Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies

The Potential Role of Liver Transplantation as a Treatment Option in Colorectal Liver Metastases

Liver resection is the only potentially curative treatment option in patients with liver metastases from colorectal cancer, but only about 20% of the patients are resectable. Liver transplantation of patients with unresectable liver metastases was attempted in the early era but it was abandoned due to poor survival. During the last decade, several case reports, a controlled pilot study, and a retrospective cohort study indicated that prolonged disease-free survival and overall survival can be obtained in a proportion of these patients. Strict selection criteria have not yet been well defined, but tumor load, response to chemotherapy, pretransplant carcinoembryonic antigen level, and time interval from resection of the primary tumor to transplant are all factors related to outcome. Carefully selected patients may obtain 5-year overall survival that approaches conventional indications for liver transplant. The scarcity of liver grafts is a significant problem, but this can possibly to some extent be addressed by use of extended criteria grafts and novel surgical techniques. There is an increasing interest in liver transplantation in these patients in the transplant community, and currently 4 clinical trials are active and are recruiting.

An Overview of the Current Management of Bilobar Colorectal Liver Metastases

Bilobar colorectal liver metastases (BCRLM) present a challenging scenario for liver surgeons globally. The following article aims to provide an overview of the different strategies which may be utilised in order to successfully manage advanced BCRLM.

CEACAM1 is associated with recurrence after hepatectomy for colorectal liver metastasis

BACKGROUND

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) is re-expressed at the invasion front of colorectal cancer. CEACAM1 expression at metastatic sites remains to be investigated. The current study aims to clarify the association between CEACAM1 expression and recurrence after hepatectomy of colorectal liver metastasis and to address whether CEACAM1 induces tumor-initiating properties needed for growth at metastatic sites.

METHODS

Immunohistochemical analyses for CEACAM1 were performed in 67 patients with liver metastasis of colorectal cancer who had undergone curative hepatectomy. The risk factors for postoperative recurrence were calculated based on a CEACAM1 cytoplasmic domain isoform at the primary tumor invasion front. To investigate the effects of CEACAM1 cytoplasmic isoforms on HT29 and HCT116 colorectal cancer cells, Western blotting for CD44 and CD133, flow cytometry for ALDH1 activity, and soft-agar colony formation assay were performed.

RESULTS

CEACAM1 long (CEACAM1-L) and short (CEACAM1-S) cytoplasmic domain isoforms are strongly expressed on cancer cells in the liver metastases. Enhanced CEACAM1-S expression in the state of CEACAM1-L dominance at the primary tumor invasion front was an independent factor for colorectal cancer recurrence after curative hepatectomy. CEACAM1-4S-transfected HT29 and HCT116 cells had significantly higher CD44 expression and ALDH1 activity and increased the growth in anchorage-independent condition.

CONCLUSIONS

High expression of CEACAM1-S at the primary lesion invasion front is associated with recurrence and prognosis of patients with colorectal liver metastasis after curative hepatectomy. The expression of CEACAM1-4S enhances the tumor-initiating property of colorectal cancer cells.

Pretreatment albumin may aid in patient selection for intrahepatic Y-90 microsphere transarterial radioembolization (TARE) for malignancies of the liver

Background

Hepatic malignancies are common including primary malignancies and metastases. Transarterial radioembolization (TARE) is an important treatment option. We reviewed safety and efficacy of (TARE) in our patients to identify factors that may impact treatment outcomes in a heterogeneous population.

Methods

All patients that received TARE at the Medical University of South Carolina from March 2006 through May of 2014 were included. Kaplan-Meier estimates on overall survival (OS) from date of first procedure are reported. Potential prognostic factors for OS were evaluated using log rank tests and Cox proportional hazards models.

Results

In the 114 patients that received TARE at our institution, median follow-up was 6.4 months (range, 0-86 months) with the following histologies: colorectal (CR) n=55, hepatocellular (HC) n=20, cholangiocarcinoma (CC) n=16, neuroendocrine (NE) n=12, breast (BR) n=6, other n=5. At least 1 line of prior systemic therapy was noted in 79% of patients. Median OS was significantly better with NE and BR histology, and in those with normal albumin levels. With an albumin >3.4 median OS was 10.3 months, but was only 3.1 months with an albumin <3 g/dL. Grade ≥2 toxicity was observed in 22 patients (19.3%) including 9 (7.9%) with Grade 3 and 1 (0.9%) with Grade 4 toxicity.

Conclusions

TARE is a relatively safe and effective treatment for intrahepatic malignancies. Patients with NE and BR histology as well as those with better hepatic synthetic function were associated with significantly better survival. Our data suggest that patients with albumin below 3 g/dL may not derive significant benefit from TARE.

Splenectomy after partial hepatectomy accelerates liver regeneration in mice by promoting tight junction formation via polarity protein Par 3-aPKC

AIMS

Several experimental studies have demonstrated that removal of the spleen accelerates liver regeneration after partial hepatectomy. While the mechanism of splenectomy promotes liver regeneration by the improvement of the formation of tight junction and the establishment of hepatocyte polarity is still unknown.

MAIN METHODS

We analyzed the cytokines, genes and proteins expression between 70% partial hepatectomy mice (PHx) and simultaneous 70% partial hepatectomy and splenectomy mice (PHs) at predetermined timed points.

KEY FINDINGS

Compared with the PHx group mice, splenectomy accelerated hepatocyte proliferation in PHs group. The expression of Zonula occludens-1 (ZO-1) indicated that splenectomy promotes the formation of tight junction during liver regeneration. TNF-α, IL-6, HGF, TSP-1 and TGF-β1 were essential factors for the formation of tight junction and the establishment of hepatocytes polarity in liver regeneration. After splenectomy, Partitioning defective 3 homolog (Par 3) and atypical protein kinase C (aPKC) regulate hepatocyte localization and junctional structures in regeneration liver.

SIGNIFICANCE

Our data suggest that the time course expression of TNF-α, IL-6, HGF, TSP-1, and TGF-β1 and the change of platelets take part in liver regeneration. Combination with splenectomy accelerates liver regeneration by improvement of the tight junction formation which may help to establish hepatocyte polarity via Par 3-aPKC. This may provide a clue for us that splenectomy could accelerate liver regeneration after partial hepatectomy of hepatocellular carcinoma and living donor liver transplantation.

Laparoscopic Parenchyma-sparing Liver Resection for Colorectal Metastases

Background

Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchyma-sparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center.

Patients and methods

LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months.

Results

296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Five-year overall survival was 48%, median overall survival was 56 months.

Conclusions

LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.

Survival prediction in patients with resectable colorectal liver metastases: Clinical risk scores and tumor response to chemotherapy

Clinical risk scores and response to pre-operative chemotherapy are prognostic factors of colorectal liver metastases. The aim of the present study was to evaluate the effectiveness of combining these factors to predict patient survival and to select patients for curative therapy. The study included 189 patients who underwent hepatectomy following neo-adjuvant chemotherapy, for initially resectable colorectal liver metastases, between January 2005 and December 2015. Patients were stratified into four sub-groups: A1-2, low clinical risk scores with/without a response to pre-operative chemotherapy; and B1-2, high clinical risk scores with or without a response to pre-operative chemotherapy. Treatment and survival data were analysed. Survival was significantly longer in patients with low clinical risk scores and a response to pre-operative chemotherapy; these factors were confirmed as independent prognostic factors by multivariate analysis. Combining clinical risk score and chemotherapy response classification, patient survival was significantly longer for groups A1-2/B1 compared with for group B2, in which only 10.2% of patients were alive after 5 years. Of those with no response to first-line chemotherapy, survival was significantly longer in patients who responded to second-line chemotherapy. A combined clinical risk score and chemotherapy response classification may aid in identifying suitable candidates for potentially curative therapy.

Pulmonary metastasectomy: an overview

Metastasectomy is the most frequent surgical resection undertaken by thoracic surgeons, being the lung the second common site of metastases. The present oncological criteria for pulmonary metastasectomy are: (I) the primary cancer need to be controlled or controllable; (II) no extrathoracic metastasis-that is not controlled or controllable-exists; (III) all of the tumor must be resectable, with adequate pulmonary reserve; (IV) there are no alternative medical treatment options with lower morbidity. General favourable prognostic features in patients with pulmonary metastases are: (I) one or few metastases; (II) long disease free interval; (III) normal CEA levels in colorectal cancers. Negative predictive features in patients candidate to pulmonary metastasectomies are: (I) active primary cancer; (II) extrathoracic metastases; (III) inability to obtain surgical radicality; (IV) mediastinal lymphatic spread. The lack of controlled trials and studies limited by short follow-up and small cohorts did not allow to overcome some skepticism; moreover, the heterogeneity of these patients in terms of demographic, biologic and histologic characteristics represents a clear limit even in the largest series. On the basis of present knowledge, without results coming from on-going randomized trials, radical resection, histology, and disease free interval seem to be independent prognostic factors identifying a cohort of patients maximally benefitting from lung metastasectomy.

Recurrent maxillary sinus cancer with only adrenal metastasis

Maxillary sinus cancer is rare, and often presents as a locally advanced disease. Recurrence commonly occurs locoregionally, while fewer patients present with distant metastasis; the most common sites involved are the lung and bone. This report discusses the case of a 64-year-old male who presented with a mass in the left submandibular area. Biopsy was performed and histological analysis identified a poorly differentiated squamous cell carcinoma. After staging work up, it was concluded the patient had a maxillary sinus squamous cell carcinoma at clinical stage IVA. The patient received a left partial maxillectomy and left radical neck dissection followed by postoperative chemoradiotherapy. After three months of CRT, the patient developed a left adrenal gland metastasis without locoregional failure. The patient subsequently received a laparoscopic left adrenalectomy and the results of histological analysis revealed a poorly-differentiated squamous cell carcinoma. Within one month of surgery, the patient had developed multiple metastases at the left adrenalectomy site and succumbed to the disease four months later.

Adjuvant hepatic artery infusion chemotherapy after hemihepatectomy for gastric cancer liver metastases

BACKGROUND

The most frequent pattern of recurrence is remnant liver after hepatectomy for gastric cancer liver metastases (GLM). The evidence of adjuvant hepatic artery infusion chemotherapy (HAIC) after hepatectomy for GLM is lacking. The aim of this study was to evaluate the efficacy of adjuvant HAIC after hemihepatectomy for GLM.

METHODS

Between 2001 and 2012, 14 patients who underwent hemihepatectomy for GLM were included in this study. Adjuvant HAIC to the remnant hemiliver was the FEM regimen (333 mg/m² 5-fluorouracil each week, 30 mg/m² epirubicin once every 4 weeks, and 2.7 mg/m² mitomycin-C once every 2 weeks) and was administered for 6 months after hemihepatectomy. Clinicopathological prognostic factors for survival were analyzed using a prospectively collected database.

RESULTS

Nine patients had solitary GLM, and 5 patients had multiple GLM before surgery. The median period from hemihepatectomy to HAIC was 30 days. The 6-month HAIC completion rate was 79% (n = 11/14). Reasons of HAIC failure included liver dysfunction (n = 1), catheter infection (n = 1), and development of multiple recurrence (n = 1). The median follow-up was 29 (range 8-166) months. Recurrences were detected in 8 patients (57%). The site of recurrences included lung (n = 1), lymph nodes (n = 1), peritoneal dissemination (n = 1), brain (n = 1), pleural (n = 1), and multiple sites (n = 3). The overall 5-year survival rate was 43%. The pathological T4 classification and the preoperative CEA ≥5 ng/mL were significant prognostic factors for overall survival.

CONCLUSIONS

Adjuvant HAIC after hemihepatectomy for GLM prevents remnant liver recurrence and may contribute to long-term survival.

Association of Surgical Treatment, Systemic Therapy, and Survival in Patients With Abdominal Visceral Melanoma Metastases, 1965-2014: Relevance of Surgical Cure in the Era of Modern Systemic Therapy

Importance

Systemic therapy for metastatic melanoma has evolved rapidly during the last decade, and patient treatment has become more complex.

Objective

To evaluate the survival benefit achieved through surgical resection of melanoma metastatic to the abdominal viscera in patients treated in the modern treatment environment.

Design, Setting, and Participants

This retrospective review of the institutional melanoma database from the John Wayne Cancer Institute at Providence St Johns Health Center, a tertiary-level melanoma referral center, included 1623 patients with melanoma diagnosed as having potentially resectable abdominal metastases before (1969-2003) and after (2004-2014) advances in systemic therapy.

Main Outcomes and Measures

Overall survival (OS).

Results

Of the 1623 patients identified in the database with abdominal melanoma metastases, 1097 were men (67.6%), and the mean (SD) age was 54.6 (14.6) years. Of the patients with metastatic melanoma, 1623 (320 [19.7%] in the 2004-2014 period) had abdominal metastases, including 336 (20.7%) with metastases in the gastrointestinal tract, 697 (42.9%) in the liver, 138 (8.5%) in the adrenal glands, 38 (2.3%) in the pancreas, 109 (6.7%) in the spleen, and 305 (18.8%) with multiple sites. Median OS was superior in surgical (n = 392; 18.0 months) vs nonsurgical (n = 1231; 7.0 months) patients (P < .001). The most favorable 1-year and 2-year OS was seen after surgery for gastrointestinal tract (52% and 41%) and liver (51% and 38%) metastases, respectively. Multivariable analysis found increasing age (hazard ratio [HR], 1.01; 95% CI, 1.00-1.01; P = .02) and the presence of ulceration (HR, 1.21; 95% CI, 1.01-1.45; P = .04) were associated with a worse OS. Alternatively, treatment with metastasectomy (HR, 0.59; 95% CI, 0.46-0.74; P < .001) and metastases involving the gastrointestinal tract (HR, 0.65; 95% CI, 0.48-0.87; P = .004) were associated with a better OS. The systemic treatment era did not significantly affect outcomes (HR, 0.82; 95% CI, 0.67-1.02; P = .15). Overall, patients with gastrointestinal tract metastases undergoing complete, curative resection derived the greatest benefit, with a median OS of 64 months.

Conclusions and Relevance

To our knowledge, this series is the largest single-institution experience with abdominal melanoma metastases, demonstrating that surgical resection remains an important treatment consideration even in the systemic treatment era.

Perioperative Liver Function after Hepatectomy in a Tertiary University Hospital in Damascus

Background:

Liver resection is the only viable therapeutic treatment option for several neoplastic entities of the liver. Although, the number of resectable patients is increasing in Syria, liver failure is still a major complication affecting mortality and morbidity rates.

Methods:

Between 2009 and 2016, 104 patients undergoing liver resection in Damascus University Faculty of Medicine were retrospectively analyzed. Liver function tests were conducted before surgery (ps) and in the perioperative period (po) and comparisons were performed with division into anatomic VS non-anatomic or malignant VS non-malignant groups.

Results:

Liver synthetic, excretory and detoxifying functions deteriorated after liver resection (INR ps ‘presurgery’=1.129 po ‘perioperative’=1.426 P<0.001, TP ps=7.426 po=5.581 P<0.001, ALB ps=4.204 po=3.242 P<0.001, T-Bill ps=0.061 po=0.136 P<0.001) and liver cell necrosis increased after resection (ALT ps=27.597 po=200.221 P<0.001, AST ps=33.395 po=190.553 P<0.001). There was no significant difference in liver functions when we compared anatomic VS non-anatomic groups or malignant VS non-malignant groups, but liver cell necrosis was higher with malignancies (ALT malignant group=236.475 non-malignant group=89.5 P=0.002, AST malignant group=222.644 non-malignant group=101.125 P=0.001).

Conclusion:

Although liver resection affects liver function significantly, no differences in outcomes were found between anatomic VS non anatomic or malignant VS non-malignant groups.

Does mesenchymal stem cell improve the liver regeneration after the 70% hepatectomy?

Purpose:

To evaluate the effects of mesenchymal stem cells on liver regeneration in rats following a 70% hepatectomy.

Methods:

Forty rats were subjected to 70% hepatectomy and then ~106 mesenchymal stem cells (test group), or saline solution (control group), were infused into their livers via the portal vein. Each treatment group was divided into early and late subgroups (euthanized 3 d and 5 d following the operation, respectively). Group comparisons of Albumin, aminotransaminases (AST, ALT), and Alcaline Phosphatase (AP) levels, proliferative index (ki-67+ straining), and mitotic cell counts were conducted.

Results:

No significant differences in liver regeneration rate, number of mitoses, proliferative index, or serum levels of albumin, AST, or AP were observed. ALT levels were higher in the test group than in the control group (p<.05).

Conclusions:

Mesenchymal stem-cell therapy did not improve liver regeneration rate 3 d or 5 d after 70% hepatectomy in rats. Likewise, the therapy appeared not to affect liver function, proliferative index, or number of mitoses significantly.

Introduction of the resection severity index as independent risk factor limiting survival after resection of colorectal liver metastases

BACKGROUND

The purpose of this study is to evaluate the influence of the recently introduced resection severity index (RSI) in patients with liver resection for hepatocellular carcinoma on survival after resection of colorectal liver metastases. The RSI quantifies pre-operatively the liver cellular damage, liver synthetic function and loss of organ parenchyma.

METHODS

All consecutive patients who underwent liver resection for metastases of colorectal cancer (CLM) between 2000 and 2015 were included in this study. Risk factors limiting survival were analyzed using univariable and multivariable Cox regression analyses.

RESULTS

The median survival after liver resection for CLM was 3.0 years. Significant independent risk factors for mortality were the RSI (p = 0.029; hazard ratio (HR): 1.088, 95%-confidence interval (95%-CI): 1.009-1.174), age at resection in years (p = 0.001; HR: 1.017, 95%-CI: 1.007-1.027), pre-operative hemoglobin level (p = 0.041; HR: 0.932, 95%-CI: 0.891-0.997), the cecum as location of primary CRC (p < 0.001; HR: 2.023, 95%-CI: 1.403-2.833), adjuvant chemotherapy (p < 0.001; HR: 1.506, 95%-CI: 1.212-1.878), local relapse of the primary tumor (p = 0.027; HR: 1.591, 95%-CI: 1.057-2.297), the units of intra-operatively transfused packed red blood cells (p < 0.001; HR: 1.068, 95%-CI: 1.033-1.104), the size of the largest metastasis (p = 0.002; HR: 1.005, 95%-CI: 1.002-1.008) and the metastasis' distance to the resection margin (p = 0.014; HR: 0.984, 95%-CI: 0.972-0.997).

CONCLUSION

The RSI is an independent prognostic factor for survival after liver resection for CLM. Besides the extent of liver resection certain primary tumor characteristics have to be taken into account to ensure long-term survival.

Next generation sequencing of progressive colorectal liver metastases after portal vein embolization

Portal vein embolization (PVE) can be required to stimulate liver regeneration before hepatectomy for colorectal liver metastasis (CRCLM), however PVE may also trigger CRCLM progression in patients initially exhibiting chemotherapy response. Using RNA-seq, we aimed to determine the molecular networks involved in metastatic progression in this context. A prospective study including all CRCLM patients undergoing PVE prior to hepatectomy was conducted. Paired biopsies of metastatic lesions were obtained prior to and after PVE and total RNA was isolated and used to prepare Illumina rRNA-depleted TruSeq stranded cDNA libraries for HiSeq 100 bp paired-end sequencing. Patients were classified with progression of disease (PD_PVE) or stable disease (SD_PVE) post-PVE using 3D-CT tumor volumetric analysis.

RESULTS

Twenty patients were included, 13 (65.0%) in the PD_PVE group (median 58.0% (18.6-234.3) increase in tumor volume) and 7 (35.0%) in the SD_PVE group exhibiting continuous chemotherapy response (median -14.3% (-40.8 to -2.8) decrease in tumor volume) (p < 0.0001). Our results showed that progressive CRCLM after PVE undergo gene expression changes that indicate activation of core cancer pathways (IL-17 (p = 5.94 × 10^-03), PI3K (p = 8.71 × 10^-03), IL6 and IGF-1 signaling pathways), consistent with changes driven by cytokines and growth factors. Differential expression analysis in a paired model of progression (EdgeR, DeSeq) identified significantly dysregulated genes in the PD_PVE group (FOS, FOSB, RAB20, IRS2).

CONCLUSION

Differentially expressed genes and pathways with known links to cancer and metastasis were identified post-PVE in patients with disease progression. Highlighting these molecular changes is a crucial first step towards development of targeted therapeutic strategies that may mitigate the effects of PVE on tumor growth.

Case-controlled study comparing peri-operative and cancer-related outcomes after major hepatectomy and parenchymal sparing hepatectomy for metastatic colorectal cancer

INTRODUCTION

Liver resection is potentially curative in selected patients with colorectal liver metastases (CLM). There has been a trend towards parenchyma sparing hepatectomy (PSH) rather than major hepatectomy (MH) due to lower perioperative morbidity. Although data from retrospective series suggest that long-term survival after PSM are similar to MH, these reports may be subject to selection bias. The aim of this study was to compare outcomes of PSH and MH in a case-controlled study.

PATIENTS AND METHODS

917 consecutive patients who underwent liver resection for CLM during 2000-2010 were identified from a prospective database. 238 patients who underwent PSH were case-matched with 238 patients who had MH, for age, gender, tumour number, maximum tumour diameter, primary Dukes' stage, synchronicity and chemotherapy status using a propensity scoring system. Peri-operative outcomes, recurrence and long-term survival were compared.

RESULTS

Fewer PSH patients received peri-operative blood transfusions (p < 0.0001). MH patients had greater incidence of complications (p = 0.04), grade III/IV complications (p = 0.01) and 90-day mortality (p = 0.03). Hospital stay was greater in the MH group (p = 0.04). There was no difference in overall/disease-free survival.

CONCLUSION

Patients with resectable CLM should be offered PSH if technically feasible. PSH is safer than MH without compromising long-term survival.

Resection of synchronous liver metastases between radiotherapy and definitive surgery for locally advanced rectal cancer: short-term surgical outcomes, overall survival and recurrence-free survival

AIM

There is debate as to the correct treatment algorithm sequence for patients with locally advanced rectal cancer with liver metastases. The aim of the study was to assess safety, resectability and survival after a modified 'liver-first' approach.

METHOD

This was a retrospective study of patients undergoing preoperative radiotherapy for the primary rectal tumour, followed by liver resection and, finally, resection of the primary tumour. Short-term surgical outcome, overall survival and recurrence-free survival are reported.

RESULTS

Between 2009 and 2013, 45 patients underwent liver resection after preoperative radiotherapy. Thirty-four patients (76%) received neoadjuvant chemotherapy, 24 (53%) concomitant chemotherapy during radiotherapy and 17 (43%) adjuvant chemotherapy. The median time interval from the last fraction of radiotherapy to liver resection and rectal surgery was 21 (range 7-116) and 60 (range 31-156) days, respectively. Rectal resection was performed in 42 patients but was not performed in one patient with complete response and two with progressive metastatic disease. After rectal surgery three patients did not proceed to a planned second stage liver (n = 2) or lung (n = 1) resection due to progressive disease. Clavien-Dindo ≥Grade III complications developed in 6.7% after liver resection and 19% after rectal resection. The median overall survival and recurrence-free survival in the patients who completed the treatment sequence (n = 40) were 49.7 and 13.0 months, respectively. Twenty of the 30 patients who developed recurrence underwent further treatment with curative intent.

CONCLUSION

The modified liver-first approach is safe and efficient in patients with locally advanced rectal cancer and allows initial control of both the primary tumour and the liver metastases.

Centralization of Liver Cancer Surgery and Impact on Multidisciplinary Teams Working on Stage IV Colorectal Cancer

Surgical resection is the most effective treatment approach for colorectal liver metastases but only a minority of patients is suitable for upfront surgery. The treatment strategies of stage IV colorectal cancer have shifted towards a continuum of care in which medical and surgical treatment combinations are tailored to the clinical setting of the individual patient. The optimization of treatment through appropriate decision-making and multimodal therapy for stage IV colorectal cancer require a joint multidisciplinary meeting in a centralized liver cancer unit.

Recommendations for SIR-Spheres Y-90 resin microspheres in chemotherapy-refractory/intolerant colorectal liver metastases

A Spanish expert panel reviewed current evidence for the use of SIR-Spheres Y-90 resin microspheres in patients with chemotherapy refractory/intolerant unresectable colorectal liver metastases. Substantial evidence for its efficacy and safety is available from a randomized controlled study, retrospective comparative studies and several single arm studies. Clinical evidence data obtained from more than 1500 patients have led to the inclusion of selective internal radiation therapy in the 2016 ESMO Clinical Guidelines as third-line treatment. This publication results from an expert panel meeting, where published evidence and author's experiences were shared to position SIR-Spheres Y-90 resin microspheres in Spain for the treatment of chemotherapy refractory/intolerant unresectable colorectal liver metastases, and second, to define the patient subgroup that will benefit the most with this treatment.

Multifaceted Interpretation of Colon Cancer Stem Cells

Colon cancer is one of the leading causes of cancer-related deaths worldwide, despite recent advances in clinical oncology. Accumulating evidence sheds light on the existence of cancer stem cells and their role in conferring therapeutic resistance. Cancer stem cells are a minor fraction of cancer cells, which enable tumor heterogeneity and initiate tumor formation. In addition, these cells are resistant to various cytotoxic factors. Therefore, elimination of cancer stem cells is difficult but essential to cure the malignant foci completely. Herein, we review the recent evidence for intestinal stem cells and colon cancer stem cells, methods to detect the tumor-initiating cells, and clinical significance of cancer stem cell markers. We also describe the emerging problems of cancer stem cell theory, including bidirectional conversion and intertumoral heterogeneity of stem cell phenotype.

Long-term outcomes after resection of para-aortic lymph node metastasis from left-sided colon and rectal cancer

PURPOSE

Para-aortic lymph node (PALN) metastasis from colorectal cancer is rare and often not suitable for surgery. However, in selected patients, radical resection may bring about longer survival. The aim of this study was to evaluate long-term outcomes of resection of left-sided colon or rectal cancer with simultaneous PALN metastasis.

METHODS

The study included 2122 patients with left-sided colon or rectal cancer (30 patients with and 2092 patients without PALN metastasis) who underwent resection with curative intent between 2002 and 2013. Clinicopathological characteristics, long-term outcomes of resection, and factors related to poor postoperative survival in patients with PALN metastasis were investigated.

RESULTS

Of a total of 2122 total patients, 16 of 50 patients (32.0%) with lymph node metastasis at the root of the inferior mesenteric artery had PALN metastasis. The 5-year overall survival rates for 18 patients who underwent R0 resection and 12 patients who did not were 29.1 and 10.4%, respectively (p = 0.017). Factors associated with poor postoperative survival among patients who underwent R0 resection were presence of conversion therapy, lack of adjuvant chemotherapy, carcinoembryonic antigen >20 ng/mL, and lateral lymph node metastasis in rectal cancer patients. The 5-year recurrence-free survival rate was 14.8%.

CONCLUSIONS

Although recurrence was frequent, R0 resection for left-sided colon or rectal cancer with PALN metastasis was associated with longer survival than R1/R2 resection. Furthermore, the 5-year overall survival rate in the R0 group was relatively favorable for stage IV. Therefore, R0 resection may prolong survival compared with chemotherapy alone in selected patients.

Effect of non-alcoholic liver disease on recurrence rate and liver regeneration after liver resection for colorectal liver metastases

BACKGROUND

Resection of metastases is the only potential cure for patients with liver metastasis from colorectal cancer (crc-lm). But despite an improved overall 5-year survival, the recurrence rate is still as high as 60%. Non-alcoholic fatty liver disease (nafld) can decrease the liver's capacity to regenerate after resection and might also affect cancer recurrence, potentially by elevating transforming growth factor β, levels of specific metalloproteinases, and oxidative stress. The objective of the present work was to determine the effect of the histologic features of nafld on cancer recurrence and liver regeneration.

METHODS

This retrospective analysis considered 60 patients who underwent an R0 hepatectomy for crc-lm. Volumetric analysis of the liver was calculated using axial view, portovenous phase, 2.5 mm thickness, multiphasic computed tomography images taken before and after surgery. The histologic features of nafld (steatosis, inflammation, and ballooning) were scored using the nafld activity score, and the degree of fibrosis was determined.

RESULTS

The hepatic recurrence rate was 38.33%. Median overall survival duration was 56 months. Median disease-free survival duration was 14 months, and median hepatic disease-free survival duration was 56 months. Multivariate analysis revealed significant correlations of hepatic disease-free survival with hepatocyte ballooning (p = 0.0009), lesion diameter (p = 0.014), and synchronous disease (p = 0.006). Univariate and multivariate analyses did not reveal any correlation with degree of steatosis or recurrence rate.

CONCLUSIONS

This study reveals an important potential negative effect of hepatocyte ballooning on hepatic disease-free survival.

A rare case of esophageal metastasis from pancreatic ductal adenocarcinoma: a case report and literature review

Purpose

We report a very unique case of an esophageal metastasis from a pancreatic ductal adenocarcinoma (PDAC) primary.

Methods

After obtaining consent from the patient, all relevant records of the case were obtained and retrospectively reviewed.

Results

At presentation, the patient was diagnosed with synchronous pancreatic and esophageal cancer. He received six months of neoadjuvant therapy including FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) and stereotactic body radiation therapy (SBRT) to the pancreatic tumor followed by a combined pancreaticoduodenectomy and Ivor Lewis esophagectomy. Review of the final esophageal specimen revealed normal overlying squamous mucosa with an underlying focus of metastatic PDAC. The patient remains alive with no evidence of disease 17 months from surgery and 25 months from diagnosis.

Conclusions

Differentiating an esophageal metastasis from a PDAC primary versus a synchronous esophageal carcinoma is very difficult despite state-of-the-art diagnostic techniques performed at a high-volume tertiary cancer center. Extensive evaluation and continued follow-up of PDAC patients presenting with a synchronous esophageal lesion in a multidisciplinary setting may help ensure efficient and accurate management. In our case, neoadjuvant FOLFIRINOX and SBRT to the primary PDAC tumor followed by surgery has been an effective approach for this patient.

Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation

Colorectal cancer patients have a high incidence of liver metastasis (ml-CRC). Surgical resection is the gold standard for treatment of hepatic metastasis but only a small percent of patients are traditional candidates based on disease extent and adequate size of the future liver remnant (FLR). Interventions such as portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are performed to increase FLR for operative conversion. Limitations to PVE include intrahepatic disease progression, portal vascular invasion, and utilization with concurrent chemotherapy. ALPPS is associated with a high morbidly and mortality. Radiation lobectomy (RL) with yttrium-90 (Y-90) delivers transarterial ablative brachytherapy to the future hepatectomy site which generates FLR hypertrophy similar or greater than PVE. Early results indicate that RL is safe, effective, and may offer unique benefits by providing cytoreduction of hepatic metastases which extends FLR hypertrophy time and allows FLR surveillance to gauge disease biology. A retrospective analysis of four patients with ml-CRC treated with RL prior to hepatectomy was performed to evaluate initial safety, efficacy, FLR hypertrophy, and radiopathologic correlation. Adverse events after RL and hepatectomy were evaluated. Imaging findings were analyzed for efficacy defined as FLR hypertrophy and disease control. Radiopathologic correlation was performed after histologic analysis. RL was well tolerated without major adverse events or hepatic decompensation. FLR hypertrophy ranged from 24.9% to 119% at mean follow-up of three months. The majority of complications were related to surgical instrumentation of the FLR due to upstaging at time of surgery. Hepatectomy specimen histology demonstrated complete pathologic response in 50% of patients, 50% radiopathologic concordance rate, and no significant hepatic fibrosis. Initial experience with neoadjuvant RL for ml-CRC is safe and provides both durable disease control and FLR hypertrophy with concurrent chemotherapy. A 50% complete pathologic response rate raises the possibility of definitive chemoradiation in poor surgical candidates. Prospective investigation is required.

Feasibility, safety and efficacy of two-stage hepatectomy for bilobar liver metastases of colorectal cancer: a LiverMetSurvey analysis

BACKGROUND

The combination of liver resection and chemotherapy has become the standard of care for colorectal liver metastases (LM). The objective of the present study was to evaluate the impact of two-stage hepatectomy (TSH) on the long-term survival of patients with bilobar LM.

METHODS

We included adult (over-18) patients from the LiverMetSurvey registry with confirmed multiple colorectal LM and having undergone either one-stage hepatectomy or TSH with curative intent. The "TSH (2/2)" group (n = 625) comprised patients having completed both stages of TSH; the "TSH (1/2)" group (n = 244) comprised patients having undergone only the first stage of TSH; the "hepatectomy" group. The primary outcome criterion was the overall survival (OS). The secondary outcomes were the morbidity and mortality rates.

RESULTS

The 30- and 90-day mortality rates were respectively 3.8% and 9.3% in the TSH (2/2) group, 9.4% and 16.4% in the TSH (1/2) group, and 5.4% and 9.1% in the "hepatectomy" group. The three-year OS rate was 45% in the TSH (2/2) group, 30% in the TSH (1/2) group and 50.7% in the hepatectomy group.

CONCLUSION

The LiverMetSurvey registry's data indicate that TSH is associated with rather good long-term survival and acceptable morbidity and mortality rates.

A randomised controlled trial to assess the cost-effectiveness of intensive versus no scheduled follow-up in patients who have undergone resection for colorectal cancer with curative intent

BACKGROUND

Intensive follow-up after surgery for colorectal cancer is common practice but lacks a firm evidence base.

OBJECTIVE

To assess whether or not augmenting symptomatic follow-up in primary care with two intensive methods of follow-up [monitoring of blood carcinoembryonic antigen (CEA) levels and scheduled imaging] is effective and cost-effective in detecting the recurrence of colorectal cancer treatable surgically with curative intent.

DESIGN

Randomised controlled open-label trial. Participants were randomly assigned to one of four groups: (1) minimum follow-up (n = 301), (2) CEA testing only (n = 300), (3) computerised tomography (CT) only (n = 299) or (4) CEA testing and CT (n = 302). Blood CEA was measured every 3 months for 2 years and then every 6 months for 3 years; CT scans of the chest, abdomen and pelvis were performed every 6 months for 2 years and then annually for 3 years. Those in the minimum and CEA testing-only arms had a single CT scan at 12-18 months. The groups were minimised on adjuvant chemotherapy, gender and age group (three strata).

SETTING

Thirty-nine NHS hospitals in England with access to high-volume services offering surgical treatment of metastatic recurrence.

PARTICIPANTS

A total of 1202 participants who had undergone curative treatment for Dukes' stage A to C colorectal cancer with no residual disease. Adjuvant treatment was completed if indicated. There was no evidence of metastatic disease on axial imaging and the post-operative blood CEA level was ≤ 10 µg/l.

MAIN OUTCOME MEASURES

Primary outcome Surgical treatment of recurrence with curative intent. Secondary outcomes Time to detection of recurrence, survival after treatment of recurrence, overall survival and quality-adjusted life-years (QALYs) gained.

RESULTS

Detection of recurrence During 5 years of scheduled follow-up, cancer recurrence was detected in 203 (16.9%) participants. The proportion of participants with recurrence surgically treated with curative intent was 6.3% (76/1202), with little difference according to Dukes' staging (stage A, 5.1%; stage B, 7.4%; stage C, 5.6%; p = 0.56). The proportion was two to three times higher in each of the three more intensive arms (7.5% overall) than in the minimum follow-up arm (2.7%) (difference 4.8%; p = 0.003). Surgical treatment of recurrence with curative intent was 2.7% (8/301) in the minimum follow-up group, 6.3% (19/300) in the CEA testing group, 9.4% (28/299) in the CT group and 7.0% (21/302) in the CEA testing and CT group. Surgical treatment of recurrence with curative intent was two to three times higher in each of the three more intensive follow-up groups than in the minimum follow-up group; adjusted odds ratios (ORs) compared with minimum follow-up were as follows: CEA testing group, OR 2.40, 95% confidence interval (CI) 1.02 to 5.65; CT group, OR 3.69, 95% CI 1.63 to 8.38; and CEA testing and CT group, OR 2.78, 95% CI 1.19 to 6.49. Survival A Kaplan-Meier survival analysis confirmed no significant difference between arms (log-rank p = 0.45). The baseline-adjusted Cox proportional hazards ratio comparing the minimum and intensive arms was 0.87 (95% CI 0.67 to 1.15). These CIs suggest a maximum survival benefit from intensive follow-up of 3.8%. Cost-effectiveness The incremental cost per patient treated surgically with curative intent compared with minimum follow-up was £40,131 with CEA testing, £43,392 with CT and £85,151 with CEA testing and CT. The lack of differential impact on survival resulted in little difference in QALYs saved between arms. The additional cost per QALY gained of moving from minimum follow-up to CEA testing was £25,951 and for CT was £246,107. When compared with minimum follow-up, combined CEA testing and CT was more costly and generated fewer QALYs, resulting in a negative incremental cost-effectiveness ratio (-£208,347) and a dominated policy.

LIMITATIONS

Although this is the largest trial undertaken at the time of writing, it has insufficient power to assess whether or not the improvement in detecting treatable recurrence achieved by intensive follow-up leads to a reduction in overall mortality.

CONCLUSIONS

Rigorous staging to detect residual disease is important before embarking on follow-up. The benefit of intensive follow-up in detecting surgically treatable recurrence is independent of stage. The survival benefit from intensive follow-up is unlikely to exceed 4% in absolute terms and harm cannot be absolutely excluded. A longer time horizon is required to ascertain whether or not intensive follow-up is an efficient use of scarce health-care resources. Translational analyses are under way, utilising tumour tissue collected from Follow-up After Colorectal Surgery trial participants, with the aim of identifying potentially prognostic biomarkers that may guide follow-up in the future.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41458548.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 32. See the NIHR Journals Library website for further project information.

Early prediction of postoperative liver dysfunction and clinical outcome using antithrombin III-activity

BACKGROUND AND AIMS

Antithrombin III (ATIII) has been reported to be associated with liver pathologies and was shown to predict outcome in patients undergoing liver resection for hepatocellular carcinoma. We now aimed to assess whether perioperative ATIII-activity could predict postoperative outcome in patients without underlying liver disease, as well as in a routine clinical setting of patients undergoing hepatic resection.

METHODS

ATIII-activity was evaluated preoperatively and on the first (POD1) and fifth day after liver resection in a retrospective evaluation cohort of 228 colorectal cancer patients with liver metastasis (mCRC). We further aimed to prospectively validate our results in a set of 177 consecutive patients undergoing hepatic resection.

RESULTS

Patients developing postoperative liver dysfunction (LD) had a more pronounced postoperative decrease in ATIII-activity (P<0.001). ATIII-activity on POD1 significantly predicted postoperative LD (P<0.001, AUC = 84.4%) and remained independent upon multivariable analysis. A cut-off value of 61.5% ATIII-activity was determined using ROC analysis. This cut-off was vital to identify high-risk patients for postoperative LD, morbidity, severe morbidity and mortality (P<0.001, respectively) with a highly accurate negative predictive value of 97%, which could be confirmed for LD (P<0.001) and mortality (P = 0.014) in our independent validation cohort. Further, mCRC patients below our cut-off suffered from a significantly decreased overall survival (OS) at 1 and 3 years after surgery (P = 0.011, P = 0.025).

CONCLUSIONS

The routine laboratory parameter ATIII-activity on POD1 independently predicted postoperative LD and was associated with clinical outcome. Patients with a postoperative ATIII-activity <61.5% might benefit from close monitoring and timely initiation of supportive therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01700231.

Influence of simultaneous liver and peritoneal resection on postoperative morbi-mortality and survival in patients with colon cancer treated with surgical cytoreduction and intraperitoneal hyperthermic chemotherapy

INTRODUCTION

Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (HIPEC) has recently been established as the treatment of choice for selected patients with peritoneal carcinomatosis of colonic origin. Until recently, the simultaneous presence of peritoneal and hepatic dissemination has been considered a contraindication for surgery. The aim of this paper is to analyze the morbidity, mortality and survival of patients with simultaneous peritoneal and hepatic resection with HIPEC for peritoneal carcinomatosis secondary to colon cancer.

METHODS

Between January 2010 and January 2015, 61 patients were operated on, 16 had simultaneous peritoneal and hepatic dissemination (group RH+), and 45 presented only peritoneal dissemination (group RH-).

RESULTS

There were no differences between the groups in terms of demographic data, length of surgery and extension of peritoneal disease. Postoperative grade III-V complications were significantly higher in the RH+ group (56.3 vs. 26.6%; P=.032). For the whole group, mortality rate was 3.2% (two patients in group RH-, and none in group RH+). Patients with liver resection had a longer postoperative stay (14.4 vs. 23.1 days) (P=.027). Median overall survival was 33 months for RH-, and 36 for RH+ group. Median disease-free survival was 16 months for RH-, and 24 months for RH+ group.

CONCLUSIONS

Simultaneous peritoneal cytoreduction and hepatic resection resulted in a significantly higher Clavien grade III-V morbidity and a longer hospital stay, although the results are similar to other major abdominal interventions. The application of multimodal oncological and surgical treatment may obtain similar long-term survival results in both groups.

Current status and future perspectives on treatment of liver metastasis in colorectal cancer (Review)

Liver metastasis is the most common site of colorectal cancer (CRC) metastasis. Approximately half of all colorectal cancer patients will develop liver metastases. Although radical surgery is the standard treatment modality, only 10-20% of patients are deemed eligible for resection. Despite advances in survival with chemotherapy, surgical resection is still considered the only curative option for patients with liver metastases. Much effort has been expended to address patients with metastatic liver disease. The majority of evidence stated a significant survival benefit with surgical resection to reach an overall 5-year survival rate of 35-55% after hepatic resection. However, still majority of patients will experience disease recurrence even after a successful resection. In this review, we describe current status and controversies related to treatment options for CRC liver metastases and its potential for enhancing oncologic outcomes and improving quality of life.

Laparoscopic image-based navigation for microwave ablation of liver tumors-A multi-center study

BACKGROUND

Stereotactic navigation technology has been proposed to augment accuracy in targeting intrahepatic lesions for local ablation therapy. This retrospective study evaluated accuracy, efficacy, and safety when using laparoscopic image-guided microwave ablation (LIMA) for malignant liver tumors.

METHODS

All patients treated for malignant liver lesions using LIMA at two European centers between 2013 and 2015 were included for analysis. A landmark-based registration technique was applied for intraoperative tumor localization and positioning of ablation probes. Intraoperative efficiency of the procedure was measured as number of registration attempts and time needed to achieve sufficient registration accuracy. Technical accuracy was assessed as Fiducial Registration Error (FRE). Outcome at 90 days including mortality, postoperative morbidity, rates of incomplete ablations, and early intrahepatic recurrences were reported.

RESULTS

In 34 months, 54 interventions were performed comprising a total of 346 lesions (median lesions per patient 3 (1-25)). Eleven patients had concomitant laparoscopic resections of the liver or the colorectal primary tumor. Median time for registration was 4:38 min (0:26-19:34). Average FRE was 8.1 ± 2.8 mm. Follow-up at 90 days showed one death, 24% grade I/II, and 4% grade IIIa complications. Median length of hospital stay was 2 days (1-11). Early local recurrence was 9% per lesion and 32% per patient. Of these, 63% were successfully re-ablated within 6 months.

CONCLUSIONS

LIMA does not interfere with the intraoperative workflow and results in low complication and early local recurrence rates, even when simultaneously targeting multiple lesions. LIMA may represent a valid therapy option for patients with extensive hepatic disease within a multimodal treatment approach.

Oral glucose tolerance test for preoperative assessment of liver function in liver resection

BACKGROUNDS/AIMS

We intended to determine the role of the Oral glucose tolerance test (OGTT), in addition to volumetry, in preoperative assessment of patients undergoing liver resection.

METHODS

This was a prospective study conducted at a tertiary care hospital, between February 2009 and February 2011. OGTT curve (parabolic/linear), linearity index (LI) and Parenchymal Hepatic Resection Rate (PHRR) were correlated with postoperative outcomes in terms of postoperative liver failure (PLF), by 50-50 criteria, morbidity, mortality and hospital stay.

RESULTS

Of the 33 patients included in the study, 23 (69.7%) patients underwent major liver resections. Hepatocellular carcinoma (30.3%) was the leading indication. The overall postoperative morbidity rate was 72.7%, but major complications occurred in 3 (9.1%) patients only. There was no 90-day mortality. The 50-50 criteria were met by 3 patients undergoing major resection. Significant correlation was noted between the linear OGTT curve and the overall hospital stay (12.1 days vs. 9.6 days in parabolic; p=0.04). Patients with linear OGTT met the 50-50 criteria more often (18%) than those having a parabolic curve (4.5%; p=0.25). Although the OGTT was more often linear with occurrence of morbidity (41.7% vs 11.1%), major morbidity (66.7% vs 30%) and PLF by 50-50 criteria (66.7% vs 30%), it was not statistically significant. The linearity index was marginally lower (0.9 vs 1.2) in the presence of major morbidity and PLF by 50-50 criteria.

CONCLUSIONS

Linear OGTT affects the PLF and major morbidity, therein impacting the hospital stay. OGTT LI and PHRR can help predict postoperative outcome for a given extent of liver resection.

Preoperative peripheral blood neutrophil count predicts long-term outcomes following hepatic resection for colorectal liver metastases

Preoperative systemic inflammatory response is associated with a poor long-term prognosis following resection surgery for malignant tumors. Several markers of systemic inflammation have been reported to be associated with the outcome; however, they have not currently been fully investigated. Therefore, the association between preoperative peripheral blood neutrophil count and oncological outcome following hepatic resection for colorectal liver metastasis (CRLM) was retrospectively investigated. The present study comprised 89 patients who had undergone hepatic resection for CRLM between January 2000 and March 2010. The association between preoperative peripheral blood neutrophil count and disease-free survival, in addition to overall survival, was investigated. In multivariate analysis, the presence of neoadjuvant chemotherapy (P=0.015), bilobar distribution (P=0.015) and neutrophil count ≥3,500/µl (P=0.025) were independent and significant predictors of poor disease-free survival, while significant predictors of poor overall survival consisted of >4 lymph node metastases (P=0.001), neo-adjuvant chemotherapy (P=0.003), bilobar distribution (P=0.039) and neutrophil count ≥3,500/µl (P=0.040). Additionally, tumor diameter (P=0.021) and monocyte count (P<0.0001) were observed to be significantly greater in the elevated neutrophil count group. In conclusion, preoperative peripheral blood neutrophil count may be an independent and significant indicator of poor long-term outcomes in patients with CRLM following hepatic resection.

The changing role of radiation therapy in the management of oligometastatic disease

It is clear from surgical series that there are selected patients presenting with localised metastatic disease who can be cured by radical ablation of the metastasis. To date this has been limited to surgical resection but the evolution of stereotactic ablative body radiotherapy (SABR) has opened new opportunities. Hypofractionated radiation delivery in 1 to 5 fractions can achieve durable local control with low toxicity. The focus is now to develop robust biomarkers so that those with true oligometastatic and thereby potentially curable disease can be selected for this approach.

Bilobar versus unilobar multiple colorectal liver metastases: a propensity score analysis of surgical outcomes and recurrence patterns

BACKGROUND

Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long-term outcomes and recurrence patterns after one-stage resection in patients with bilobar versus unilobar MCLM.

METHODS

The records of patients undergoing parenchymal-sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching.

RESULTS

The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short-term outcomes did not differ between the two groups. Five-year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence-free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver-only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns.

CONCLUSIONS

The clearance of bilobar MCLM by one-stage resection of parenchymal-sparing intent provided comparable long-term survival to unilobar MCLM.

Population-based study on resection rates and survival in patients with colorectal liver metastasis in Norway

Background

Detailed knowledge about the proportion of patients with colorectal liver metastases (CLM) undergoing resection is sparse. The aim of this study was to analyse cumulative resection rates and survival in patients with CLM.

Methods

For this population-based study of patients developing CLM during 2011–2013, data were extracted from the Norwegian Patient Registry and the Cancer Registry of Norway.

Results

A total of 2960 patients had CLM; their median overall survival was 10·9 months. Liver resection was performed in 538 patients. The cumulative resection rate was 20·0 per cent. The cumulative resection rate was 23·3 per cent in patients aged less than 40 years, 31·1 per cent in patients aged 40–59 years, 24·7 per cent in those aged 60–74 years, 17·9 per cent in those aged 75–79 years and 4·7 per cent in patients aged 80 years or more (P &lt; 0·001). In multivariable analysis, resection rate was associated with age, extrahepatic metastases, disease-free interval and geographical region. Overall survival after diagnosis of CLM was affected by liver resection (hazard ratio (HR) 0·54, 95 per cent c.i. 0·34 to 0·86), rectal cancer (HR 0·82, 0·74 to 0·90), metachronous disease (HR 0·66, 0·60 to 0·74), increasing age (HR 1·32, 1·28 to 1·37), region, and extrahepatic metastases (HR 1·90, 1·74 to 2·07). Three- and 4-year overall survival rates after hepatectomy were 73·2 and 54·8 per cent respectively.

Conclusion

The cumulative resection rate in patients with CLM in Norway between 2011 and 2013 was 20 per cent. Resection rates varied across geographical regions, and with patient and disease characteristics.

Impact of the C-reactive protein to albumin ratio on long-term outcomes after hepatic resection for colorectal liver metastases

BACKGROUND

The aim of this study is to investigate the association C-reactive protein to albumin (CRP/Alb) ratio, a novel inflammation based prognostic score, and long-term outcomes among patients with colorectal liver metastases (CRLM) after hepatic resection.

METHODS

We retrospectively investigated 106 patients who underwent hepatic resection for CRLM and explored the relationship between CRP/Alb ratio and long-term outcomes.

RESULTS

In multivariate analysis, more than 4 lymph node metastases (p = 0.003), presence of neo-adjuvant chemotherapy (p = 0.008) and CRP/Alb ratio ≥ 0.04 (p = 0.021) were independent and significant predictors of cancer recurrence, while more than 4 lymph node metastases (p = 0.001), presence of neo-adjuvant chemotherapy (p < 0.001), and CRP/Alb ratio ≥ 0.04 (p = 0.002) were independent and significant predictors of poor overall survival.

CONCLUSIONS

The CRP/Alb ratio seems to be a predictor of poor long-term outcomes in patients with CRLM after hepatic resection.

A multinational report of technical factors on stereotactic body radiotherapy for oligometastases

AIM

Oligometastatic cancer is being increasingly managed with aggressive local therapy using stereotactic body radiation therapy (SBRT). However, few guidelines exist. We summarize the results of an international survey reviewing technical factors for extracranial SBRT for oligometastatic disease to guide safe management.

MATERIALS & METHODS

Seven high-volume centers contributed. Levels of agreement were categorized as strong (6-7 common responses), moderate (4-5), low (2-3) or no agreement.

RESULTS & CONCLUSION

We present the results of a multi-national and multi-institutional survey of technical factors of SBRT for extracranial oligometastases. Key methods including target delineation, prescription doses, normal tissue constraints, imaging and set-up for safe implementation and practice of SBRT for oligometastasis have been identified. This manuscript will serve as a foundation for future clinical evaluations.

A Long-Term Survivor of Metastatic Pancreatic Adenocarcinoma: Free of Recurrence 12 Years After Treatment of Oligometastatic Disease

Aggressive local therapy for patients with oligometastatic pancreatic ductal adenocarcinoma (PDAC) has traditionally not been pursued due to high rates of distant progression. We describe a 62-year-old male initially presenting with resectable PDAC who underwent the Whipple procedure but developed multiple liver metastases within two months of starting adjuvant gemcitabine. Oxaliplatin was added to the regimen and complete resolution of the liver lesions resulted. He remained disease-free for five years until re-staging revealed a small lung nodule. This was resected and confirmed to be metastatic PDAC. After additional adjuvant gemcitabine, the patient remained free of recurrence for 12 years after diagnosis of metastatic disease and ultimately passed away from complications of ascending cholangitis associated with stricture at the biliary-enteric anastomosis site. He had no evidence of disease recurrence at the time of death. Next-generation sequencing of the tumor was unrevealing, showing only an activating mutation of KRAS and a deleterious mutation of tumor protein p53 (TP53). Our case suggests that while the prognosis for metastatic PDAC is poor, the population is nonetheless heterogeneous. Prognostic biomarkers are needed for the identification of patients for whom aggressive local treatment of oligometastatic PDAC may be warranted.

Resection after preoperative chemotherapy versus synchronous liver resection of colorectal cancer liver metastases: A propensity score matching analysis

This study aimed to determine the prognostic effects of preoperative chemotherapy for colorectal cancer liver metastasis (CLM).We retrospectively evaluated 2 groups of patients between January 2006 and August 2012. A total of 53 patients who had ≥3 hepatic metastases underwent resection after preoperative chemotherapy (preoperative chemotherapy group), whereas 96 patients who had ≥3 hepatic metastases underwent resection with a curative intent before chemotherapy for CLM (primary resection group). A propensity score (PS) model was used to compare the both groups.The 3-year disease-free survival (DFS) rates were 31.7% and 20.4% in the preoperative chemotherapy and primary resection groups, respectively (log-rank = 0.015). Analyzing 32 PS matched pairs, we found that the DFS rate was significantly higher in the preoperative chemotherapy group than in the primary resection group (3-year DFS rates were 34.2% and 16.8%, respectively [log-rank = 0.019]). Preoperative chemotherapy group patients had better DFSs than primary resection group patients in various multivariate analyses, including crude, multivariable, average treatment effect with inverse probability of treatment weighting model and PS matching.Responses to chemotherapy are as important as achieving complete resection in cases of multiple hepatic metastases. Preoperative chemotherapy may therefore be preferentially considered for patients who experience difficulty undergoing complete resection for multiple hepatic metastases.

Long-term outcomes of radiofrequency ablation combined with hepatectomy compared with hepatectomy alone for colorectal liver metastases

Background

Combining radiofrequency ablation (RFA) with hepatectomy may enable treatment with curative intent for patients with colorectal liver metastasis (CRLM). However, the oncological outcomes in comparison with resection alone remain to be clarified.

Methods

Patients who underwent a first hepatectomy between 2001 and 2012 for CRLM were enrolled. Short- and long-term outcomes of patients who underwent hepatectomy plus RFA were compared with those of patients who had hepatectomy alone using propensity score matching.

Results

Of a total of 553 patients, hepatectomy + RFA and hepatectomy alone were performed in 37 and 516 respectively. Before matching, patients in the hepatectomy + RFA group were characterized primarily by a larger tumour burden. After matching of 31 patients who underwent hepatectomy + RFA with 93 who had hepatectomy alone, background characteristics were well balanced. In the matched cohort, overall and disease-free survival in the hepatectomy + RFA group were no different from those among patients who had hepatectomy alone (5-year overall survival rate 57 versus 61 per cent, P = 0·649; 5-year disease-free survival rate 19 versus 17 per cent, P = 0·865). Local recurrence at the ablated site was observed in four of 31 patients (13 per cent). Although overall local recurrence (ablated site and/or cut surface) was more frequent in the hepatectomy + RFA group (9 of 31 (29 per cent) versus 11 of 93 (12 per cent); P = 0·032), there was no difference in intrahepatic disease-free survival between the two groups (P = 0·705).

Conclusion

Hepatectomy + RFA achieved outcomes comparable to hepatectomy alone. Combining RFA with hepatectomy should be considered as an option to achieve cure.

Recurrence of liver metastases from colorectal cancer and repeat liver resection

OBJECTIVE

The purpose of this study was to assess the resectability and effectiveness of repeat hepatectomy for relapsing liver metastases of colorectal origin in terms of morbidity, mortality, overall survival, and disease-free survival.

METHODS

A retrospective study was performed on a prospective cohort of patients with colorectal liver metastases who underwent repeat surgery at Hospital Universitario San Cecilio, Granada (Spain), from March 2003 to June 2013. Primary outcome variables included survival and morbidity within 30 days post-surgery.

RESULTS

A total of 147 patients with colorectal liver metastases underwent surgical excision during the study period; 61 patients had liver recurrence, and 34 of these received repeat surgery. The overall survival rate at 5 and 10 years for resected patients (n=27/34) was 48% and 48%. Mean hospital stay was 8.9 ± 3.5 days, morbidity was 9%, and mortality was 0%.

CONCLUSION

Repeat liver resection for colorectal liver metastases is a safe, effective surgical procedure whose results are similar to those obtained after initial liver resection.

Repeat hepatectomy is independently associated with favorable long-term outcome in patients with colorectal liver metastases

Up to three‐quarters of patients undergoing liver resection for colorectal liver metastases (CRLM) develop intrahepatic recurrence. Repeat hepatic resection appears to provide the optimal chance of cure for these patients. The aim of this study was to analyze short‐ and long‐term outcomes following index and repeat hepatectomy for CRLM. Clinicopathological data were obtained from a prospectively maintained database. Perioperative variables and outcomes were compared using the Chi‐squared test. Variables associated with long‐term survival following index and second hepatectomy were identified by Cox regression analyses. Over the study period, 488 patients underwent hepatic resection for CRLM, with 71 patients undergoing repeat hepatectomy. There was no significant difference in rates of morbidity (P = 0.135), major morbidity (P = 0.638), or mortality (P = 0.623) when index and second hepatectomy were compared. Performance of repeat hepatectomy was independently associated with increased overall and cancer‐specific survival following index hepatectomy. Short disease‐free interval between index and second hepatectomy, number of liver metastases >1, and resection of extrahepatic disease were independently associated with shortened survival following repeat resection. Repeat hepatectomy for recurrent CRLM offers short‐term outcomes equivalent to those of patients undergoing index hepatectomy, while being independently associated with improved long‐term patient survival.

Liver Transplantation for Unresectable Metastases from Colon Adenocarcinoma

Liver transplantation is an option that improves quality of life and prolongs life expectancy in patients with different types of liver disease. Liver transplantation is controversial for colorectal metastases and is not recommended in clinical practice guidelines. In this case report, we present, to our knowledge, the first liver transplantation for colorectal metastases conducted in Colombia, with a successful follow-up of more than 2 years. Patients with these characteristics who underwent liver transplantation experience reduced mortality and exponentially improved quality of life.