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Doykov M, Kostov G, Dimov R. Surgical Management of Liver Metastases from Colorectal Cancer: A Single-Surgeon Preliminary Findings Report. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Colorectal cancer is a significant medical and social problem. Approximately half of the patients with colorectal carcinoma develop liver metastasis. Most commonly, they are identified during the diagnostic process or the initial surgery. After the diagnostics, only 15% of the cases are referred to receive radical surgery. Liver resection in patients with hepatic metastases is the only way to improve their survival. Objective: To introduce a surgical strategy used for the treatment of colorectal liver metastases. Materials and Methods: The study included 539 patients who underwent surgery for colorectal carcinoma in the Department of Surgery at University Hospital "Kaspela" during the period 2014–2020. This data was collected from the patients' disease history. Results: Of the 539 patients with colorectal carcinoma, 74 (13.7%) were diagnosed with synchronous liver metastases. In 38 (51.3%) of the cases, the metastases were solitary, of which 21 were removed simultaneously and 17 at the follow-up stage. In 8 (10.8%) cases, more than one (2 to 3) solitary metastasis was established near the edges. They were also removed simultaneously. In 6 patients (8.1%), bi-lobar and peripherally localized solitary lesions were found, which were removed instantly and chemotherapy was administered. In 22 (29.7%) of the patients with multiple bi-lobar metastases, only a biopsy was performed, and surgery was carried out only in those affected by chemotherapy. Conclusion: The possibilities of simultaneous and stepwise liver resections were expanded by focusing on individual approach preferences and improving diagnostic methods, liver surgery techniques, and modern chemotherapy. This increased the survival rate of patients with colorectal liver metastases.
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Kulkarni S, Sondhi M, Gupta S, Bhalla A. Staging laparoscopy for assessing inoperability in gastrointestinal malignancies: Is it useful? MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2021. [DOI: 10.4103/mjdrdypu.mjdrdypu_23_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Wang S, Yin CH, Zhang XY, Shang ZM, Huang LM, Luo N, Wang AQ, Dong LL, Liu HX, Zhu JY. Conversion to resectability using transcatheter arterial chemoembolization alternating with mFOLFOX6 in patients with colorectal liver metastases. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:92. [PMID: 31741664 PMCID: PMC6856540 DOI: 10.4103/jrms.jrms_879_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 05/31/2017] [Accepted: 01/30/2019] [Indexed: 11/10/2022]
Abstract
Background: Colorectal cancer is one of the most common malignancies in the world, and about 25% of colorectal cancer patients present with colorectal cancer liver metastases (CRCLM) even at new diagnosis. The study was to evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) alternating with mFOLFOX6 in Chinese patients with unresectable CRCLM. Materials and Methods: In this study, by combining the systemic and regional treatment, the resectability rate, overall survival, and progression-free survival were measured with addition of TACE. Included patients had Eastern Cooperative Oncology Group performance status 0–2. Sixty-two patients received mFOLFOX6 plus one TACE after 2 weeks of chemotherapy; after 2 weeks, the next periodical treatment repeated. Patients received operation when the liver metastases were converted to resectability or severe tumor-associated complications occurred. Results: We found that 28 patients (45.2%) patients received operation after the treatment of TACE combined with systemic chemotherapy. The median time from initial treatment to the operation was 6 months. The median follow-up period was 41 months in all the patients. The 3-year survival rate of resected patients and unresected patients was 54% and 17%, respectively. Post-TACE syndrome was the major adverse reaction (81%). Other adverse reactions were neutropenia, nausea, and neurotoxicity. No patient died of the adverse reactions. The resection rate was related to hepatic segments and vasculature involvement. Conclusion: Taken together, TACE alternating with mFOLFOX6 has been proved to be safe and effective for CRCLM treatment to improve resection rate and prolong the survival time.
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Affiliation(s)
- Shuai Wang
- Department of Laboratory, Cancer Institute, The Affiliated Hospital of Qingdao University, Qingdao, Weifang, People's Republic of China.,Department of Laboratory, Qingdao Cancer Institute, Qingdao, Weifang, People's Republic of China.,Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Chun Hui Yin
- Department of Intervention, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Xin Yan Zhang
- Department of Intervention, The Affiliated Weihai Second Municipal Hospital of Qingdao University, Weihai, Shandong, People's Republic of China
| | - Zhi Mei Shang
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Li Min Huang
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Nan Luo
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - An Quan Wang
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Ling Ling Dong
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Hong Xing Liu
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
| | - Jing Yan Zhu
- Department of Oncology, Weifang Traditional Chinese Medicine Hospital, Weifang, Shandong, People's Republic of China
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Recent Strategies and Paradigm Shift in Management of Hepatic Metastasis from Colorectal Cancer. Indian J Surg Oncol 2018; 9:456-460. [PMID: 30538372 DOI: 10.1007/s13193-018-0766-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 05/08/2018] [Indexed: 10/16/2022] Open
Abstract
The liver is the most common site for metastasis from colorectal cancers (CRCs). There are so many new armamentarium, which have increased the life expectancy and progression-free survival. There are various available guidelines, such as NCCN, ESMO, and ASCO, which provide an insight into the latest modalities and new protocols. We have tried to elucidate into paradigm shift of the management.
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Stewart CL, Warner S, Ito K, Raoof M, Wu GX, Kessler J, Kim JY, Fong Y. Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure? Curr Probl Surg 2018; 55:330-379. [PMID: 30526930 DOI: 10.1067/j.cpsurg.2018.08.004] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Camille L Stewart
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Susanne Warner
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Kaori Ito
- Department of Surgery, Michigan State University, Lansing, MI
| | - Mustafa Raoof
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Geena X Wu
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Jonathan Kessler
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA
| | - Jae Y Kim
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA.
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Fuks D, Pierangelo A, Validire P, Lefevre M, Benali A, Trebuchet G, Criton A, Gayet B. Intraoperative confocal laser endomicroscopy for real-time in vivo tissue characterization during surgical procedures. Surg Endosc 2018; 33:1544-1552. [DOI: 10.1007/s00464-018-6442-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/05/2018] [Indexed: 12/20/2022]
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Granata V, Fusco R, Avallone A, Catalano O, Piccirillo M, Palaia R, Nasti G, Petrillo A, Izzo F. A radiologist's point of view in the presurgical and intraoperative setting of colorectal liver metastases. Future Oncol 2018; 14:2189-2206. [PMID: 30084273 DOI: 10.2217/fon-2018-0080] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Multidisciplinary management of patients with metastatic colorectal cancer requires in each phase an adequate choice of the most appropriate imaging modality. The first challenging step is liver lesions detection and characterization, using several imaging modality ultrasound, computed tomography, magnetic resonance and positron emission tomography. The criteria to establish the metastases resectability have been modified. Not only the lesions number and site but also the functional volume remnant after surgery and the quality of the nontumoral liver must be taken into account. Radiologists should identify the liver functional volume remnant and during liver surgical procedures should collaborate with the surgeon to identify all lesions, including those that disappeared after the therapy, using intraoperative ultrasound with or without contrast medium.
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Affiliation(s)
- Vincenza Granata
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Roberta Fusco
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Antonio Avallone
- Abdominal Oncology Division, Istitutonazionale Tumori - IRCSS - Fondazione G Pascale, Napoli, Italia
| | - Orlando Catalano
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Mauro Piccirillo
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Raffaele Palaia
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Guglielmo Nasti
- Abdominal Oncology Division, Istitutonazionale Tumori - IRCSS - Fondazione G Pascale, Napoli, Italia
| | - Antonella Petrillo
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Francesco Izzo
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
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Abstract
INTRODUCTION Colorectal cancer is a significant global health issue with over 1 million cases diagnosed annually throughout the world. 15% of patients diagnosed with colorectal cancer will have liver metastases and 60% will develop liver metastases if they have metastatic disease. Oligometastatic colorectal cancer confined to the liver represents an intermediate state in the evolution of metastatic capacity that opens the opportunity for local interventions. Areas covered: The literature supports long-term survival if patients undergo liver resection of colorectal metastases. This article reviews the liver-directed therapeutic strategies available for the management of metastatic liver disease including hepatic arterial infusion therapy, radiofrequency ablation, radiation therapy and transarterial chemoembolization. Expert commentary: Great advances have been made with the use of liver directed therapies. In the USA using hepatic arterial infusions with FUDR and Decadron along with systemic therapy, 5 year survivals after liver resection have improved. In Europe with the use of HAI of Oxaliplatin, more patients have been able to get to resection and have obtained higher survival rates, even in second line therapy. New advances in ablative therapy have improved results to get all disease treated at resection for the treatment of reccurrence.
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Affiliation(s)
- Ciara M Kelly
- a Department of Graduate Medical Education , Memorial Sloan Kettering Cancer Center , New York , USA
| | - Nancy E Kemeny
- b Memorial Sloan-Kettering Cancer Center , Weill Medical College of Cornell University , New York , USA
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Shi J, Li Y, Liang S, Zeng J, Liu G, Mu F, Li H, Chen J, Liu T, Niu L. Analysis of circulating tumor cells in colorectal cancer liver metastasis patients before and after cryosurgery. Cancer Biol Ther 2016; 17:935-42. [PMID: 27415969 PMCID: PMC5036405 DOI: 10.1080/15384047.2016.1210731] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In this study, we determined the number of peripheral blood circulating tumor cells (CTCs) pre- and post-cryosurgery in patients with colorectal cancer liver metastasis as a reference for understanding the relevance of any changes to the efficacy of cryosurgery. CTC numbers and CTC-related gene expression were measured in the peripheral blood of 55 patients with colorectal liver metastasis at 1 day before and 7 and 30 d after cryoablation using magnetic activated cell sorting (MACS) and fluorescence activated cell sorting (FACS) combined with real-time quantitative PCR (RT-qPCR). The number of CTCs decreased significantly with postoperative time (P < 0.01). Delta cycle threshold values for the CTC-related genes CEA, Ep-CAM, CK18 and CK19 increased significantly after cryoablation. Furthermore, the expression of CEA, Ep-CAM, CK18 and CK19 decreased significantly with time after cryoablation (P < 0.01). RT-qPCR and FACS combined with MACS has significant diagnostic and prognostic value for evaluating the efficacy of cryosurgery in patients with advanced colorectal cancer.
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Affiliation(s)
- Jian Shi
- a Department of General Surgery , The Second Hospital of Jilin University , Changchun , Jilin , China
| | - Yuan Li
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Shuzhen Liang
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Jianying Zeng
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Guifeng Liu
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Feng Mu
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Haibo Li
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Jibing Chen
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
| | - Tongjun Liu
- a Department of General Surgery , The Second Hospital of Jilin University , Changchun , Jilin , China
| | - Lizhi Niu
- b Fuda Cancer Hospital , Jinan University School of Medicine, Guangzhou Fuda Cancer Institute , Guangzhou , Guangdong , China
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Abstract
The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA.
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Qadan M, D'Angelica MI. Complex Surgical Strategies to Improve Resectability in Borderline-Resectable Disease. CURRENT COLORECTAL CANCER REPORTS 2015; 11:369-377. [PMID: 28090195 DOI: 10.1007/s11888-015-0290-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Colorectal cancer is the third most common malignancy in the USA and continues to pose a significant epidemiologic problem, despite major advances in the treatment of patients with advanced disease. Up to 50 % of patients will develop metastatic disease at some point during the course of their disease, with the liver being the most common site of metastatic disease. In this review, we address the relatively poorly defined entity of borderline-resectable colorectal liver metastases. The workup and staging of borderline-resectable disease are discussed. We then discuss management strategies, including surgical techniques and medical therapies, which are currently utilized in order to improve resectability.
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Affiliation(s)
- Motaz Qadan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C898, New York, NY 10065, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C898, New York, NY 10065, USA
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13
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Abstract
For the 20% of patients with resectable colorectal liver metastases (CRLM), hepatic resection is safe, effective and potentially curative. Factors related to the primary and metastatic tumors individually and in clinical risk-scoring schemes are the best prognostic factors, although it is difficult to define patient groups with resectable, liver-limited CRLM that should be excluded from surgery. Systemic chemotherapy for metastatic colorectal cancer has improved but does not improve overall survival as adjuvant therapy after resection. Conversion to complete resection with systemic and/or hepatic arterial infusion chemotherapy is an appropriate goal for patients with unresectable CRLM.
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Conversion Chemotherapy for Unresectable Colorectal Liver Metastases: Are We Making a Difference? CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0271-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Connor AA, Burkes R, Gallinger S. Strategies in the Multidisciplinary Management of Synchronous Colorectal Cancer and Resectable Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2014. [DOI: 10.1007/s11888-014-0222-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Dunne DFJ, Gaughran J, Jones RP, McWhirter D, Sutton PA, Malik HZ, Poston GJ, Fenwick SW. Routine staging laparoscopy has no place in the management of colorectal liver metastases. Eur J Surg Oncol 2013; 39:721-5. [PMID: 23618549 DOI: 10.1016/j.ejso.2013.03.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/22/2013] [Accepted: 03/27/2013] [Indexed: 11/19/2022] Open
Abstract
AIMS Staging laparoscopy has been recommended in the management of patients with colorectal liver metastases prior to hepatectomy in order to reduce the incidence and associated morbidity of futile laparotomies. The utility of staging laparoscopy has not been assessed in patients undergoing CT, PET-CT and MRI as standard preoperative staging. METHODS All patients undergoing attempted open hepatectomy for colorectal liver metastases between 1/4/2008 and 31/3/2012 were identified from a prospectively maintained research database. All patients who underwent futile laparotomy were identified, with demographics and operative notes subsequently analysed. RESULTS A total of 274 patients underwent attempted open hepatectomy during the study period. At laparotomy 12 (4.4%) patients were found to have irresectable disease. There were no unifying demographic factors within the patients undergoing futile laparotomy. CONCLUSIONS With modern imaging, the potential yield of staging laparoscopy is low. Staging laparoscopy should not be used routinely, but may have a role in the case of specific clinical concerns.
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Affiliation(s)
- D F J Dunne
- Northwestern Hepatobiliary Unit, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, United Kingdom.
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Laparoscopic Ultrasound for Hepatocellular Carcinoma and Colorectal Liver Metastasis. Surg Laparosc Endosc Percutan Tech 2013; 23:135-44. [DOI: 10.1097/sle.0b013e31828a0b9a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Intraoperative Ultrasound. Updates Surg 2013. [DOI: 10.1007/978-88-470-2664-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Weiss MJ, D'Angelica MI. Patient selection for hepatic resection for metastatic colorectal cancer. J Gastrointest Oncol 2012; 3:3-10. [PMID: 22811864 DOI: 10.3978/j.issn.2078-6891.2012.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 01/12/2012] [Indexed: 12/12/2022] Open
Affiliation(s)
- Matthew J Weiss
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Weiss MJ, Ito H, Araujo RLC, Zabor EC, Gonen M, D'Angelica MI, Allen PJ, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Hepatic pedicle clamping during hepatic resection for colorectal liver metastases: no impact on survival or hepatic recurrence. Ann Surg Oncol 2012; 20:285-94. [PMID: 22868921 DOI: 10.1245/s10434-012-2583-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hepatic pedicle clamping is often used during liver resection. While its use reduces blood loss and transfusion requirements, the long-term effect on survival and recurrence has been debated. This study evaluates the effect of hepatic pedicle clamping [i.e., Pringle maneuver (PM)] on survival and recurrence following hepatic resection for colorectal liver metastasis (CRLM). METHODS Patients who underwent R0 resection for CRLM from 1991 to 2004 were identified from a prospectively maintained database. Operative, perioperative, and clinicopathological variables were analyzed. The primary outcomes were disease-free survival (DFS) and liver recurrence (LR). Disease extent was categorized using a well-defined clinical risk score (CRS). Subgroup analysis was performed for patients given preoperative systemic chemotherapy and postoperative pump chemotherapy. RESULTS This study included 928 consecutive patients with median follow-up of 8.9 years. PM was utilized in 874 (94%) patients, with median time of 35 min (range 1-181 min). On univariate analysis, only resection type (p<0.001) and tumor number (p=0.002) were associated with use of PM. Younger age (p=0.006), longer operative time (p<0.001), and multiple tumors (p=0.006) were associated with prolonged PM (>60 min). There was no association between DFS, overall survival (OS) or LR and Pringle time. Neither the CRS nor use of neoadjuvant therapy stratified disease-related outcome with respect to use of PM. CONCLUSIONS PM was used in most patients undergoing resection for CRLM and did not adversely influence intrahepatic recurrence, DFS, or OS.
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Affiliation(s)
- Matthew J Weiss
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Pelvic anatomy as a factor in laparoscopic rectal surgery: a prospective study. Surg Laparosc Endosc Percutan Tech 2012; 21:334-9. [PMID: 22002269 DOI: 10.1097/sle.0b013e31822b0dcb] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate factors affecting the difficulty of laparoscopic total mesorectal excision (L-TME), focusing on the pelvic anatomy. METHODS Seventy-four patients who underwent L-TME were prospectively enrolled. Tumor and patient factors, including magnetic resonance imaging-based pelvic measurements (obstetric conjugate, sacral length, sacral depth, interspinous distance, and intertuberous distance), were analyzed with respect to pelvic dissection time. Variable significantly correlated with pelvic dissection time in linear regression were considered risk factors which we defined as lower or upper quartile of each significant variable. Patients were categorized into 3 groups: easy group, no risk factors; moderate group, 1 to 2 risk factors; and difficult group, ≥ 3 risk factors. RESULTS Multivariate analysis showed that long sacral length, shallow sacral angle, narrow intertuberous diameter, and large tumor size were significantly associated with longer pelvic dissection time (P=0.018, P<0.001, P=0.034, P=0.032, respectively). The cutoff values of the upper quartile were 11.5 cm and 4.5 cm for sacral length and tumor size, and cutoff values of the lower quartile were 3.0 cm and 8.9 cm for sacral depth and intertuberous diameter. Logistic regression analysis showed that difficult group significantly contributed to intraoperative complication (95% confidence interval: 1.364-122.313, P=0.026) but not postoperative complication. CONCLUSIONS Having a narrow, deep pelvis and a large tumor were not found to adversely affect postoperative outcomes. However, in terms of operation time and intraoperative difficulty, anatomical factors should be taken into consideration when planning L-TME.
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The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of patients with resectable colorectal liver metastases: a meta-analysis. Am J Surg 2012; 204:84-92. [PMID: 22244586 DOI: 10.1016/j.amjsurg.2011.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 07/06/2011] [Accepted: 07/06/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND The role of staging laparoscopy (SL) with laparoscopic ultrasound (LUS) in patients with resectable colorectal liver metastases (CRLM) remains controversial. METHODS A meta-analysis of all studies (from 1998 to the present) on the effect of SL/LUS in patients with potentially resectable CRLM with respect to alteration in surgical management was performed. RESULTS Twelve studies satisfied the inclusion criteria. A total of 1,047 patients underwent SL/LUS. The true yield of SL/LUS for CRLM was 19% (95% confidence interval [CI], 16%-22%), with a diagnostic odds ratio of 132 (95% CI, 56-310) and an overall sensitivity of 59% (95% CI, 53%-65%). Subgroup analysis for detection of other liver and peritoneal lesions showed a sensitivity of 59% (95% CI, 49%-67%) and 75% (95% CI, 63%-85%) respectively. There was major between-study heterogeneity for all analyses, with no obvious cause revealed by meta-regression. CONCLUSIONS The true benefit of using SL/LUS universally seems limited. It appears more useful as an adjunct in patients when peritoneal disease is suspected.
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Turrini O, Ewald J, Viret F, Sarran A, Goncalves A, Delpero JR. Two-stage hepatectomy: who will not jump over the second hurdle? Eur J Surg Oncol 2012; 38:266-73. [PMID: 22244437 DOI: 10.1016/j.ejso.2011.12.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 09/07/2011] [Accepted: 12/12/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection in patients with bilobar colorectal liver metastasis (CLM). OBJECTIVE To determine the predictive factors of failure of two-stage hepatectomy. METHOD Between 2000 and 2010, 48 patients with irresectable CLM were eligible for two-stage hepatectomy. The planned strategy was a) cleaning of the left hepatic lobe (first hepatectomy), b) right portal vein embolisation and c) right hepatectomy (second hepatectomy). Six patients had occult CLM (n = 5) or extra-hepatic disease (n = 1), which was discovered during the first hepatectomy. Thus, 42 patients completed the first hepatectomy and underwent portal vein embolisation in order to receive the second hepatectomy. Eight patients did not undergo a second hepatectomy due to disease progression. RESULTS Upon univariate analysis, two factors were identified that precluded patients from having the second hepatectomy: the combined resection of a primary tumour during the first hepatectomy (p = 0.01) and administration of chemotherapy between the two hepatectomies (p = 0.03). An independent association with impairment to perform the two-stage strategy was demonstrated by multivariate analysis for only the combined resection of the primary colorectal cancer during the first hepatectomy (p = 0.04). CONCLUSION Due to the small number of patients and the absence of equivalent conclusions in other studies, we cannot recommend performance of an isolated colorectal resection prior to chemotherapy. However, resection of an asymptomatic primary tumour before chemotherapy should not be considered as an outdated procedure.
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Affiliation(s)
- O Turrini
- Department of Surgical Oncology, Institut Paoli Calmettes and Université de la Méditerranée, 232 Boulevard Sainte Marguerite, 13009 Marseille, France.
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Carpenter S, Fong Y. Real-time fluorescence imaging of abdominal, pleural, and lymphatic metastases. Methods Mol Biol 2012; 872:141-157. [PMID: 22700409 DOI: 10.1007/978-1-61779-797-2_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Virally-directed fluorescence imaging has the potential to revolutionize intra-operative oncologic staging and tumor resection. Many viruses genetically engineered to specifically infect tumor cells as cancer therapy can be further modified to have a visible marker gene for cancer staging. In this chapter, we describe such a herpes simplex virus (HSV) modified to be detected by fluorescence. Other viruses so designed can be similarly used in cancer detection and staging. Replication-competent, tumor-specific HSV NV1066 expresses green fluorescent protein (GFP) in infected cancer cells. One single dose of NV1066 administered via intratumor, intracavitary, or systemic injection can spread within and across body cavities to target tumor cells while sparing normal tissue cells from infection. Tumors otherwise invisible by conventional laparoscopy appear green with the use of an endoscope equipped with a fluorescent filter. Furthermore, with GFP expression easily visualized by stereomicroscopy, microscopic, and pathologic analysis is significantly enhanced. This chapter addresses NV1066-directed visualization of peritoneal, pleural, and lymphatic metastases. This chapter also provides protocols for the production of tumor models in various body cavities in rodents.
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Affiliation(s)
- Susanne Carpenter
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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[Surgical treatment of liver metastasis in patients with colorectal cancer]. Presse Med 2011; 41:58-67. [PMID: 22138292 DOI: 10.1016/j.lpm.2011.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/19/2011] [Indexed: 02/06/2023] Open
Abstract
Half of patients with colorectal cancer have liver metastasis during their illness. Surgical resection of metastases represents the only curative treatment with prolonged survival in more than 50 % of patients. The aim of liver resection is complete excision of the lesions with histological negative margins while preserving sufficient functional liver parenchyma. In patients with diffuse liver disease, the radiofrequency ablation of metastases may be associated with surgical resection. The use of portal vein remobilization and neoadjuvant chemotherapy can also increase the number of patients for curative treatment. Despite this progress, from 50 to 60 % of patients relapse after complete resection of MHCCR. Surgical treatment of recurrent aggressive and effective chemotherapy allows the prolonged survival of these patients. The modern treatment of liver metastasis of colorectal cancers can be envisaged as part of a multidisciplinary approach to increase the number of patients for curative treatment.
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Misiakos EP, Karidis NP, Kouraklis G. Current treatment for colorectal liver metastases. World J Gastroenterol 2011; 17:4067-75. [PMID: 22039320 PMCID: PMC3203357 DOI: 10.3748/wjg.v17.i36.4067] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Revised: 11/30/2010] [Accepted: 12/07/2010] [Indexed: 02/06/2023] Open
Abstract
Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver, with five-year survival rates up to 58% in selected cases. However, only a minority are resectable at the time of diagnosis. Continuous research in this field aims at increasing the percentage of patients eligible for resection, refining the indications and contraindications for surgery, and improving overall survival. The use of surgical innovations, such as staged resection, portal vein embolization, and repeat resection has allowed higher resection rates in patients with bilobar disease. The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection. Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Current management of colorectal liver metastases requires a multidisciplinary approach, which should be individualized in each case.
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Settmacher U, Dittmar Y, Knösel T, Schöne U, Heise M, Jandt K, Altendorf-Hofmann AK. Predictors of long-term survival in patients with colorectal liver metastases: a single center study and review of the literature. Int J Colorectal Dis 2011; 26:967-81. [PMID: 21584664 DOI: 10.1007/s00384-011-1195-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE Prognosis after resection of liver metastases of colorectal cancer is influenced by a variety of clinical factors. For more than 20 years, efforts have been made to restructure and simplify prognostic parameters into clinical scores. We evaluated the influence of various clinical and pathological factors on survival and recurrence and developed a simple model for risk stratification. METHODS We have analyzed a total of 13 prognostic factors in 382 consecutive and prospectively enrolled R0-resected patients and applied our data set to ten published prognostic scoring systems. Prognostic factors that influenced disease-specific and disease-free survival were included into a model clinical risk score. RESULTS The 5- and 10-year observed survival rates were 43% and 28%, respectively, for all 382 patients. The disease-specific 5- and 10-year survival rates were 49% and 37%, respectively; the 5- and 10-year recurrence rates were 68% and 70%, respectively. For patients with synchronous liver metastases, survival was not affected by the timing of liver resection. The prognosis after treatment of any recurrence was best after the accomplishment of a repeated R0 situation, independent of the location of the recurrence. In the multivariate analysis, the disease-specific survival and recurrence rates were statistically significantly influenced by more than three lymph node metastases of the primary tumor, more than two lesions within the liver, and the presence of extrahepatic tumor. CONCLUSIONS From these data, we have developed a simple score for the risk stratification which may be useful for future studies on interdisciplinary management of colorectal liver metastases.
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Affiliation(s)
- Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, Jena, 07740, Germany.
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Anaya DA, Blazer DG, Abdalla EK. Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma. Semin Intervent Radiol 2011; 25:110-22. [PMID: 21326552 DOI: 10.1055/s-2008-1076684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.
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Affiliation(s)
- Daniel A Anaya
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Lin AY, Chua MS, Choi YL, Yeh W, Kim YH, Azzi R, Adams GA, Sainani K, van de Rijn M, So SK, Pollack JR. Comparative profiling of primary colorectal carcinomas and liver metastases identifies LEF1 as a prognostic biomarker. PLoS One 2011; 6:e16636. [PMID: 21383983 PMCID: PMC3044708 DOI: 10.1371/journal.pone.0016636] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 01/03/2011] [Indexed: 12/19/2022] Open
Abstract
Purpose We sought to identify genes of clinical significance to predict survival and the risk for colorectal liver metastasis (CLM), the most common site of metastasis from colorectal cancer (CRC). Patients and Methods We profiled gene expression in 31 specimens from primary CRC and 32 unmatched specimens of CLM, and performed Significance Analysis of Microarrays (SAM) to identify genes differentially expressed between these two groups. To characterize the clinical relevance of two highly-ranked differentially-expressed genes, we analyzed the expression of secreted phosphoprotein 1 (SPP1 or osteopontin) and lymphoid enhancer factor-1 (LEF1) by immunohistochemistry using a tissue microarray (TMA) representing an independent set of 154 patients with primary CRC. Results Supervised analysis using SAM identified 963 genes with significantly higher expression in CLM compared to primary CRC, with a false discovery rate of <0.5%. TMA analysis showed SPP1 and LEF1 protein overexpression in 60% and 44% of CRC cases, respectively. Subsequent occurrence of CLM was significantly correlated with the overexpression of LEF1 (chi-square p = 0.042), but not SPP1 (p = 0.14). Kaplan Meier analysis revealed significantly worse survival in patients with overexpression of LEF1 (p<0.01), but not SPP1 (p = 0.11). Both univariate and multivariate analyses identified stage (p<0.0001) and LEF1 overexpression (p<0.05) as important prognostic markers, but not tumor grade or SPP1. Conclusion Among genes differentially expressed between CLM and primary CRC, we demonstrate overexpression of LEF1 in primary CRC to be a prognostic factor for poor survival and increased risk for liver metastasis.
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Affiliation(s)
- Albert Y Lin
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, California, United States of America.
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Rocha FG, D'Angelica M. Treatment of liver colorectal metastases: role of laparoscopy, radiofrequency ablation, and microwave coagulation. J Surg Oncol 2011; 102:968-74. [PMID: 21166000 DOI: 10.1002/jso.21720] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Up to 50% of patients with colorectal cancer will develop metastatic disease in the liver. While surgical extirpation remains the best option for long-term survival, several complementary modalities such as laparoscopy, radiofrequency ablation, and microwave coagulation have gained wide acceptance as primary and adjunct therapies for both resectable and unresectable disease. This review will focus on the application and outcome of these techniques in patients with colorectal liver metastases.
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Affiliation(s)
- Flavio G Rocha
- Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Feroci F, Fong Y. Use of clinical score to stage and predict outcome of hepatic resection of metastatic colorectal cancer. J Surg Oncol 2010; 102:914-21. [DOI: 10.1002/jso.21715] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Gaujoux S, Allen PJ. Role of staging laparoscopy in peri-pancreatic and hepatobiliary malignancy. World J Gastrointest Surg 2010; 2:283-90. [PMID: 21160897 PMCID: PMC2999692 DOI: 10.4240/wjgs.v2.i9.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/18/2010] [Accepted: 09/24/2010] [Indexed: 02/06/2023] Open
Abstract
Even after extensive preoperative assessment, staging laparoscopy may allow avoidance of non-therapeutic laparotomy in patients with radiographically occult metastatic or locally unresectable disease. Staging laparoscopy is associated with decreased postoperative pain, a shorter hospital stay and a higher likelihood of receiving systemic therapy compared to laparotomy but its yield has decreased with improvements in imaging techniques. Current uses of staging laparoscopy include the following: (1) In the staging of pancreatic adenocarcinoma, laparoscopic staging allows for the identification of sub-radiographic metastatic disease in locally advanced cancer in approximately 30% of patients and, in radiographically resectable cancer, may identify metastatic disease in 10%-15% of cases; (2) In colorectal liver metastases, selective use of laparoscopic staging in patients with a clinical risk score of over 2 identifies unresectable disease in approximately 20% of patients; (3) In hepatocellular carcinoma, laparoscopic staging could be selectively used in high-risk patients such as those with clinically apparent liver cirrhosis and in patients with major vascular invasion or bilobar tumors; and (4) In biliary tract malignancy, staging laparoscopy may be used in all patients with potentially resectable primary gallbladder cancer and in selected patients with T2/T3 hilar cholangiocarcinoma. Because of the decreasing yield of SL secondary to improvements in imaging techniques, staging laparoscopy should be used selectively for patients with pancreatic and hepatobiliary malignancy to avoid unnecessary non-therapeutic laparotomy and to improve resource utilization. Each individual surgeon should apply his or her threshold as to whether staging laparoscopy is indicated according to the quality of preoperative imaging studies and the availability of resources at their own institution.
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Affiliation(s)
- Sebastien Gaujoux
- Sebastien Gaujoux, Peter J Allen, Hepatobiliary Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C-887, New York, NY 10021, United States
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Surgical treatment of hepatic colorectal metastasis: evolving role in the setting of improving systemic therapies and ablative treatments in the 21st century. Cancer J 2010; 16:103-10. [PMID: 20404606 DOI: 10.1097/ppo.0b013e3181d7e8e5] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Liver resection has clearly been established as the standard treatment for resectable colorectal liver metastases. This article will review the expanding role for hepatectomy in this disease. Faster and safer hepatectomies are allowing combined resections of the primary cancer and synchronous hepatic metastases. Effective neoadjuvant chemotherapy, as well as increasing data demonstrating effectiveness and safety of combined hepatectomy and ablative therapies, have further expanded the pool of patients now selected for resection. The end result is that increasing numbers of patients are undergoing acceptably aggressive surgical therapies with extension of life and possible cure. Successful multimodality therapies are also now allowing for long-term survival even in patients not cured of cancer. The prolonged survival of most patients treated by hepatectomy has allowed a long-term analysis of the patterns of recurrence, which emphasize the importance of controlling liver disease for prolongation of life. These improvements in treatments for hepatic metastases have come with a precipitous escalation of the costs of care. This will likely require that future clinical trials and algorithms of care not only be based on cancer outcome data but also on value analysis of treatment and follow-up regimens.
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Clinical Risk Score Can be Used to Select Patients for Staging Laparoscopy and Laparoscopic Ultrasound for Colorectal Liver Metastases. World J Surg 2010; 34:2141-5. [DOI: 10.1007/s00268-010-0630-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wong SL, Mangu PB, Choti MA, Crocenzi TS, Dodd GD, Dorfman GS, Eng C, Fong Y, Giusti AF, Lu D, Marsland TA, Michelson R, Poston GJ, Schrag D, Seidenfeld J, Benson AB. American Society of Clinical Oncology 2009 clinical evidence review on radiofrequency ablation of hepatic metastases from colorectal cancer. J Clin Oncol 2009; 28:493-508. [PMID: 19841322 DOI: 10.1200/jco.2009.23.4450] [Citation(s) in RCA: 292] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To review the evidence about the efficacy and utility of radiofrequency ablation (RFA) for hepatic metastases from colorectal cancer (CRHM). METHODS The American Society of Clinical Oncology (ASCO) convened a panel to conduct and analyze a comprehensive systematic review of the RFA literature from Medline and the Cochrane Collaboration Library. RESULTS Because data were considered insufficient to form the basis of a practice guideline, ASCO has instead published a clinical evidence review. The evidence is from single-arm, retrospective, and prospective trials. No randomized controlled trials have been included. The following three clinical issues were considered by the panel: the efficacy of surgical hepatic resection versus RFA for resectable tumors; the utility of RFA for unresectable tumors; and RFA approaches (open, laparoscopic, or percutaneous). Evidence suggests that hepatic resection improves overall survival (OS), particularly for patients with resectable tumors without extrahepatic disease. Careful patient and tumor selection is discussed at length in the literature. RFA investigators report a wide variability in the 5-year survival rate (14% to 55%) and local tumor recurrence rate (3.6% to 60%). The reported mortality rate was low (0% to 2%), and the major complications rate was commonly reported to be between 6% and 9%. RFA is currently performed with all three approaches. CONCLUSION There is a compelling need for more research to determine the efficacy and utility of RFA to increase local recurrence-free, progression-free, and disease-free survival as well as OS for patients with CRHM. Clinical trials have established that hepatic resection can improve OS for patients with resectable CRHM.
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Merkel S, Bialecki D, Meyer T, Müller V, Papadopoulos T, Hohenberger W. Comparison of clinical risk scores predicting prognosis after resection of colorectal liver metastases. J Surg Oncol 2009; 100:349-57. [PMID: 19572329 DOI: 10.1002/jso.21346] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to compare the risk scores of Fong et al., Nordlinger et al., and the TNM classification of colorectal liver metastases proposed by the UICC. METHODS Data from 282 consecutive patients undergoing 303 liver resections for metastatic colorectal cancer between 1995 and 2006 at the Department of Surgery, University of Erlangen were analyzed. The median follow-up time was 34 months. A curative (R0) resection was performed in 92% of the patients. RESULTS Applying the clinical risk score of Fong with preoperative data identified three risk groups. The survival rates between "low risk" (n = 22) and "intermediate risk" (n = 222) diverged (P = 0.073). The survival rates between "intermediate risk" and "high risk" (n = 59) differed significantly (P = 0.030). Using the risk scoring system of Nordlinger, patients were divided into two risk groups (i.e., "low risk" (n = 218) and "intermediate risk" (n = 68)). Significant differences in survival between the groups were noted (P = 0.012). Applying the clinical TNM classification of colorectal liver metastases revealed no significant differences in survival between the risk groups. CONCLUSIONS Our study found the clinical risk score developed by Fong et al. to be a reliable preoperative prognostic tool for selecting patients for surgical resection of colorectal liver metastases.
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Affiliation(s)
- Susanne Merkel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany.
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Ayiomamitis GD, Low JK, Alkari B, Lee SH, Ammori BJ. Role of laparoscopic right portal vein ligation in planning staged or major liver resection. J Laparoendosc Adv Surg Tech A 2009; 19:409-13. [PMID: 19215213 DOI: 10.1089/lap.2008.0238] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS Right portal vein ligation (PVL) has its recognized role in inducing hypertrophy of future liver remnant (FLR) prior to major liver resection. The aim of this study was to evaluate the safety, feasibility, and effectiveness of laparoscopic right PVL and to explore its applications. METHODS Laparoscopic right PVL was employed either during staging laparoscopy when a right hepatic trisectionectomy was indicated, leaving a small (<25%) FLR (indication 1), or during a laparoscopic left hepatic lobectomy (left lateral sectionectomy) when a second-stage right hemihepatectomy was to follow (indication 2). A follow up cross-sectional liver imaging was performed 4-6 weeks later with liver volumetry to confirm hypertrophy of the FLR before proceeding to major hepatectomy. RESULTS Six patients (female, 5), 74-83 years old, underwent a laparoscopic right PVL, of whom 4 patients fulfilled indication 1 while 2 patients fulfilled indication 2. The median operating time for indication 1 was 60 minutes. There were no intra- or postoperative complications, and all procedures were completed laparoscopically. Repeat imaging of the liver demonstrated a median (range) hypertrophy of FLR of 24.5% (range, 20.7-33.1%). The right liver experienced atrophy. CONCLUSIONS In the hands of the experienced laparoscopic hepatobiliary surgeon, laparoscopic right PVL is feasible and safe, and induces adequate regeneration of the FLR. Laparoscopic right PVL has its applications at the time of staging laparoscopy in patients requiring a right hepatic trisectionectomy in the presence of a small FLR and as part of a staged liver resection in patients with bilobar liver disease that spares segments 1 and 4.
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Kemeny NE, Melendez FDH, Capanu M, Paty PB, Fong Y, Schwartz LH, Jarnagin WR, Patel D, D'Angelica M. Conversion to resectability using hepatic artery infusion plus systemic chemotherapy for the treatment of unresectable liver metastases from colorectal carcinoma. J Clin Oncol 2009; 27:3465-71. [PMID: 19470932 DOI: 10.1200/jco.2008.20.1301] [Citation(s) in RCA: 205] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To determine the conversion to resectability in patients with unresectable liver metastases from colorectal cancer treated with hepatic arterial infusion (HAI) plus systemic oxaliplatin and irinotecan (CPT-11). PATIENTS AND METHODS Forty-nine patients with unresectable liver metastases (53% previously treated with chemotherapy) were enrolled onto a phase I protocol with HAI floxuridine and dexamethasone plus systemic chemotherapy with oxaliplatin and irinotecan. Results Ninety-two percent of the 49 patients had complete (8%) or partial (84%) response, and 23 (47%) of the 49 patients were able to undergo resection in a group of patients with extensive disease (73% with > five liver lesions, 98% with bilobar disease, 86% with > or = six segments involved). For chemotherapy-naïve and previously treated patients, the median survival from the start of HAI therapy was 50.8 and 35 months, respectively. The only baseline variable significantly associated with a higher resection rate was female sex. Variables reflecting extensive anatomic disease, such as number of lesions or number of vessels involved, were not significantly associated with the probability of resection. CONCLUSION The combination of regional HAI floxuridine/dexamethasone and systemic oxaliplatin and irinotecan is an effective regimen for the treatment of patients with unresectable liver metastases from colorectal cancer, demonstrating a 47% conversion to resection (57% in chemotherapy-naïve patients). Future randomized trials should compare HAI plus systemic chemotherapy with systemic therapy alone to assess the additional value of HAI therapy in converting patients with hepatic metastases to resectability.
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Affiliation(s)
- Nancy E Kemeny
- Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, 1275 York Ave, New York, NY 10065, USA.
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Nanashima A, Araki M, Tobinaga S, Kunizaki M, Hidaka S, Shibata K, Mochinaga K, Sawai T, Isomoto H, Ohnita K, Uehara M, Nagayasu T. Relationship between period of survival and clinicopathological characteristics in patients with colorectal liver metastasis. Eur J Surg Oncol 2009; 35:504-9. [PMID: 19167860 DOI: 10.1016/j.ejso.2009.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 12/25/2008] [Accepted: 01/02/2009] [Indexed: 12/27/2022] Open
Abstract
AIM Cancer death in the early period after hepatectomy still occurs in patients with colorectal liver metastasis (CLM). We examined the relationship between clinicopathological parameters and survival periods in 130 CLM patients who underwent hepatectomy. PATIENTS/METHODS Patients were divided into four groups: Group 1 (5-year survivors without tumor relapse), Group 2 (survivors at 2-5 years), Group 3 (cancer death at 2-5 years), and Group 4 (cancer death within 2 years). RESULTS A short surgical margin was frequent in Group 4 compared to Group 1 (31 vs. 78%, P<0.05). Primary node-positive status, absence of fibrous pseudo-capsular formation, higher Clinical Risk Score, and tumor recurrence within 12 months were frequent in Group 4 (P<0.05). Multivariate analysis revealed a short surgical margin (HR; 3.5) and early tumor relapse (HR; 5.9) as independently significant related parameters (P<0.05). CONCLUSIONS Sufficient surgical margins and careful follow-up for early tumor relapse may be important for improving postoperative outcomes for CLM patients.
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Affiliation(s)
- A Nanashima
- Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Pawlik TM, Assumpcao L, Vossen JA, Buijs M, Gleisner AL, Schulick RD, Choti MA. Trends in nontherapeutic laparotomy rates in patients undergoing surgical therapy for hepatic colorectal metastases. Ann Surg Oncol 2008; 16:371-8. [PMID: 19020939 DOI: 10.1245/s10434-008-0230-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 10/06/2008] [Accepted: 10/08/2008] [Indexed: 11/18/2022]
Abstract
Surgery is the treatment of choice in selected patients with hepatic colorectal metastases. Despite improvements in preoperative imaging, patients can undergo unnecessary nontherapeutic laparotomy. The aim of this study was to examine trends in nontherapeutic laparotomy rates in patients undergoing planned surgical therapy for hepatic colorectal metastases. Data from 530 operations (461 patients) undergoing potentially curative surgical therapy for colorectal liver metastases between 1994 and 2005 were analyzed. The incidence of nontherapeutic laparotomy was determined and factors associated with nontherapeutic laparotomy were identified. Overall, 49 nontherapeutic laparotomies were performed (9.2%). Higher nontherapeutic laparotomy rates were seen in patients with multiple metastases and tumor size >5 cm (both P < 0.05). Preoperative positron emission tomography (PET) imaging was associated with lower risk of nontherapeutic laparotomy [5.6% versus 12.4%, P = 0.009, odds ratio (OR) = 0.42]. At laparotomy, extrahepatic findings were the reason for nontherapeutic laparotomy in 44.9% of cases. The nontherapeutic laparotomy rate significantly decreased over time (14.9% for 1994-1997 versus 9.6% for 1998-2001 versus 4.7% for 2002-2005; P = 0.003). While patients in each time period were similar with regard to tumor specific factors, utilization of PET imaging (P < 0.001) as well as resection plus ablation (P = 0.004) increased over time. We conclude that prevalence of nontherapeutic laparotomy for patients undergoing surgical exploration for hepatic colorectal metastases has decreased significantly in recent years to less than 5%. The reasons for this trend are probably multifactorial and may include improved preoperative assessment, such as PET imaging, as well as salvage surgical options.
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Affiliation(s)
- Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD 22187, USA
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Gunvén P, Blomgren H, Lax I, Levitt SH. Curative stereotactic body radiotherapy for liver malignancy. Med Oncol 2008; 26:327-34. [DOI: 10.1007/s12032-008-9125-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 10/24/2008] [Indexed: 12/22/2022]
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Sharma S, Camci C, Jabbour N. Management of hepatic metastasis from colorectal cancers: an update. ACTA ACUST UNITED AC 2008; 15:570-80. [PMID: 18987925 DOI: 10.1007/s00534-008-1350-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 02/20/2008] [Indexed: 12/17/2022]
Abstract
Approximately 50%-60% of patients with colorectal cancers will develop liver lesions in their life span. Despite the potential of surgical resection to provide long-term survival in this subset of patients, only 15%-20% are found to be resectable. The introduction of new neoadjuvant chemotherapeutic agents and the expanding criteria of resection have enhanced the overall 5-year survival from 30% to 60% in the past decade. The use of technical innovations such as staged resection; portal vein embolization, and repeat resection have allowed higher resection rates in patients with bilobar disease. Extrahepatic primary and liver-exclusive recurrent disease no longer represent an absolute contraindication to resection. The role of regional therapy using hepatic arterial infusion is being redefined for liver-exclusive unresectable disease. Adjuvant chemotherapy in combination with regional therapies is being looked at from fresh perspectives. Ablative approaches have gained a firm role both as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Overall, the management of hepatic metastasis from colorectal cancers requires a multimodal approach.
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Affiliation(s)
- Sharad Sharma
- Nazih Zuhdi Transplant Institute, 3300 North West Expressway, Oklahoma, OK 73112, USA
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Nanashima A, Sumida Y, Abo T, Tobinaga S, Takeshita H, Hidaka S, Yasutake T, Nagayasu T, Mine M, Sawai T. A modified grading system for post-hepatectomy metastatic liver cancer originating from colorectal carcinoma. J Surg Oncol 2008; 98:363-70. [DOI: 10.1002/jso.21114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chang L, Stefanidis D, Richardson WS, Earle DB, Fanelli RD. The role of staging laparoscopy for intraabdominal cancers: an evidence-based review. Surg Endosc 2008; 23:231-41. [PMID: 18813972 DOI: 10.1007/s00464-008-0099-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 07/08/2008] [Indexed: 02/06/2023]
Abstract
Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.
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Affiliation(s)
- L Chang
- Department of General Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA.
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Abstract
Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.
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Affiliation(s)
- Andrew A. Gumbs
- Division of Upper GI and Endocrine Surgery, Department of Surgery, Columbia University College of Physicians and SurgeonsNew York NYUSA
| | - Brice Gayet
- Institut Mutualiste Montsouris, Boulevard JourdanParisFrance
| | - Michel Gagner
- Department of Surgery, Mount Sinai Medical CenterMiami Beach FLUSA
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Bretagnol F, Hatwell C, Farges O, Alves A, Belghiti J, Panis Y. Benefit of laparoscopy for rectal resection in patients operated simultaneously for synchronous liver metastases: preliminary experience. Surgery 2008; 144:436-41. [PMID: 18707042 DOI: 10.1016/j.surg.2008.04.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 04/16/2008] [Indexed: 12/27/2022]
Abstract
BACKGROUND Resection of the rectal primary neoplasm with synchronous liver metastases (LM) is warranted, because this is the only strategy with curative potential. Combined resection remains controversial because of the risk of morbidity and necessity of a curative abdominal approach to warrant liver resection. Laparoscopic colorectal resection may be beneficial and could facilitate this procedure. METHODS Between February 2006 and June 2007, 10 patients underwent 1-step laparoscopic resection for primary rectal cancer combined with open resection of synchronous LM. RESULTS All patients underwent a laparoscopic mesorectal excision (n = 10). Liver resections included right hepatectomy (n = 1), bi- or trisegmentectomy (n = 3), and metastasectomy (n = 6). The rectosigmoid specimen was extracted through the right subcostal or a short midline incision used for open liver resection, except in 3 patients who underwent a 1-step totally laparoscopic resection of both the colorectal and hepatic neoplasms. The overall morbidity was 40%. The median hospital stay was 12 days (range, 5-40). Overall morbidity (29% vs 40%) and hospital stay (12 vs 12 days) were similar to those observed in a previous cohort of 27 patients undergoing laparoscopic mesorectal excision only. CONCLUSION This pilot study suggests that laparoscopic rectal resection with synchronous resection of LM is feasible with low morbidity and short hospital stay. Moreover, laparoscopy facilitates the operation approach for synchronous major hepatectomy.
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Effect of postoperative morbidity on long-term survival after hepatic resection for metastatic colorectal cancer. Ann Surg 2008; 247:994-1002. [PMID: 18520227 DOI: 10.1097/sla.0b013e31816c405f] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Resection is the most effective treatment for metastatic colorectal cancer (MCRC) to the liver. However, postoperative morbidity is common and its impact on long-term oncological outcome is unclear. The objective of this study was to evaluate the impact of postoperative morbidity on the long-term outcome after liver resection for MCRC. METHODS Medical records of patients who underwent liver resection for MCRC with curative intent between 1991 and 2002 were reviewed. Patients who died of postoperative complications were excluded; operative and perioperative data, including morbidity and clinicopathological variables, were analyzed. Patients were stratified by disease extent and risk of recurrence using a clinical risk scoring system. RESULTS A total of 1067 patients were included in the study and the median follow-up period was 41 months. The overall morbidity rate was 42%; the 5-year disease-specific survival (DSS) and overall disease-free survival (DFS) rates of patients who had complications were 41% and 25%, respectively, compared with 48% and 33%, respectively, for patients who did not have complications (P = 0.0059 for DSS, P = 0.0053 for DFS). On multivariate analysis, morbidity was not an independent predictor of either DSS or DFS; however, in a subgroup of patients with low clinical risk scores, morbidity was associated with a significant reduction in both DSS and DFS. CONCLUSIONS Postoperative morbidity adversely affects long-term outcome after hepatic resection for MCRC in patients at lower risk for recurrence. Efforts aimed at reducing perioperative morbidity will not only reduce usage of resources but will likely further enhance the therapeutic benefit of resection for such patients.
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Abstract
A number of cancers present with synchronous or metachronous hepatic metastases. Historically, many of these patients were considered unresectable and were treated with either systemic chemotherapy or supportive care. Today, a variety of options exist for the management of hepatic metastases. Newer agents for systemic therapy continue to be introduced and are providing improved progression-free and overall survival and increased resectability of liver metastases. However, complete surgical resection of isolated hepatic metastases remains the optimal management for these patients. Surgical interventions can be offered to patients with hepatic-only metastases. Hepatic artery chemotherapy represents an adjunct for those patients undergoing resection and can improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer generation biologic agents can improve results. New therapeutic modalities to treat lesions that are unresectable include ablative techniques such as radiofrequency ablation (RFA) and cryoablation. This article will examine modalities of diagnosis of hepatic metastases and highlight the data regarding hepatic resection for metastases of several types of primary cancers, the rationale for, and efficacy of, hepatic arterial chemotherapy, in both the postoperative adjuvant setting and in unresectable liver disease, and review the current literature for ablative techniques in the treatment of liver metastases.
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Affiliation(s)
- Cletus A Arciero
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
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Tamandl D, Herberger B, Gruenberger B, Schoppmann SF, Puhalla H, Schindl M, Schima W, Jakesz R, Gruenberger T. Adequate preoperative staging rarely leads to a change of intraoperative strategy in patients undergoing surgery for colorectal cancer liver metastases. Surgery 2008; 143:648-57. [DOI: 10.1016/j.surg.2007.11.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Revised: 11/15/2007] [Accepted: 11/16/2007] [Indexed: 12/27/2022]
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