Chemotherapy and surgery: new perspectives on the treatment of unresectable liver metastases

Optimizing resection for "responding" hepatic metastases after neoadjuvant chemotherapy

Fifty percent of patients with colorectal cancer will develop metastases at some time during their disease, with the liver being the most common site. Recent advances in the treatment of metastatic colorectal cancer have led to a change in treatment paradigm. What follows is a review of the surgical management of hepatic colorectal metastases responding to neoadjuvant chemotherapy. In addition, the complexity of treating patients with "disappearing" colorectal liver metastases is discussed.

Improvements in population-based survival of patients presenting with metastatic rectal cancer in the south of the Netherlands, 1992-2008

We analysed population-based treatment and survival data of patients who presented with metastatic rectal cancer. All patients diagnosed with primary synchronous metastatic rectal cancer between 1992 and 2008 in the Eindhoven Cancer Registry area were included. Date of diagnosis was divided into three periods (1992–1999, 2000–2004, 2005–2008) according to the availability of chemotherapy type. We assessed treatment patterns and overall survival according to period of diagnosis. The proportion of patients diagnosed with stage IV disease increased from 16% in 1992–1999 to 20% in 2005–2008 (P < 0.0001). Chemotherapy use increased from 5% in 1992 to 61% in 2008 (P < 0.0001). Resection rates of the primary tumour decreased from 65% in 1992 to 27% in 2008 (P < 0.0001), while metastasectomy rates remained constant since 1999 (9%). Median survival increased from 38 weeks (95% confidence interval (CI) 32–44) in 1992–1999 to 53 weeks (95% CI 48–61) in 2005–2008. Among patients not receiving chemotherapy median survival remained approximately 30 weeks. Multivariable analysis confirmed the lower risk of death among patients diagnosed in more recent years. Increased use of chemotherapy went together with improved median survival among patients with metastatic rectal cancer in the last two decades. Stage migration as an effect of more effective imaging procedures is likely to be partly responsible for this improved survival.

[Oncosurgical strategies for metastatic liver cancer]

Patients with liver metastases from colorectal cancer (CRC) present a major public health challenge with approximately, 1,2 million cases of CRC occur yearly worldwide. Resection of colorectal liver metastases (CRLM) is the only treatment offering the possibility of cure and has been shown to provide clear survival benefits. However, only 10 to 20% of patients with CRLM are eligible for this procedure upfront. During the last decade, major advances in the management of CRLM have taken place involving three fields: oncology, interventional radiology, and surgery. These advances have increased the resectability rate to 20-30% of cases with a 5-year survival of 35-50%. Neoadjuvant treatment with chemotherapeutic agents such as irinotecan and oxaliplatin, and hepatic artery infusion combined with systemic therapy and biologic agents (bevacizumab, cetuximab) play an important role in increasing the number of patients eligible to secondary resection. However, with the progressive use of neoadjuvant chemotherapy further studies are necessary to answer questions such as the risk: benefit ratio in maximizing response rates versus vascular changes in the liver (current opinion still divided concerning their importance). These questions remain challenging and should not be underestimated. In this review, we have described the current oncosurgical strategies employed in patients with resectable and non resectable CRLM, their benefits, and future treatment strategies.

Pre-operative nomogram to predict risk of peri-operative mortality following liver resections for malignancy

INTRODUCTION

The majority of liver resections for malignancy are performed in older patient with major co-morbidities. There is currently no pre-operative, patient-specific method to determine the likely peri-operative mortality for each individual patient. The aim of this study was to develop a pre-operative nomogram based on the presence of co-morbidities to predict risk of peri-operative mortality following liver resections for malignancy.

METHODS

The Nationwide Inpatient Sample database was queried to identify adult patients that underwent liver resection for malignancy. The pre-operative co-morbidities, identified as predictors were used and a nomogram was created with multivariate regression using Taylor expansion method in SAS software, surveylogistic procedure. Training set (years 2000-2004) was utilized to develop the model and validation set (year 2005) was utilized to validate this model.

RESULTS

A total of 3,947 and 972 patients were included in training and validation sets, respectively. The overall actual-observed peri-operative mortality rates for training and validation sets were 4.1% and 3.2%, respectively. The decile-based calibration plots for the training set revealed good agreement between the observed probabilities and nomogram-predicted probabilities. Similarly, the quartile-based calibration plot for the validation set revealed good agreement between the observed and predicted probabilities. The accuracy of the nomogram was further reinforced by a good concordance index of 0.80 with a 95% confidence interval of 0.72 and 0.87.

CONCLUSIONS

This pre-operative nomogram may be utilized to predict the risk of peri-operative mortality following liver resection for malignancy.

Advances in therapeutics for liver metastasis from colorectal cancer

The evolution of chemotherapeutic regimens that include targeted molecular agents has resulted in a breakthrough in the management of advanced colorectal liver metastasis (CLM), improving the progression-free survival after liver resection, and rendering initially unresectable liver tumors resectable, with reported resection rates ranging from 13% to 51%. In addition, the criteria used for selecting patients for hepatectomy have been expanding because of advances in surgical techniques and improvements in chemotherapy. However, the increasing use of chemotherapy has raised concern about potential hepatotoxicities such as steatosis, chemotherapy-associated steatohepatitis, and sinusoidal obstruction syndrome, and their deleterious effects on postoperative outcome. The present review focuses on the advantages and disadvantages of chemotherapy, strategies for the prevention and diagnosis of chemotherapy-associated liver injury, and the adoption of more aggressive surgical approaches, which have changed the traditional paradigm for CLM.

Survival outcomes of a salvage patient population after radioembolization of hepatic metastases with yttrium-90 microspheres

PURPOSE

To determine in a retrospective study the potential benefit on survival outcomes of radioembolization using yttrium-90 ((90)Y) resin microspheres in a cohort of patients presenting with chemotherapy-refractory liver metastases, primarily from colorectal cancer (CRC).

MATERIALS AND METHODS

Over 3 years, 249 patients were referred to the authors' center to determine suitability for radioembolization as treatment for hepatic metastases. All patients were defined as salvage, having failed first-line and second-line chemotherapies. These patients were divided into group 1 (CRC) and group 2 (all other cancers, eg, breast, neuroendocrine) and assessed for overall survival (OS) as a whole and according to group.

RESULTS

Using (90)Y resin microspheres, 208 patients were treated, undergoing 223 radioembolization treatments. The median OS was 8.3 months for the whole cohort, 7.9 months for group 1, and 8.7 months for group 2. At the 3-month follow-up, there was an overall adverse event rate of 9%. At the end of the data collection period, 62 patients were still alive.

CONCLUSIONS

Radioembolization shows promise as an effective and safe treatment for patients with chemotherapy-refractory hepatic metastases providing an extension to survival in the salvage setting.

Regional hepatic chemotherapies in the treatment of colorectal cancer metastases to the liver

The liver is the most common site of metastatic spread of colorectal cancer (CRC). Liver may be the only site of spread in as many as 30% to 40% of patients with advanced disease and can be treated with regional therapies directed toward their liver tumors. Surgery is currently the only potentially curative treatment, with a 5-year survival rate as high as 30% to 40% in selected patients. However, fewer than 25% of cases are candidates for curative resection. A number of other locoregional therapies, such as radiofrequency or microwave ablation, cryotherapy, and chemotherapy, may be offered to patients with unresectable but isolated liver metastases. However, for most patients with metastatic spread beyond the liver, systemic chemotherapy rather than regional therapy is a more appropriate option. We review the status of various regional hepatic chemotherapies in the treatment of colorectal metastases to the liver in the light of the available, published prospective, randomized trials; this discipline has not yet been properly applied to the burgeoning use of locally ablative techniques. The regional strategies reviewed include portal venous infusion (PVI) of 5-fluorouracil (5-FU), intra-arterial chemotherapy (hepatic arterial infusion [HAI]), chemoembolization, and selective internal radiation therapy (SIRT).

[Prognostic factors and survival of metastatic colorectal cancer in the Sousse University Hospital (Tunisia): comparative study of two treatment period of 200 patients]

Between 1994 and 2005, 200 patients with metastatic colo-rectal cancers were treated in the Sousse CHU (Tunisia), we analysed two groups of patients, the group 1 was treated in the period after 1999 (N = 64), the group 2 was treated in the period between 1999 and 2005 (N = 136).

PATIENTS AND METHODS

Mean age of the patients was 50 years, localisation of metastases was liver in 67.3% of cases, 23% of patients had multiple metastases, 44% of cases developed metastases after a median period of 11.4 months. All patients had received first line of chemotherapy, the regimen of chemotherapy was in the group 1, Fufol in the majority of cases (76%), the regimen of chemotherapy was in the group 2, simplified LV5FU2 associated to irinotecan in the majority of cases (83%), 28% of all patients received second line of chemotherapy.

RESULTS

The median survival was 13.8 months in the group 1 and 19 months in the group 2. Overall survival rates at 2 years were 35% and 42% (p = 0.02) in group 1 and 2, respectively. Prognostic factors for a better survival using univariate analysis were: normal ACE (P < 0.01), normal liver analysis (P < 0.001), response after 3 cycles of chemotherapy (P < 0.0005), resection of liver metastases (P < 0.05). The multivariate analysis (cox model) revealed only one independent factor: radiologic response after 3 cycles of chemotherapy (P < 0.03).

CONCLUSION

The prognostic of patients with metastatic disease is poor, although palliative chemotherapy after the recent advances and the use of new drugs have been shown to be able to prolong survival and to improve the quality of life over best supportive care. This study report amelioration of prognostic and survival of metastatic colorectal cancers in Tunisia.

Multimodal treatment options for bilobar colorectal liver metastases

Purpose

We evaluated individualized multimodal oncological strategies in patients with bilobular colorectal liver metastases (biCRC-LM) as well as their effect on R0 resection rates, disease-free survival (DFS), and overall survival (OS).

Methods

Between January 2001 and December 2008, 64 patients were assigned to straightforward or two-stage liver resection ± preoperative 5-fluorouracil (5FU)-based chemotherapy (CTx). Postoperative strategy after R0-resection was either “wait and see” or “adjuvant” therapy (3 cycles of CTx or anti-carcinoembryonic antigen (CEA)-radioimmunotherapy with ¹³¹I-labetuzumab in a dose of 40–50 mCi/m²).

Results

Forty-three initially unresectable patients received preoperative CTx for downsizing of their biCRC-LM. Straightforward or two-stage liver resection was intended in 40 and 24 patients, respectively. Histopathologically confirmed R0-liver resection could be achieved in 47 patients. Surgical morbidity and mortality rates were 33% and 1.5%, respectively. Postoperatively, 26 patients received anti-cancer therapy (5 × CTx, 21 × anti-CEA-radioimmunotherapy). After R0-liver resection, median OS was significantly better compared to R1/R2 resections followed by palliative 5FU-CTx (38 versus 19 months, p = 0.035). There was no significant difference in DFS (p = 0.650) and OS (p = 0.435) between straightforward and two-stage liver resection. Compared to “wait and see” strategy, the application of postoperative therapy in adjuvant intent was associated with a better OS (p = 0.048).

Conclusion

Extensive liver resection within multimodal treatment concepts is justified in patients with biCRC-LM when complete resection of all metastases seems to be achievable.

Tumor marker evolution: comparison with imaging for assessment of response to chemotherapy in patients with colorectal liver metastases

Background

As the real clinical significance of carcinoembryonic antigen (CEA) and carbohydrate antigen 19.9 (CA19.9) evolution during preoperative chemotherapy for colorectal liver metastases (CLM) is still unknown, we explored the correlation between biological and radiological response to chemotherapy, and their comparative impact on outcome after hepatectomy.

Methods

All patients resected for CLM at our hospital between 1990 and 2004 with the following eligibility criteria were included in the study: (1) preoperative chemotherapy, (2) complete resection of CLM, (3) no extrahepatic disease, and (4) elevated baseline tumor marker values. A 20% change of tumor marker levels while on chemotherapy was used to define biological response (decrease) or progression (increase). Correlation between biological and radiological response at computed tomography (CT) scan, and their impact on overall survival (OS) and progression-free survival (PFS) after hepatectomy were determined.

Results

Among 119 of 695 consecutive patients resected for CLM who fulfilled the inclusion criteria, serial CEA and CA19.9 were available in 113 and 68 patients, respectively. Of patients with radiological response or stabilization, 94% had similar biological evolution for CEA and 91% for CA19.9. In patients with radiological progression, similar biological evolution was observed in 95% of cases for CEA and in 64% for CA19.9. On multivariate analysis, radiological response (but not biological evolution) independently predicted OS. However, progression of CA19.9, but not radiological response, was an independent predictor of PFS.

Conclusions

In patients with CLM and elevated tumor markers, biological response is as accurate as CT imaging to assess “clinical” response to chemotherapy. With regards to PFS, CA19.9 evolution has even better prognostic value than does radiological response. Assessment of tumor markers could be sufficient to evaluate chemotherapy response in a nonsurgical setting, limiting the need of repeat imaging.

Selective metastatic tumor labeling with green fluorescent protein and killing by systemic administration of telomerase-dependent adenoviruses

We previously constructed telomerase-dependent, replication-selective adenoviruses OBP-301 (Telomelysin) and OBP-401 [Telomelysin-green fluorescent protein (GFP); TelomeScan], the replication of which is regulated by the human telomerase reverse transcriptase promoter. By intratumoral injection, these viruses could replicate within the primary tumor and subsequent lymph node metastasis. The aim of the present study was to evaluate the possibility of systemic administration of these telomerase-dependent adenoviruses. We assessed the antitumor efficacy of OBP-301 and the ability of OBP-401 to deliver GFP in hepatocellular carcinoma (HCC) and metastatic colon cancer nude mouse models. We showed that i.v. administration of OBP-301 significantly inhibited colon cancer liver metastases and orthotopically implanted HCC. Further, we showed that OBP-401 could visualize liver metastases by tumor-specific expression of the GFP gene after portal venous or i.v. administration. Thus, systemic administration of these adenoviral vectors should have clinical potential to treat and detect liver metastasis and HCC.

Long-term results of hepatectomy after hepatic arterial infusion chemotherapy for initially unresectable hepatic colorectal metastases

BACKGROUND

The prognosis of unresectable hepatic colorectal metastases is poor even if chemotherapy is administered. The purpose of this study was to evaluate the long-term efficacy of hepatic arterial infusion (HAI) chemotherapy and hepatectomy following HAI for such condition.

METHODS

Seventy-two patients with unresectable hepatic colorectal metastases received continuous HAI of 5-fluorouracil.

RESULTS

The overall response rate was 38%. The median survival of all patients was 18 months. The overall 3-year survival rate was 18%. Seven patients (10%) survived more than 58 months. Of the eight patients with a complete response, seven developed liver and/or lung metastases, and of these, one patient undergoing additional hepatectomy has been disease-free and the other six receiving chemotherapy died of disease. Another complete-response case died of liver abscess. Of the 19 patients with a partial response, six could undergo hepatectomy after HAI. The overall 5-year survival rate of seven patients undergoing hepatectomy was 71%, whereas for patients without hepatectomy, the rate was 0%.

CONCLUSIONS

Most patients showing response after HAI for unresectable hepatic colorectal metastases had relapses. The long-term prognosis of patients undergoing hepatectomy after HAI was favorable. Therefore, when HAI makes liver metastases resectable, they should be resected.

Secondary hepatic resection as a therapeutic goal in advanced colorectal cancer

Surgery is the only curative option for patients with liver metastases of colorectal cancer, but few patients present with resectable hepatic lesions. Chemotherapy is increasingly used to downstage initially unresectable disease and allow for potentially curative surgery. Standard chemotherapy regimens convert 10%-20% of cases to resectable disease in unselected populations and 30%-40% of those with disease confined to the liver. One strategy to further increase the number of candidates eligible for surgery is the addition of active targeted agents such as cetuximab and bevacizumab to standard chemotherapy. Data from a phase III trial indicate that cetuximab increases the number of patients eligible for secondary hepatic resection, as well as the rate of complete resection when combined with first-line treatment with the FOLFIRI regimen. The safety profiles of preoperative cetuximab or bevacizumab have not been thoroughly assessed, but preliminary evidence indicates that these agents do not increase surgical mortality or exacerbate chemotherapy-related hepatotoxicity, such as steatosis (5-fluorouracil), steatohepatitis (irinotecan), and sinusoidal obstruction (oxaliplatin). Secondary resection is a valid treatment goal for certain patients with initially unresectable liver metastases and an important end point for future clinical trials.

Câncer colorretal metastático: papel atual dos anticorpos monoclonais e a individualização de seu uso

INTRODUÇÃO: Apesar dos poucos casos de cura no câncer colorretal metastático, a última década foi marcada por avanços na disponibilidade de novos fármacos com mecanismos de ação distintos e aplicabilidade em várias linhas de tratamento. De fato, a sobrevida mediana de pacientes com câncer colorretal metastático praticamente dobrou ao longo dos últimos 10 anos, e parte dessa mudança se deve à introdução dos anticorpos monoclonais, capazes de reconhecer antígenos com importância patogênica em tumores. OBJETIVO: Apresentar revisão dos resultados obtidos com os anticorpos monoclonais usados em câncer colorretal. MÉTODOS: Revisão de 29 trabalhos publicados e obtidos nas fontes atuais de busca virtual. Foram revisados o papel do Bevacizumabe - anticorpo contra o VEGF; o Cetuximabe e Panitumumabe - anticorpos contra o EGFR e o oncogene K-Ras na resposta ao tratamento. CONCLUSÃO: Sugere-se ao final algoritmo de tratamento com anticorpos monoclonais.

Bevacizumab protects against sinusoidal obstruction syndrome and does not increase response rate in neoadjuvant XELOX/FOLFOX therapy of colorectal cancer liver metastases

AIM

In patients suffering from colorectal cancer liver metastases, 5-fluorouracil-based chemotherapy plus oxaliplatin ensures superior response rates at the cost of hepatic injury. Knowledge about the consequences of bevacizumab on chemotherapy-induced hepatic injury and tumor response is limited.

METHODS

Resected liver specimens from patients of two prospective, non-randomized trials (5-fluorouracil/oxaliplatin+/-bevacizumab) were analyzed retrospectively. Hepatotoxicity to the non-tumor bearing liver was evaluated for sinusoidal obstruction syndrome, hepatic steatosis and fibrosis. Tumor response under chemotherapy was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST).

RESULTS

Bevacizumab decreased the severity of the sinusoidal obstruction syndrome. Bevacizumab had no impact on hepatic steatosis and fibrosis. The addition of bevacizumab to chemotherapy had no effect on tumor response compared to combination chemotherapy alone.

CONCLUSIONS

This analysis shows that bevacizumab protects against the sinusoidal obstruction syndrome and thus provides the histological explanation of the safe use of bevacizumab prior to liver resection. Furthermore, we show that bevacizumab does not improve tumor response according to RECIST.

Two-stage hepatectomy (R0) with portal vein ligation--towards curing patients with extended bilobular colorectal liver metastases

BACKGROUND AND AIMS

Patients with bilobular colorectal liver metastases (CRLM) experience poor prognosis, especially when curative resection cannot be achieved. However, resectability in these patients is often limited by low future remnant liver volume (FRLV). The latter can be enhanced by a two-stage liver resection, using portal vein ligation to induce liver hypertrophy. The aim of this prospective pilot study was to evaluate safety, secondary resectability, and time to recurrence of two-stage hepatectomy with portal vein ligation (PVL) and complete surgical clearance of the FRLV in patients with bilobular CRLM.

MATERIALS AND METHODS

Out of 24 patients (63+/-8.26 years) with extended bilobular CRLM (metachronous n=10, synchronous n=14), 18 received preoperative 5-FU-based chemotherapy combined with oxaliplatin or irinotecan. Staging included thoracoabdominal computed tomography and (18)F-fluorodeoxyglucose-positron emission tomography scans. First-stage procedure consisted of PVL, resection of all CRLM in the FRLV, and radiofrequency ablation (RFA) of CRLM situated near the future resection plane.

RESULTS

During first-stage procedure, 7x RFA, 4x non-anatomical resections, and 4x bisegmentectomies were performed additionally to PVL. FRLV/body-weight ratio increased from 0.4% to 0.6% within 55 days (median) after PVL. Second-stage hepatectomy was performed in 19 patients without tumor progression. R0 resection was possible in 14 patients. During a median follow-up of 17 months, intrahepatic recurrence occurred in two, and extrahepatic recurrence in nine out of 14 patients.

CONCLUSION

Two-stage hepatectomy with PVL and complete surgical clearance of FRLV is safe even after intensified systemic chemotherapy resulting in a curative resection rate of 58.3% (73.7% of re-explored cases).

Innovations in chemotherapy for metastatic colorectal cancer: an update of recent clinical trials

It has been estimated that cancer of the colon and rectum (CRC) would be diagnosed in 153,760 men and women in the U.S. alone in 2007. Approximately one in five patients has metastatic CRC (mCRC) at diagnosis, which, at best, is associated with a 5-year survival rate of just 10.3%. Oxaliplatin- and irinotecan-based combination regimens are standard first-line therapies for mCRC. Recent studies suggest that survival outcomes can possibly be further improved by adding biologic agents to chemotherapy. Novel treatment strategies are being investigated to optimize the opportunity for patients to receive and benefit from the increasing number of available active agents and to further improve the efficacy, safety, and tolerability of multiagent therapy. These include switching therapy before progression, maintenance therapy, and chemotherapy-free intervals. Recent innovations in chemotherapy for mCRC are reviewed, with a focus on emerging data that may significantly improve both survival and quality of life for patients with CRC in the future.

Treatment of the elderly colorectal cancer patient: SIOG expert recommendations

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Location of liver metastases reflects the site of the primary colorectal carcinoma

OBJECTIVE

The present study was designed to investigate whether the different venous return of different locations of colorectal carcinomas affects the lobar distribution of metastases to the liver, due to the "streaming" within the portal vein.

MATERIAL AND METHODS

The site of the primary colorectal carcinoma was divided into the right- and left hemicolon according to the different venous drainage via the superior and the inferior mesenteric/splenic vein. Both groups were analyzed for the distribution of the metastases in the liver. The anatomic site of the liver metastases was detected by intraoperative exploration and differentiated between the two lobes using the Cantlie line.

RESULTS

Out of a total of 178 patients, 109 men and 69 women with 264 metastases were eligible for the study. The ratio of metastases in the right and left hemiliver was 3.6:1 for 35 right-sided primary tumors (p=0.002) compared with 2.1:1 for 143 left-sided primary tumors (p=NS). No significant differences were evident for the sub-analysis of involved liver segments.

CONCLUSIONS

The results of our study support the existence of the "streaming" effect in the portal vein. Right-sided colon carcinomas predominantly involve the right hemiliver, while left-sided colon carcinomas involve the liver homogeneously, considering the size ratio of the right to left liver lobe, which is about 2:1. Knowledge of streaming may help us to understand the spread of abdominal malignancies and may provide a reference concerning the possible primary site depending on metastatic distribution in the liver.

Bevacizumab, Capecitabine, and Oxaliplatin As Neoadjuvant Therapy for Patients With Potentially Curable Metastatic Colorectal Cancer

Purpose

Patients with colorectal cancer (CRC) and liver metastases have a poor prognosis, but can benefit from perioperative chemotherapy and disease resection. Bevacizumab improves outcomes in patients with metastatic CRC; however, its impact on surgical complications and hepatic regeneration after liver resection remains to be determined.

Patients and Methods

Fifty-six patients with metastatic CRC with liver metastases potentially curable by resection were eligible for this single-center, nonrandomized phase II trial. Eligibility criteria defined patients at high risk of early recurrence. Patients received biweekly bevacizumab plus capecitabine and oxaliplatin for six cycles. The sixth cycle of therapy did not include bevacizumab, resulting in 5 weeks between the last administration of bevacizumab and surgery.

Results

Objective response to neoadjuvant chemotherapy was achieved in 41 patients (73%). Fifty-two patients underwent liver resection including 11 with synchronous primary tumor resection. No increased intraoperative bleeding events or wound-healing complications were observed and only three patients (6%) required perioperative blood transfusions. Further surgery was necessary in a single patient. Postoperative liver function and regeneration were normal in all but one patient. No postoperative mortality occurred and morbidity was encountered in 11 patients (20%). The mean length of postoperative hospitalization was 9 days (± 4.0).

Conclusion

These data suggest that bevacizumab can be safely administered until 5 weeks before liver resection in patients with metastatic CRC without increasing the rate of surgical or wound healing complications or severity of bleeding. To our knowledge, they are also the first to show that neoadjuvant bevacizumab does not affect liver regeneration after resection.

Effect of Molecular Therapeutics on Liver Regeneration in a Murine Model

Purpose

Unresectable metastatic colorectal cancer (CRC) can be rendered resectable with systemic chemotherapy in approximately 20% of cases. Most patients with metastatic CRC receive chemotherapy with the addition of targeted therapy with anti–vascular endothelial growth factor (VEGF) or anti–epidermal growth factor receptor (EGFR) antibodies. We sought to determine whether anti-VEGF receptor (VEGFR) or anti-EGFR therapy would impair liver regeneration after partial hepatectomy (PH) in mice.

Materials and Methods

Mice underwent either 66% PH or sham laparotomy. In the first experiment, mice in the PH group were randomly assigned to receive daily intraperitoneal injections of monoclonal antibodies (MoABs) to murine VEGFR-2 or nonspecific MoABs (control). In the second experiment, mice in the PH group were randomly assigned to receive intraperitoneal injections of antimurine EGFR or nonspecific (control) MoABs. In both experiments, therapy was initiated the day before surgery and continued until the mice were killed on day 5. Livers were collected and processed.

Results

Anti–VEGFR-2 therapy slightly impaired liver regeneration and hepatic cell proliferation compared with control. Hematoxylin and eosin staining showed no differences in liver morphology. CD105 staining showed decreased levels of activated endothelium in livers in the VEGFR-2 MoAB group. VEGFR-2 MoAB therapy decreased the levels of the cell cycle regulators cyclin D1 and cyclin D3 and the regenerative cytokine interleukin-6. Anti-EGFR therapy had no effect on liver regeneration or cellular proliferation.

Conclusion

Anti–VEGFR-2 therapy slightly impaired liver regeneration in this murine model, whereas anti-EGFR therapy had no effect on liver regeneration.

Guidelines for the detection and treatment of liver metastases of colorectal cancer

The spread of the surgical treatment for hepatic metastases have been crucial in the improvement of treatment and survival of metastatic colorectal cancer. The early and accurate diagnosis of metastases and the assessment of their size are essential factors to reach the optimal results with this treatment strategy. The precise indication of the surgical technique with or without the previous administration of neoadjuvant chemotherapy is of significant importance for the choice of R0 surgery and the timing of intervention. Although there is an agreement regarding some parameters related to diagnosis techniques and surgical criteria such as the bilobar extension, the size of the remaining liver post-surgical removal and the indication of pre-operatory chemotherapy, it is necessary to consider all these factors to set up standard criteria and optimize the results. In this article we review all these parameters, from disease follow up to detect metastatic dissemination to the basic criteria for use of neoadjuvant chemotherapy, in order to suggest some general recommendations of evidence level II and recommendation grade A.

Final analysis of colorectal cancer patients treated with irinotecan and 5-fluorouracil plus folinic acid neoadjuvant chemotherapy for unresectable liver metastases

We have previously reported that neoadjuvant therapy with modified FOLFIRI enabled nearly a third of patients with metastatic colorectal cancer (mCRC) to undergo surgical resection of liver metastases. Here, we present data from the long-term follow-up of these patients. Forty patients received modified FOLFIRI: irinotecan 180 mg m(-2), day 1; folinic acid, 200 mg m(-2); and 5-fluorouracil: as a 400 mg m(-2) bolus, days 1 and 2, and a 48-h continuous infusion 1200 mg m(-2), from day 1. Treatment was repeated every 2 weeks, with response assessed every six cycles. Resected patients received six further cycles of chemotherapy postoperatively. Nineteen (47.5%) of 40 patients achieved an objective response; 13 (33%) underwent resection. After a median follow-up of 56 months, median survival for all patients was 31.5 months: for non-resected patients, median survival was 24 months and was not reached for resected patients. Median time to progression was 14.3 and 5.2 months for all and non-resected patients, respectively. Median disease-free (DF) survival in resected patients was 52.5 months. At 2 years, all patients were alive (8 DF), and at last follow-up, eight were alive (6 DF). Surgical resection of liver metastases after neoadjuvant treatment with modified FOLFIRI in CRC patients achieved favourable survival times.

The role of contrast-enhanced ultrasound for focal liver lesion detection: an overview

The development of new ultrasound (US) contrast agents and sonographic techniques has considerably improved the possibilities of ultrasound in the assessment of liver tumors. An overview is given on diagnostic potential of contrast-enhanced US (CEUS) and real-time low mechanical index technique in the detection of various focal liver lesions compared with computed tomography, magnetic resonance imaging or intraoperative US. In two of our own studies that included 100 patients each we showed an increase of correct findings in CEUS compared with B-mode US from 64% to 87% and from 67% to 84% as confirmed by intraoperative evaluation of the liver. Especially after chemotherapy and in the case of small metastases, significantly more metastases were correctly detected by CEUS compared with B-mode US. These results and clinical study results in the literature show that CEUS allows tumor detection and direct visualization of the tumor vascularity and put contrast-enhanced sonography among recommended noninvasive imaging methods for focal liver lesions with improvements in diagnostic strategy.

Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group

Liver resection offers the only chance of cure for patients with advanced colorectal cancer (CRC). Typically, the 5-year survival rates following liver resection range from 25% to 40%. Unfortunately, approximately 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. However, the rapid expansion in the use of improved combination therapy regimens has increased the percentage of patients eligible for potentially curative surgery. Despite this, the selection criteria for patients potentially suitable for resection are not well documented and patient management by multidisciplinary teams, although essential, is still evolving. The goal of the European Colorectal Metastases Treatment Group is to establish pan-European guidelines for the treatment of patients with CRC liver metastases that can be adopted more widely by established treatment centres and to develop more accurate staging systems and evaluation criteria.

The role of primary tumour resection in patients with stage IV colorectal cancer

OBJECTIVE

The management of stage IV colorectal cancer is controversial. Resection of the primary tumour to prevent obstruction, bleeding or perforation is the traditional approach, although survival benefit is undetermined. Management consisting of diverting ostomy, enteric bypass, laser recanalization or endoscopic stenting is an alternative to radical resection. The purpose of this study was to determine the role of resection of the primary tumour in patients with stage IV colorectal cancer, with specific attention paid to survival benefit and safety.

METHOD

This was a retrospective review of all stage IV colon and rectal cancer patients in our tumour registry between 1991 and 2002. Data collected included patient demographics, presenting symptoms, detail from the hospital course including diagnostic data and operative management, complications and survival time (days). Survival analysis was performed to assess the effect of primary tumour resection on long-term survival.

RESULTS

109 patients were studied. Sixty-two (57%) patients (group I) underwent resection of the primary tumour, whereas 47 (43%) patients (group II) were managed without resection. Median survival times for groups I and II were 375 (IQR: 179-759) and 138 (IQR: 35-262) days respectively (P < 0.0001). After controlling for age, sex, tumour location and level of liver involvement as well as liver function, patients who underwent resection still survived longer (HR = 0.34, 95% CI: 0.21-0.55).

CONCLUSION

Palliative resection of the primary tumour plays an essential role in the management of stage IV colorectal cancer. Resection can offer increased survival and is indicated in certain patients with incurable disease. Limited metastatic tumour burden of the liver was associated with better survival in such patients.

Chemotherapy for colorectal cancer in the metastatic and adjuvant setting: past, present and future

There have been significant advances in the use of chemotherapy in the treatment of colorectal cancer patients over the last 20 years. Initial improvements in treatment were made with increased understanding of the pharmacology of 5-fluorouracil and the discovery of modulators of its activity (e.g., leucovorin). However, in the last few years the discovery of new cytotoxic drugs with efficacy in large bowel cancer (e.g., oxaliplatin and irinotecan) and monoclonal antibodies (e.g., bevacizumab and cetuximab) have significantly improved patient outcome and prognosis. Systemic chemotherapy in the metastatic setting has been shown to prolong survival and improve quality of life. Chemotherapy now also has a clear role as an adjunct to surgery to improve survival in stage III and certain 'high-risk' stage II colorectal cancer patients. The evolution of chemotherapy use, current practice in the metastatic and adjuvant setting and possible future directions are discussed.

Developing Strategies for Liver Metastases From Colorectal Cancer

Five-year survival rates of patients with liver metastases from colorectal cancer range from 30% to 40% for those who undergo successful resection procedures, and is almost nil among those unable to have surgery. However, improved chemotherapy strategies for nonoperable patients (specifically, the use of neoadjuvant oxaliplatin- and irinotecan-based regimens) have increased response rates and tumor downstaging such that 15% to 30% of initially nonoperable patients are able to have secondary, or rescue, surgery. Preliminary data also indicate that new targeted therapies should further increase response rates and thus resection rates. Operative techniques such as portal vein embolization and two-stage procedures for patients with multiple or large tumors, as well as use of cryosurgery and radiofrequency ablation, are also contributing to more effective removal of liver metastases from colorectal cancer. This brief report describes data supporting the expanding application of hepatectomy for patients with colorectal liver metastases.

The role and limitations of 18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scan and computerized tomography (CT) in restaging patients with hepatic colorectal metastases following neoadjuvant chemotherapy: comparison with operative and pathological findings

BACKGROUND

Recent data confirmed the importance of 18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in the selection of patients with colorectal hepatic metastases for surgery. Neoadjuvant chemotherapy before hepatic resection in selected cases may improve outcome. The influence of chemotherapy on the sensitivity of FDG-PET and CT in detecting liver metastases is not known.

METHODS

Patients were assigned to either neoadjuvant treatment or immediate hepatic resection according to resectability, risk of recurrence, extrahepatic disease, and patient preference. Two-thirds of them underwent FDG-PET/CT before chemotherapy; all underwent preoperative contrast-enhanced CT and FDG-PET/CT. Those without extensive extrahepatic disease underwent open exploration and resection of all the metastases according to original imaging findings. Operative and pathological findings were compared to imaging results.

RESULTS

Twenty-seven patients (33 lesions) underwent immediate hepatic resection (group 1), and 48 patients (122 lesions) received preoperative neoadjuvant chemotherapy (group 2). Sensitivity of FDG-PET and CT in detecting colorectal (CR) metastases was significantly higher in group 1 than in group 2 (FDG-PET: 93.3 vs 49%, P<0.0001; CT: 87.5 vs 65.3, P=0.038). CT had a higher sensitivity than FDG-PET in detecting CR metastases following neoadjuvant therapy (65.3 vs 49%, P<0.0001). Sensitivity of FDG-PET, but not of CT, was lower in group 2 patients whose chemotherapy included bevacizumab compared to patients who did not receive bevacizumab (39 vs 59%, P=0.068).

CONCLUSIONS

FDG-PET/CT sensitivity is lowered by neoadjuvant chemotherapy. CT is more sensitive than FDG-PET in detecting CR metastases following neoadjuvant therapy. Surgical decision-making requires information from multiple imaging modalities and pretreatment findings. Baseline FDG-PET and CT before neoadjuvant therapy are mandatory.

Surgical resection of colorectal liver metastases in patients with expanded indications: a single-center experience with 501 patients

PURPOSE

This study was designed to investigate survival after curative resection of colorectal liver metastases in patients with expanded indications.

METHODS

A total of 501 patients had 545 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard to the number or size of the tumors, locoregional invasion, or extrahepatic disease, except that resection had potential to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy.

RESULTS

A total of 259 patients had expanded indications (52 percent), including 14 with liver metastases >10 cm, 194 with bilateral deposits, 140 with four or more liver metastases, and 73 with extrahepatic disease. The overall actuarial survival rates at one, three, five, and ten years were 88, 67, 45, and 36 percent, respectively, for patients with classic indications and 84, 53, 34, and 24 percent, respectively, for patients with expanded indications (P = 0.0009). In the group of expanded indications, there were more patients who received preoperative than postoperative chemotherapy: 72 (28 percent) vs. 18 (7 percent; P < 0.0001), and 148 (70 percent) vs. 131 (61 percent; P = 0.0466). In a multivariate analysis, four or more liver metastases and extrahepatic disease were independent predictors of poor outcome. Adjuvant chemotherapy significantly improved survival (P = 0.0002).

CONCLUSIONS

This study suggested that liver resection should be indicated in patients with expanded indications. The extent of the benefits of preoperative and postoperative chemotherapy needs to be quantitated.

Liver resection for primarily unresectable colorectal metastases downsized by chemotherapy

This study was performed prospectively to assess the effect of systemic chemotherapy (FOLFIRI protocol) in patients with initially unresectable colorectal liver metastases (CRLM) and, after performing liver resection in patients with downsized metastases, to compare the postoperative and long-term results with those of patients with primarily resectable CRLM. Records from a prospective database including all consecutive admissions for CRLM between June 2000 and June 2004 were reviewed. The analysis addressed all patients who underwent hepatectomy for primarily resectable CRLM (Group A), or underwent chemotherapy for primarily unresectable CRLM and among these, particularly the patients who were finally resected after downsizing of CRLM (Group B). There were 60 primarily resected patients (Group A). Forty-two other patients underwent chemotherapy; after an average of nine courses, 18 of them (42.8%) with significantly downsized lesions were explored and 15 (35.7%, Group B) were resected, whereas three had peritoneal metastases. Group B differed from Group A for a significantly higher rate of synchronous CRLM upon diagnosis of colorectal cancer, a larger size of CRLM upon evaluation in our center, and a lower rate of major hepatectomies (20.0% vs. 51.6 %) at surgery. No patient in Group B had positive margins of resection. Operative mortality was nil and morbidity was 20.0% in both groups. In Group B vs. Group A median survival after hepatectomy was 46 vs. 47 months (n.s), 3-year survival rate was 73% vs. 71% (n.s.), disease-free survival rate was 31% vs. 58% (p = 0.04) and, at a median follow-up of 34 months, tumor recurrence rate was 53.3% vs. 28.3% (n.s.). Four out of the eight Group B patients with recurrence underwent a re-resection, and were alive at 9 to 67 months after the first resection. These results show that in about one-third of the patients with primarily unresectable CRLM, downsizing of the lesions by chemotherapy (FOLFIRI protocol) permitted a subsequent curative resection. In these patients, operative risk and survival did not differ from the figures observed in primarily resectable patients and, in spite of a lower disease-free survival with more frequent recurrence, re-resection still represented a valid option to continue treatment.

Contrast-enhanced ultrasonography to detect liver metastases : a prospective trial to compare transcutaneous unenhanced and contrast-enhanced ultrasonography in patients undergoing laparotomy

BACKGROUND/AIMS

The advent of contrast-enhanced ultrasound (CEUS) has called into question the efficacy of standard ultrasonographic techniques. In this study, we evaluated B-mode and color-duplex imaging and CEUS in the detection of liver metastases, using intraoperative and histological findings as a reference.

MATERIALS AND METHODS

Before laparotomy, 108 patients suspected of having liver metastases were prospectively examined with B-mode and color-duplex imaging, followed by contrast-enhanced ultrasound (2.4 ml SonoVue). Patients with unresectable tumors (n=8) were excluded from the analysis. The sonographic diagnosis in the remaining 100 patients was compared to the intraoperative and histological findings.

RESULTS/FINDINGS

CEUS improved the sensitivity for detecting liver lesions from 56.3% (B-mode) to 83.8% (CEUS) (p=0.004). In particular, the contrast agent led to an improvement in ultrasonographic detection in the following cases: nodular metastases smaller than one centimeter; after adjuvant chemotherapy; for tumors near the surface of the liver; and for lesions situated around the ligamentum teres.

INTERPRETATION/CONCLUSIONS

CEUS provides significant improvement in the detection of liver metastases, and should therefore, be performed routinely in the surveillance of cancer patients.

Cetuximab in the treatment of metastatic colorectal cancer

Cetuximab is a chimeric monoclonal antibody that binds to the epidermal growth factor receptor and thereby inhibits cell proliferation, metastasis and angiogenesis. Preclinical studies indicate that cetuximab induces synergistic antitumor activity when combined with chemotherapy or radiation. This observation is supported by clinical trials demonstrating that cetuximab improves tumor response when used in conjunction with modern chemotherapy in patients with metastatic colorectal cancer. Improved treatment efficacy may help to increase the rate of hepatic metastasis resection after downsizing of initially unresectable lesions. In pretreated patients, cetuximab may restore the sensitivity to irinotecan and, therefore, has been registered in this setting. Ongoing studies are investigating the integration of anti-epidermal growth factor receptor and anti-vascular endothelial growth factor strategies into new treatment regimens. Promising results have already been obtained in a trial combining irinotecan, bevacizumab and cetuximab.

Loco-regional recurrence from colon cancer: a population-based study

BACKGROUND

The survival after colon cancer surgery has not improved to the same extent as after rectal cancer treatment and studies on loco-regional recurrence after colon cancer surgery are scarce. The aim of this study was to assess the problem of loco-regional recurrence after potentially curative resections for colon cancer, regarding incidence, risk factors, management, and outcome.

METHODS

All 1,856 patients submitted to potentially curative surgery for colon cancer in the Stockholm/Gotland region in Sweden between 1996 and 2000 were followed until January 2005 or until death. Follow-up data were prospectively collected. Risk factors for loco-regional recurrences were analyzed, treatment and outcome for patients with recurrence was studied.

RESULTS

The cumulative 5-year incidence of loco-regional recurrence was 11.5%. Tumor locations in the right flexure and in the sigmoid colon, bowel perforation and emergent surgery were identified as independent risk factors for loco-regional recurrence. The risk also increased with increasing T- and N-stage. The median survival for all 192 patients with loco-regional recurrence was 9 months. Surgery was performed in 110 (57%) patients. In 23 (12%) patients a complete tumor clearance was achieved and the estimated 5-year survival in this group was 43%.

CONCLUSION

Loco-regional recurrence from colon cancer is a significant clinical problem. A multidisciplinary treatment approach, including preoperative staging, a complete resection of the recurrence and more effective adjuvant treatments may improve the outcome.

Liver resection for metastatic colorectal cancer in the age of neoadjuvant chemotherapy and bevacizumab

Hepatic metastases from colorectal carcinoma (CRC) were once thought to portend a uniformly grim outcome; however, improvements in chemotherapeutic and surgical approaches have led to significant advances as well as new clinical challenges. Some 60% of the 150,000 patients diagnosed with CRC each year in the United States will develop hepatic metastases. Only a fraction of these metastases are resectable at the time of presentation, but an increasing number of patients are able to undergo resection after neoadjuvant chemotherapy. Additionally, recent trials have demonstrated the efficacy of using chemotherapy with bevacizumab as first-line therapy for metastatic CRC, but how this treatment will affect surgical resection is unknown. Herein, we review the recent literature regarding neoadjuvant chemotherapy for hepatic metastases from CRC, discuss key aspects of the basic science of hepatic regeneration with regard to angiogenic mediators, and outline the key problems to be solved so that a rational strategy can be developed to treat patients with hepatic colorectal metastases in the age of neoadjuvant chemotherapy and antiangiogenic drugs.

Outcome of metastatic colorectal cancer: analysis of a consecutive series of 229 patients. The impact of a multidisciplinary approach

PURPOSE

New chemotherapy agents and integrated treatments have improved the prognosis of patients with metastatic colorectal cancer.

METHODS

From January 2000 to December 2002, 229 consecutive metastatic patients were prospectively followed and their outcomes were analyzed. They were divided initially into four treatment groups: A, palliative chemotherapy for extensive extrahepatic disease with or without hepatic disease (97 patients); B, palliative chemotherapy as in Group A for extensive hepatic disease unlikely to become resectable (36 patients); C, neoadjuvant chemotherapy for potentially resectable liver metastases if responsive to therapy (33 patients); D, immediate surgery for liver metastases (63 patients).

RESULTS

The series was analyzed after a median follow-up of 22.6 months. The median progression-free survival was 9, 7.3, 11.5, and 26 months in Groups A, B, C, and D, respectively. The median overall survival was 20.1, 17.2, 24.8, and >48 months in Groups A, B, C, and D, respectively. The outcome was considered for the 69 patients with metastases confined to the liver (Groups B and C), who were treated initially with chemotherapy. Surgery was performed in 21 patients (5 from Group B, and 16 from Group C) and was R0 in 16. In resected patients, the median progression-free survival was 14.7 months and the median overall survival was 40.5 months. In unresected patients, the median progression-free survival was 7.6 months and the median overall survival was 17.5 months.

CONCLUSIONS

Neoadjuvant therapy may prolong overall survival in a subset of patients with multiple hepatic metastases. The global impact on progression-free survival is low; less than one-half of the patients resected after chemotherapy are disease-free at three years. However, patients resected after chemotherapy obtained overall survival similar to that of primary surgery, suggesting a positive role for integrated approaches.

Towards a pan-European consensus on the treatment of patients with colorectal liver metastases

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.

Strategies to treat primary unresectable colorectal liver metastases

The liver is the most common site of metastases in patients with colorectal cancer (CRC), and hepatic metastases are responsible for fatalities in at least two thirds of patients with colorectal malignancy. However, the only available treatment associated with long-term survival in patients with CRC metastases is liver resection. While recent studies have shown that liver resection achieves a 5-year overall survival from 37% to 58%, only 10% to 20% of patients with colorectal liver metastases are eligible for resection. Pharmacologic developments and conceptual advances in chemotherapy, regional treatment, and aggressive surgical strategies have ultimately changed the current treatment of patients with primary unresectable liver metastases caused by CRC. Patients who were treated by only palliative chemotherapy a few years ago presently have a variety of strategies available to render their disease surgically resectable with the potential for long-term survival. These advances are the result of a strong collaboration between medical oncologists and surgeons. The development of new chemotherapy protocols that offer the potential for curative surgery with optimum timing within the natural history of this metastatic disease is a shared therapeutic challenge.

Novel two-step resection for lesions between the middle hepatic vein and vena cava which allows the middle hepatic vein to be preserved

Patients with bilobar colorectal cancer metastases to the liver present a unique problem in terms of resection. They sometimes require a staged approach to resection that takes advantage of the liver's ability to regenerate, as well as the newer chemotherapeutic agents (e.g., oxaloplatin, irinotecan (CPT-11), and bevacizumab) that have become available. In cases of multiple bilobar metastases, if segment IV is clear of tumor, a left lateral segmentectomy (LLS) can be performed, followed several months later by a formal right hepatectomy. The remnant liver composed of the hypertrophied segment IV is drained by the middle hepatic vein (MHV). In this context, patients with lesions between the origin of the MHV and the inferior vena cava (IVC) present a particularly difficult problem. Conventional excision would require an extended hepatectomy and division of the MHV along with either the right or left hepatic veins (RHV, LHV). This would make it impossible to continue with a formal resection of the remaining lesions in the contralateral liver without sacrificing the sole remaining hepatic vein. We present a novel two-step hepatectomy for lesions between the MHV and the IVC that allows the MHV to be preserved and all lesions to be resected.