear, its widespread use has raised concerns about the use of Bev as part of perioperative chemotherapy.

METHODS

We retrospectively reviewed all patients who received Bev and underwent liver resection between July 2004 and July 2008 at the McGill University Health Center. Chemotherapy-related toxicity, response to chemotherapy, surgical morbidity and mortality, liver function and survival data were assessed.

RESULTS

A total of 35 patients were identified. Of these, 26 (74.3%) patients received oxaliplatin-based cytotoxic chemotherapy, six (17.1%) received irinotecan-based therapy and the remainder received both agents. A total of 17 patients (48.6%) underwent portal vein embolization prior to resection and 12 (34.3%) underwent staged resection for extensive bilobar disease. A median of six cycles of preoperative Bev were administered. Nine patients (25.7%) experienced grade 3 or higher chemotherapy-related toxicities. Four events were deemed to be related to Bev. The overall response rate was 65.7% (complete and partial response). One patient progressed on therapy, but this did not prevent R0 resection. The incidence of postoperative morbidity was 42.3%. A total of 21.7% of complications were Clavien grade 3 or higher. There were no perioperative mortalities. There were no cases of severe sinusoidal injury or steatohepatitis. The Kaplan-Meier estimate of 4-year survival was 52.5%.

CONCLUSIONS

These data confirm the safety of chemotherapy regimens which include Bev in the perioperative setting and demonstrate that such perioperative chemotherapy in patients with CRLM does not adversely affect patient outcome. There was no increase in perioperative morbidity compared with published rates. The addition of Bev to standard chemotherapy may improve response rates, which may, in turn, impact favourably on patient survival.

Hepatic resection for colorectal metastases: the impact of surgical margin status on outcome

An R0 margin width of 1 cm has traditionally been considered a prerequisite to minimize local recurrence and optimize survival following hepatic resection for metastatic colorectal cancer. However, recent data have called into question the prognostic importance of the '1-cm rule'. Specifically, several studies have noted that, although an R0 resection is important, the actual margin width may not be as critical. We provide a brief overview of the impact of an R1 vs. an R0 resection on local recurrence and overall survival. In addition, we specifically review the impact of margin width in patients who have undergone an R0 resection. Finally, we highlight those factors most associated with an increased likelihood of an R1 resection and provide recommendations for avoiding and dealing with microscopic carcinoma discovered intraoperatively at the cut parenchymal transection margin.

Effect of heat-shock protein-90 (HSP90) inhibition on human hepatocytes and on liver regeneration in experimental models

BACKGROUND

Targeting heat shock protein 90 (HSP90) has gained great interest for cancer therapy. However, in view of novel multimodality therapy approaches for treating hepatic metastases, concerns have raised regarding the impact of targeted therapies on liver regeneration and repair. In this study, we investigated the impact of HSP90 inhibition on liver regeneration in murine models.

METHODS

Effects of HSP90 inhibition on the activation of signaling intermediates, expression of vascular endothelial growth factor (VEGF), and hepatocyte growth factor (HGF) were investigated in primary human hepatocytes (PHHs) in vitro. Effects of HSP90 inhibition on liver regeneration and repair were determined in a murine hepatectomy model and in a model with acute carbon tetrachloride (CCl(4))-induced liver damage.

RESULTS

Inhibition of HSP90 effectively diminished the constitutive phosphorylation of Akt, Erk, and STAT3 in PHHs. Conversely, inhibition of HSP90 significantly increased the expression of both VEGF and HGF mRNA, and induced HSP70 protein in PHH cultures in vitro. In vivo, HSP90 inhibition significantly upregulated constitutive VEGF mRNA and HSP70 in murine livers and did not impair liver re-growth after 70% hepatectomy. Furthermore, BrdUrd-staining and histological quantification of necrotic areas revealed that HSP90 inhibition did not impair liver regeneration following partial hepatectomy, or liver repair that occurs after toxic liver injury with CCl(4).

CONCLUSION

Targeting HSP90 does not negatively affect the multifactorial process of liver regeneration and repair in vivo. Hence, the use of inhibitors to HSP90 appears to be a valid option for neoadjuvant therapy of liver metastases when subsequent surgery is intended.

Chemotherapy within 30 days prior to liver resection does not increase postoperative morbidity or mortality

BACKGROUND

Liver resections (LRs) are performed with increasing frequency for metastatic disease. To minimize the risk of postoperative complications, a period of 6 weeks between the last dose of chemotherapy and LR is typically recommended. The current study examines postoperative morbidity and mortality following LR in patients who received chemotherapy within 30 days prior to LR.

METHODS

The merged 2005-2007 National Surgical Quality Improvement Program (NSQIP) Participant Use File was queried for perioperative risk factors, laboratory values and postoperative occurrences or complications in patients who underwent LR. Patients were grouped according to their receipt or non-receipt of chemotherapy within 30 days prior to LR and major postoperative complications.

RESULTS

A total of 2331 patients underwent LR; 2147 did not receive chemotherapy within 30 days of resection (No Chemo group) and 184 received chemotherapy within 30 days prior to resection (Chemo group). The groups were similar with regard to preoperative co-morbidities and operative factors. The median NSQIP statistically computed morbidity probability was similar between the groups (No Chemo 0.32, Chemo 0.34; P= 0.07), whereas the median mortality probability was higher in the Chemo group (0.02) than the No Chemo group (0.014; P= 0.001). Thirty-day survival was similar between the two groups (No Chemo 97%, Chemo 98%; P= 0.44). Major complication rates did not differ between the groups (No Chemo 20%, Chemo 18%; P= 0.51). Factors associated with major complications in the Chemo group included: extent of resection; intraoperative transfusion; preoperative ascites, and preoperative haematocrit.

DISCUSSION

Major morbidity was not increased in Chemo patients. The strongest predictors of major postoperative complications in the Chemo group were extent of resection and intraoperative red cell transfusion. Although the NSQIP dataset does not include data about tumour type or chemotherapy regimen, these data suggest that LR may be safely performed within 30 days of chemotherapy, thereby minimizing the length of time during which patients do not receive systemic treatment.

Curable metastatic colorectal cancer: recommended paradigms

"Cure" for patients with stage IV colorectal cancer remains elusive, but for a growing subset of patients with colorectal liver metastases (CLMs), cure (ie, > 10-year survival without evidence of disease) is achieved in at least 17% of resected patients. Candidates for resection include those with limited and in some cases extensive hepatic disease, and in highly selected cases, patients with extrahepatic disease. Number, size, and bilaterality of CLMs no longer stand as absolute contraindications to surgery. Chemotherapy has further advanced the field of surgery for CLMs, enabling an additional group of patients who present with unresectable disease to undergo surgery after downsizing with chemotherapy. Modern surgical techniques and liver preparation allow resection after chemotherapy, with excellent results. This article summarizes the current multidisciplinary approach to treatment of CLMs. The definition of resectability, conversion of unresectable CLMs to resectable ones, advances in surgical techniques, advances in chemotherapy, and predictors of outcome are detailed.

[Key events from the 4th French-speaking congress on digestive and hepatobiliary surgery: synthesis of the oral communications and report of symposium. December 4-6 2008, Paris]

Are presented in this issue, the main oral communications presented at the 4(th) francophone congress on digestive and hepatobiliary surgery and an overview of the symposium that was dedicated to the metastatic colorectal cancer treatment. Colorectal carcinoma is the second leading cause of cancer in Europe and the third cause of cancer death in the United States. Every year in France, 36,000 new cases are diagnosed, 50% of them with visceral metastases. Among these metastasis patients, 70% exhibit liver metastases exclusively at time of diagnosis. In most patients, liver metastases are non resectable, with exclusive chemotherapy offering poor survival. Surgery is the only curative treatment. Among patients with liver metastases, 10 to 20% are resectable with 40% of them surviving at 5 years. The aim of the chemotherapy intensification schedules is to allow resection in 15 to 30% of initially non resectable metastatic patients and consequently offering some long term survivals. Regarding metastatic colorectal cancer treatment, confrontation between oncologists and surgeons is essential in order to give the opportunity to a significant number of metastatic patients to access to cure.

Complete pathological response in a patient with multiple liver metastases from colon cancer treated with Folfox-6 chemotherapy plus bevacizumab: a case report

The complete pathological response after primary chemotherapy could represent an important prognostic factor in patients affected by colorectal liver metastases. In recent studies, increasing complete pathological response seems to be correlated with longer overall survival periods and it is recognized as an important prognostic factor in patients treated with pre-operative chemotherapy. The correlation of radiological information on residual neoplastic disease after neoadjuvant treatment, obtained with CT and PET, has to be evaluated; in fact the complete disappearance of liver metastasis on radiological imaging does not always mean a complete disappearance of tumor tissue on histological examination; when it is documented with surgical procedures and confirmed by pathologist's examination, we can consider the complete pathological response. In recent years the addition of monoclonal antibodies to conventional chemotherapy may further increase the proportion of patients referred for surgery; bevacizumab before surgery has been shown to be feasible and safe, although concerns still exist regarding possible post-surgical and wound healing complications or bleeding. The limitation of the radiologic assessment of response as a surrogate for pathological response is even more relevant when antiangiogenic treatments are used. Excellent responses to bevacizumab-containing regimens do occur and referral to surgical oncology is a crucial step for documentation of complete pathological response.

Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection

BACKGROUND/AIMS

Despite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels.

MATERIALS AND METHODS

Of the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality.

RESULTS/FINDINGS

Thirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed.

INTERPRETATION/CONCLUSION

Factors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient.

In-hospital mortality for liver resection for metastases: a simple risk score

BACKGROUND

Surgical management of liver metastases from various primaries is increasingly common. The mortality of such procedures is not well-defined. Accurate predictions for perioperative risk could augment decision-making.

MATERIALS AND METHODS

The Nationwide Inpatient Sample was queried (1998-2005) for patient-discharges for hepatic procedures for metastases. Logistic regression and bootstrap methods were used to create an integer score for estimating the risk of in-hospital mortality using patient demographics, comorbidities, procedure, and hospital type. A randomly selected sample of 80% of the cohort was used to create the risk score, with validation of the score in the remaining 20%.

RESULTS

For the total 50,537 patient-discharges, overall in-hospital mortality was 2.6%. Factors included in the model were age, sex, Charlson comorbidity score, procedure type, and teaching hospital status. Integer values were assigned for calculating an additive score. Four score groups were assembled to stratify risk, with a 15-fold gradient of mortality ranging from 0.9% to 14.7% (P<0.0001). In the derivation and the validation set, the score discriminated well, with a c-statistic of 0.72 and 0.72, respectively.

CONCLUSION

An integer-based risk score can be used to predict in-hospital mortality after hepatic procedure for metastases, and may be useful for preoperative patient counseling.

Modern diagnosis and management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is rising, and the number of patients with HCC is expected to more than double over the next 1 to 2 decades. HCC meets the criteria for establishment of a surveillance program. Patients with cirrhosis, regardless of the cause, are at the highest risk for developing HCC and this is the population in which surveillance should be performed. (Alpha-fetoprotein and hepatic ultrasonography are the currently recommended surveillance tests. If a surveillance test is abnormal, there is a need for a recall test for diagnostic evaluation of HCC. Triple-phase imaging is recommended for evaluation at recall, with MRI being more sensitive and specific. Novel genetic markers can improve the histologic diagnosis of early HCC. The Barcelona staging classification is the best system for determining the prognosis of patients and it is linked to an evidence-based treatment algorithm. Resection, transplantation, and percutaneous ablation are considered curative interventions and are currently applied to about 30% of all patients with HCC.

Current management of colorectal hepatic metastasis

In the USA, cancers of the colon and rectum are the third most common site of new cancer cases and cancer deaths. With improved screening and adjuvant therapy, the survival of patients has increased substantially over the last decade. However, patients with metastatic disease often have limited survival. Hepatic metastasis is one of the most frequent sites of metastatic disease. In fact, 35-55% of patients with colorectal cancer will develop hepatic metastasis at some time during the course of their disease. Patients who are able to undergo complete resection of their hepatic metastases have the best chance of long-term survival. The goal of hepatic resection is to achieve complete resection of all metastases with microscopically negative surgical margins while preserving sufficient hepatic parenchyma. Survival following hepatic resection of colorectal metastasis now approaches 35-50%. However, approximately 65% of patients will have a recurrence at 5 years. Increasingly chemotherapeutic agents are being offered in the preoperative setting prior to operation. At the time of operation, patients with extensive hepatic disease can sometimes be offered ablative therapies combined with resection or staged approaches. Modern management of hepatic colorectal metastases necessitates a multidisciplinary approach to effectively treat these patients and increase the number of patients who will benefit from resection.

Management of chemotherapy-associated hepatotoxicity in colorectal liver metastases

Effective systemic drugs are increasingly used to treat patients with colorectal liver metastases. Recent trials have shown that chemotherapy can reduce the size of metastases that are unresectable rendering them resectable, and decrease postoperative recurrence rates in patients with initially resectable tumours. The increasing use of chemotherapy for colorectal liver metastases has raised awareness of the potential hepatotoxicities induced by systemic drugs and the effects of these drugs on outcome after hepatic resection. In this Review, we outline the rationale for the use of perioperative chemotherapy for colorectal liver metastases, associations between specific agents and patterns of liver injury, and strategies to treat patients with suspected or known chemotherapy-associated hepatotoxicity.

Hypertrophy of the non-embolized liver after chemotherapy

BACKGROUND

Neoadjuvant chemotherapy (NC(+)) and portal vein embolization (PVE) enables curative resection in more patients with colorectal-liver metastases (CRLM). However, after NC(+), structural alterations have been reported with the risk of post-operative hepatic failure. We undertook to determine if NC(+) toxicity limits future remnant liver (FRL) hypertrophy after PVE.

METHODS

PVE was performed in 20 patients, 13 (65%) of whom previously received a mean FOLFIRI (5-fluorouracil + leucovorin + irinotecan) regimen (NC(+)) of 6.6 cycles. The seven remaining patients served as the control group without NC (NC(-)).

RESULTS

CRLM were bilateral in 69% (NC(+)) and 57% (NC(-)), and synchronous in 84% (NC(+)) and 14% (NC(-)). The FRL hypertrophy rate was 54.1% (NC(+)) and 43.7% (NC(-)) (P= 0.3). CRLM were unresectable in four of our 20 patients, i.e. group NC(+): one insufficient FRL hypertrophy and one severe steatosis; and group NC(-): two tumoral progressions. In both groups, the operative parameters were comparable except for pedicular clamping: 8 (NC(+)) and 36 min (NC(-)), respectively (P < 0.05). Also, the surgical outcome rate and hospital stay were comparable. No significant pathological difference was observed between the two groups. No mortality occurred in either group.

CONCLUSION

In view of our limited experience, we conclude that hypertrophy of the non-embolized liver (FRL) is not altered after FOLFIRI-based NC.

Treatment of patients with colorectal cancer: emphasis on liver metastases

The treatment of colorectal liver metastases has progressed considerably in recent years. Coordinated multidisciplinary management of patients on clinical trials has resulted in 5-year survival rates exceeding 50%, and for certain patients cure is now a realistic goal. For all patients, the approval of six new drugs has contributed to an increase in median survival from 6 months to over 20 months. Recent molecular discoveries promise an era of tailored therapy in which only patients known to benefit will be treated, an approach that will enable more efficient use of the already stretched resources. Clinical trials continue to investigate different combinations and methods of administering approved therapies, but if the progress of the past decade is to be replicated it is imperative that we embrace innovative treatment strategies and novel trial designs. In this review, we highlight the developments that have improved survival for patients with colorectal liver metastases and discuss the many issues that challenge further progress.

Risk factors for chemotherapy-associated liver injuries: A multivariate analysis of a group of 146 patients with colorectal metastases

BACKGROUND

Chemotherapy for colorectal liver metastases (CLM) may be associated with pathologic changes to the liver parenchyma, possibly increasing the risk of surgery. The aim of this study was to determine the risk factors for chemotherapy-associated liver injuries (CALI).

METHODS

From 1998 to 2006, 146 patients underwent a liver resection for CLM within 3 months of preoperative chemotherapy. CALI were defined as follows: steatosis > or =30%, or steatohepatitis, or moderate or severe sinusoidal lesions. Univariate and multivariate analysis were used to examine the relationship between CALI and 36 other preoperative factors.

RESULTS

Pathologic examination showed CALI in 74/146 patients (51%), including sinusoidal lesions (n = 50), steatosis > or = 30% (n = 32), and steatohepatitis (n = 15). Twenty-three patients had overlapping CALI. In multivariate analysis, BMI > 27 (P = .002), hyperglycemia > 7 mmol/l (P = .006), and an interval between chemotherapy and surgery < 4 weeks (P = .011) were independent risk factors for CALI, whereas aspirin intake was associated with reduced risk of CALI (P = .002). In multivariate analysis, synchronous metastases (P = .015), unresectable liver metastases at diagnosis (P = .034), GGT plasma level > 1.5N (P = .028), and oxaliplatin-based chemotherapy (P < .01) were risk factors for sinusoidal lesions. Aspirin intake was associated with reduced risk for sinusoidal lesions (P = .03). In multivariate analysis, BMI > 27 (P = .026) was the only risk factor for steatosis or steatohepatitis.

CONCLUSION

In patients with CLM, there are few preoperative risk factors for CALI. In patients treated by oxaliplatin-based chemotherapy, aspirin intake appears to be associated with a reduced risk of sinusoidal lesions and should be tested in a randomized phase II study.

A marking technique for intraoperative localization of small liver metastases before systemic chemotherapy

Preoperative chemotherapy is increasingly used prior to resection of colorectal liver metastases (CLM). Since some of these lesions may disappear or may be hardly detectable with intraoperative ultrasound (IOUS), we describe herein a new technique to mark small lesions with coils before chemotherapy. This technique facilitates the resection of small lesions likely to disappear after preoperative chemotherapy.