Improved outcomes of colorectal cancer patients with liver metastases in the era of the multidisciplinary teams

Initial Assessment of Resectability of Colorectal Cancer Liver Metastases Versus Clinical Outcome

BACKGROUND

Surgery improves long-term survival for resectable, liver-only metastatic colorectal cancer (mCRC). With no consensus definition of "resectable" disease, decisions regarding resectability are reliant on the expertise and judgement of the treating clinician working in consultation with a multidisciplinary team (MDT). This study examines the clinical outcome versus initial assessment of resectability in an Australian population with mCRC.

PATIENTS AND METHODS

Patients with liver-only mCRC diagnosed January 2009 to December 2022 were identified from the Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry. Patients were classified based on prospectively documented treatment assessment as "resectable," "potentially resectable," or "unresectable." The correlation between initial assessment of resectability and clinical outcome, and any impact of clinicopathologic factors were examined. Kaplan-Meier analysis assessed overall survival based on initial resectability assessment and resection status.

RESULTS

Of 4437 patients with mCRC identified through TRACC, 1250 (28%) had liver-only disease at presentation, with 497 (43%), 277 (24%), and 374 (33%) classified as "unresectable," "potentially resectable," and "resectable," respectively. In total, 516 (41%) ultimately underwent surgical resection, including 30 (6%) of the "initially unresectable," 148 (53%) of the "potentially resectable," and 338 (90%) of the "resectable" at a median of 9.5, 5.9, and 2.4 months from the diagnosis of liver metastases, respectively. Resection in the "unresectable" patient population was associated with younger age (mean age 63 vs. 69, P = .0006), better performance status (ECOG 0-1 100% vs. 74%, P = .0017), and fewer comorbidities (Charlson index 0-3 in 73% vs. 53%, P = .0296) compared with no resection. Median overall survival was longer for resected versus nonresected patients across all categories: "unresectable" (59.2 vs. 17.6 months, P < .0001), "potentially resectable" (57.2 vs. 22.8 months, P < .0001), and "resectable" (108 vs. 55 months, P < .0001).

CONCLUSIONS

This real-world study demonstrates the potential for "initially unresectable" patients to become surgical candidates following systemic therapy, more likely in younger and fitter patients, with overall excellent survival outcomes in resected patients. This highlights the value of routine, repeated MDT assessments for patients with liver-only disease who are continuing to respond to systemic therapy, even for those initially considered never to be surgical candidates.

Optimal treatment strategies for borderline resectable liver metastases from colorectal cancer

BACKGROUND

Traditionally, colorectal liver metastases (CRLMs) are divided into "initially resectable" and "initially unresectable." The terminology "borderline resectable" continues to be elusive without any common consensus or definition. This narrative review aims to decode the conundrum of "borderline resectable CRLM (BR-CRLM)" and to discuss optimal treatment strategies.

METHODS

A comprehensive review was performed using Medline/PubMed and Web of Science databases with a search period ending on January 1, 2024. Using PubMed, the terms "CRLM," "BR-CRLM," and "management of BR-CRLM" were searched.

RESULTS

The 2016 European Society for Medical Oncology guidelines defined the term "resectability" in CRLM using the "technical (surgical) criteria" and the "oncologically criteria." These 2 criteria form the basis of defining BR-CRLM. Thus, BR-CRLM can be either technically easy but with unfavorable oncologically criteria or technically difficult with favorable oncologically criteria. Although defining BR-CRLM by incorporating both these criteria seems to be the most logical way forward, there is currently a lot of heterogeneity in the literature. It is generally agreed upon that some form of chemotherapy needs to be administered in BR-CRLM before embarking on surgery. Conversion chemotherapy is used in patients with BR-CRLM in which there is a possibility of resection after effective downsizing. Along with improved effective chemotherapy, great strides have been made in pushing the limits of surgery to achieve resectability in this subset of patients.

CONCLUSION

Advanced surgical techniques and locoregional liver-directed therapies coupled with perioperative chemotherapy with or without targeted therapy have made long-term survival benefit, a reality in patients with BR-CRLM. Thus, the time has come to recognize "BR-CRLM" as a distinct entity.

Multidisciplinary team meetings and their impact on survival in rectal cancer. Population-based analysis in Catalonia (Spain)

BACKGROUND

Multidisciplinary team meetings (MTMs) are considered a pillar of cancer care; however, evidence of the independent benefit of MTMs on survival in rectal cancer is controversial.

METHODS

This population-based cohort analysis included patients undergoing surgery for primary rectal cancer with curative intent. We drew data derived from three clinical audits conducted in Catalonia from 2011 to 2020. The primary outcome was 2-year survival. Multivariable Cox regression analysis was used to assess the hazard ratio for death in patients whose cases were versus were not discussed in a preoperative MTM.

RESULTS

A total of 5249 patients were included (66.1 % male, 58.3 % aged 60-79 years, 63.2 % receiving anterior resection): 4096 cases were discussed in a preoperative MTM, and 1153 were not. Multivariable Cox proportional hazards regression analysis showed that the MTM group had better survival than those with no preoperative MTM (hazard ratio 1.22, 95 % confidence interval 1.02-1.48), after adjusting for potential confounders.

CONCLUSIONS

Preoperative MTM may be associated with improved survival in patients with rectal cancer in Catalonia. Efforts to ensure universal access to MTMs for all newly diagnosed patients should be supported.

The impact of multidisciplinary cancer conferences on overall survival: a meta-analysis

BACKGROUND

Multidisciplinary cancer conferences consist of regular meetings between diverse specialists working together to share clinical decision making in cancer care. The aim of this study was to systematically review and meta-analyze the effect of multidisciplinary cancer conference intervention on the overall survival of patients with cancer.

METHODS

A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials for studies published up to July 2023. Studies reporting on the impact of multidisciplinary cancer conferences on patient overall survival were included. A standard random-effects model with the inverse variance-weighted approach was used to estimate the pooled hazard ratio of mortality (multidisciplinary cancer conference vs non-multidisciplinary cancer conference) across studies, and the heterogeneity was assessed by I2. Publication bias was examined using funnel plots and the Egger test.

RESULTS

A total of 134 287 patients with cancer from 59 studies were included in our analysis, with 48 467 managed by multidisciplinary cancer conferences and 85 820 in the control arm. Across all cancer types, patients managed by multidisciplinary cancer conferences had an increased overall survival compared with control patients (hazard ratio = 0.67, 95% confidence interval = 0.62 to 0.71, I2 = 84%). Median survival time was 30.2 months in the multidisciplinary cancer conference group and 19.0 months in the control group. In subgroup analysis, a positive effect of the multidisciplinary cancer conference intervention on overall survival was found in breast, colorectal, esophageal, hematologic, hepatocellular, lung, pancreatic, and head and neck cancer.

CONCLUSIONS

Overall, our meta-analysis found a significant positive effect of multidisciplinary cancer conferences compared with controls. Further studies are needed to establish nuanced guidelines when optimizing multidisciplinary cancer conference integration for treating diverse patient populations.

Radiofrequency Ablation Combined with Hepatic Artery Embolization Using a Tris-acryl Gelatin Microsphere for Colorectal Liver Metastases-Initial Experience

Purpose

We aim to evaluate retrospectively the feasibility, safety, and initial therapeutic outcomes of radiofrequency ablation combined with hepatic artery embolization using a tris-acryl gelatin microsphere for colorectal liver metastases.

Material and Methods

Six consecutive patients (4 men and 2 women) with median age of 68 years (range 57-78 years) underwent computed tomography fluoroscopy-guided radiofrequency ablation immediately after hepatic artery embolization using microspheres. This study evaluated tumor visibility on noncontrast-enhanced computed tomography immediately after hepatic artery embolization; analyzed local tumor progression; defined technical success as the coverage of the tumor by the ablative zone; and assessed adverse events based on Common Terminology Criteria for Adverse Events v5.0.

Results

Ten tumors with median maximum diameter of 9 mm (range 5-52 mm) were treated in nine sessions. Eight tumors (80%, 8/10 tumors) were detected as high-attenuation nodules. One tumor was treated in two sessions because follow-up computed tomography revealed an insufficient ablative margin. Therefore, the primary and secondary technical success was 90% (9/10 tumors) and 100% (10/10 tumors), respectively. Grade 2 pneumothorax was observed in one session (11%, 1/9 sessions). No grade 3 or higher adverse event was observed. The local tumor progression rate was 20% (2/10 tumors) during the median follow-up of 14 months.

Conclusions

Radiofrequency ablation following microsphere embolization may be a feasible, safe, and useful therapeutic option for controlling small colorectal liver metastases.

Active involvement of patients, radiation oncologists, and surgeons in a multidisciplinary team approach: Guiding local therapy in recurrent, metastatic rectal cancer

BACKGROUND

Despite the extensive implementation of an organized multidisciplinary team (MDT) approach in cancer treatment, there is little evidence regarding the optimal format of MDT. We aimed to investigate the impact of patient participation in MDT care on the actual application rate of metastasis-directed local therapy.

METHODS

We identified all 1211 patients with locally advanced rectal cancer treated with neoadjuvant radiochemotherapy at a single institution from 2006 to 2018. Practice patterns, tumor burden and OMD state were analyzed in recurrent, metastatic cases.

RESULTS

With a median follow-up of 60.7 months, 281 patients developed metastases, and 96 (34.2%), 92 (32.7%), and 93 (33.1%) patients had 1, 2-5, and >5 lesions, respectively. In our study, 27.1% were managed in the MDT clinic that mandated the participation of at least four to five board-certified multidisciplinary experts and patients in decision-making processes, while the rest were managed through diverse MDT approaches such as conferences, tumor board meetings, and discussions conducted via phone calls or email. Management in MDT clinic was significantly associated with more use of radiotherapy (p = 0.003) and more sessions of local therapy (p < 0.001). At the time of MDT clinic, the number of lesions was 1, 2-5, and >5 in 9 (13.6%), 35 (53.1%), and 19 (28.8%) patients, respectively. The most common states were repeat OMD (28.8%) and de novo OMD (27.3%), followed by oligoprogression (15%) and induced OMD (10.6%).

CONCLUSION

Our findings suggest that active involvement of patients and radiation oncologists, and surgeons in MDT care has boosted the probability of using local therapies for various types of OMD throughout the course of the disease.

Multidisciplinary discussion and management of synchronous colorectal liver metastases: A single center study in China

BACKGROUND

The multidisciplinary team (MDT) has been carried out in many large hospitals now. However, given the costs of time and money and with little strong evidence of MDT effectiveness being reported, critiques of MDTs persist.

AIM

To evaluate the effects of MDTs on patients with synchronous colorectal liver metastases and share our opinion on management of synchronous colorectal liver metastases.

METHODS

In this study we collected clinical data of patients with synchronous colorectal liver metastases from February 2014 to February 2017 in the Chinese People's Liberation Army General Hospital and subsequently divided them into an MDT+ group and an MDT- group. In total, 93 patients in MDT+ group and 169 patients in MDT- group were included totally.

RESULTS

Statistical increases in the rate of chest computed tomography examination (P = 0.001), abdomen magnetic resonance imaging examination (P = 0.000), and preoperative image staging (P = 0.0000) were observed in patients in MDT+ group. Additionally, the proportion of patients receiving chemotherapy (P = 0.019) and curative resection (P = 0.042) was also higher in MDT+ group. Multivariable analysis showed that the population of patients assessed by MDT meetings had higher 1-year [hazard ratio (HR) = 0.608, 95% confidence interval (CI): 0.398-0.931, P = 0.022] and 5-year (HR = 0.694, 95%CI: 0.515-0.937, P = 0.017) overall survival.

CONCLUSION

These results proved that MDT management did bring patients with synchronous colorectal liver metastases more opportunities for comprehensive examination and treatment, resulting in better outcomes.

Multimodality liver directed treatment for colorectal liver metastasis: Array of complementary options can improve outcomes - A single centre experience from India

AIM

Complimentary use of Liver directed therapies (LDTs) with systemic chemotherapy has improved oncologic outcomes in colorectal liver metastasis (CRLM). We analysed institutional results of multimodality management.

METHODS

Retrospective analysis of prospectively maintained database of CRLM patients managed with LDT including surgical resection, Ablation, Transarterial chemoembolization (TACE) or Transarterial radioembolization (TARE) between November 2011 to March 2020. Management plan was decided in multidisciplinary meeting. Resectable tumours underwent surgical resection or ablation or both in some cases. Borderline resectable or unresectable disease was treated with down staging chemotherapy or TACE/TARE followed by resection or ablation. All patients received adjuvant chemotherapy. Factors influencing survival were analysed.

RESULTS

Out of total 375 patients, surgery alone was done in 191 (50.93%) patients while surgery with other LDT in 26 patients (6.93%). Ablation alone was done in 100 (26.66%) whereas TACE/TARE were done as standalone treatment in 21 (5.6%) and 7 (1.86%) patients respectively. TACE + ablation was done in 28 (7.46%) and TARE + ablation was done in 2(0.53%) patients.5-year Overall Survival(OS) was 49.8% while Event free survival(EFS) was 21.4%. The median OS and EFS for surgical group was significantly better than non-surgical group (78 V/s 39 months; p<0.05 and 20 V/s 15 months p <0.005). The resectable (78 months) group had better median OS as compared to borderline resectable and Unresectable group (39 months and 29 months). Male gender, resectable disease and surgical intervention were associated with improved OS.

CONCLUSION

Although surgery remains the mainstay of treatment, complementary use of non-surgical LDT with systemic therapy offers possibility of good outcomes in advanced liver limited disease. Our experience highlights the impact of multidisciplinary care in optimizing CRLM treatment.

Conversion Strategy in Left-Sided RAS/BRAF Wild-Type Metastatic Colorectal Cancer Patients with Unresectable Liver-Limited Disease: A Multicenter Cohort Study

Colorectal cancer (CRC) patients frequently develop liver metastases. Different treatment strategies are available according to the timing of appearance, the burden of metastatic disease, and the performance status of the patient. Systemic treatment (ST) represents the cornerstone of metastatic disease management. However, in select cases, combined ST and surgical resection can lead to remarkable survival outcomes. In the present multicentric cohort study, we explored the efficacy of a conversion strategy in a selected population of left-sided RAS/BRAF wild-type CRC patients with liver-limited metastatic disease. Methods: The primary endpoint was to compare survival outcomes of patients undergoing ST not leading to surgery, liver resection after conversion ST, and hepatic resection with perioperative ST. Furthermore, we explored survival outcomes depending on whether the case was discussed within a multidisciplinary team. Results: Between 2012 and 2020, data from 690 patients respecting the inclusion criteria were collected. Among these, 272 patients were deemed eligible for the analysis. The conversion rate was 24.1% of cases. Fifty-six (20.6%) patients undergoing surgical resection after induction treatment (i.e., ultimately resectable) had a significant survival advantage compared to those receiving systemic treatment not leading to surgery (176 pts, 64.7%) (5-year OS 60.8% and 11.7%, respectively, Log Rank test p < 0.001; HR = 0.273; 95% CI: 0.16−0.46; p < 0.001; 5-year PFS 22.2% and 6.3%, respectively, Log Rank test p < 0.001; HR = 0.447; 95% CI: 0.32−0.63; p < 0.001). There was no difference in survival between ultimately resectable patients and those who had liver resection with perioperative systemic treatment (potentially resectable—40 pts) (5-year OS 71.1%, Log Rank test p = 0.311. HR = 0.671; 95% CI: 0.31−1.46; p = 0.314; 5-year PFS 25.7%, Log Rank test p = 0.305. HR = 0.782; 95% CI: 0.49−1.25; p = 0.306). Conclusions: In our selected population of left-sided RAS/BRAF wild-type colorectal cancer patients with liver-limited disease, a conversion strategy was confirmed to provide a survival benefit. Patients not deemed surgical candidates at the time of diagnosis and patients judged resectable with perioperative systemic treatment have similar survival outcomes.

Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients

There is still debate over how reviewing oncological histories and addressing appropriate therapies in multidisciplinary team (MDT) discussions may affect patients’ overall survival (OS). The aim of this study was to describe MDT outcomes for a single cancer center’s patients affected by colorectal liver metastases (CRLMs). From 2010 to 2020, a total of 847 patients with CRLMs were discussed at our weekly MDT meeting. Patients’ characteristics and MDT decisions were analyzed in two groups: patients receiving systemic therapy (ST) versus patients receiving locoregional treatment (LRT). Propensity-score matching (PSM) was run to reduce the risk of selection bias. The median time from MDT indication to treatment was 27 (IQR 13−51) days. The median OS was 30 (95%CI = 27−34) months. After PSM, OS for patients undergoing LRT was 51 (95%CI = 36−64) months compared with 15 (95%CI = 13−20) months for ST patients (p < 0.0001). In this large retrospective study, the MDT discussions were useful in providing the patients with all available locoregional options.

The impact of a multispecialty operative team on colorectal cancer surgery: A retrospective study from a would-be medical center in Taiwan

Some studies showed that when distant metastasis or locally advanced tumors were observed, the participation of 2 or more operating surgeons (combined surgery) in the operation could improve the prognosis of patients. The multispecialty operative team would perform combined surgery in colon cancer patients with some complications since 2015. The goal of this study is to confirm performing combined surgery would improve the outcomes of colon cancer patients. A retrospective observational study was conducted, which involved all colon cancer patients between November 2015 and December 2019 at one would-be medical center. Patients were divided into 3 cohorts: those with complicated cases and had combined surgery (C_2S), those with complicated cases and had surgery performed by a single surgeon (C_1S), and those with uncomplicated cases and had surgery performed by a single surgeon (NC_1S). Overall survival and disease-free survival were compared among the 3 groups. A total of 296 colon cancer patients during the study period. Among them, 35 were C_2S, 87 were C_1S, and 174 were NC_1S. Patients in the NC_1S group had significantly higher 12-, 24-, and 36-month OS rates compared to those in the C_1S group (P < .01). In contrast, there was no significant difference in overall survival among patients in the NC_1S and C_2S group (P =.15). The quality of surgery must be impact the prognosis, especially in the individual who was complicated case, the survival in patients who had surgery performed by multispecialty operative team would be improved.

Implementation rate and effects of multidisciplinary team meetings on decision making about radiotherapy: an observational study at a single Japanese institution

BACKGROUND

Cancer treatment requires a multidisciplinary approach. Therefore, multidisciplinary team meetings (MDTMs) have been widely used to determine the direction of treatment. However, no standard provisions exist for conducting MDTMs, and recommendations discussed in MDTMs are sometimes not implemented. ​This study analyzed the indications for radiotherapy discussed and recommended at MDTMs, identified the rate of radiotherapy recommendations for patients that were not implemented, and clarified the reasons at a single academic center in Japan.

METHODS

This was a cross-sectional study that analyzed the minutes and electronic medical records of cases discussed at MDTMs held between April 2012-March 2017 at Yamagata University Hospital. We categorized how radiotherapy was initially presented at MDTMs, determined the rate of radiotherapy recommendations made through MDTMs, analyzed whether treatment recommendations were subsequently implemented, and examined the causes of non-implementation. We performed a statistical analysis to assess some clinical factors (sex, age, number of multidisciplinary team meetings, and classification of planned treatment) associated with the non-implementation of radiotherapy recommendations from MDTMs.

RESULTS

A total of 1813 cases were discussed at MDTMs, of which 71% (1293 cases) were presented with treatment plans, including radiotherapy. Further, 66% (1205 cases) were recommended for radiotherapy through the MDTMs. Recommendations from MDTMs were not implemented in 7% (142 cases). The most typical reason for non-implementation was the clinician's opinion (30%), followed by patient preferences (27%) and disease progression (20%). Change in cancer stage and improvement in symptoms were 12% and 4%, respectively. These ratios were similar each year. We could not find the factors associated with the non-implementation of radiotherapy recommendations from MDTMs.

CONCLUSIONS

MDTMs had a significant effect on the recommendation of radiotherapy for each patient with a tumor. The primary reason for the non-implementation of decisions made at MDTMs was the opinion of clinicians and the patient's preference. These results were similar to previous studies. We need to establish a monitoring system where patients themselves can decide the treatments based on their choices while using the recommendations from MDTMs.

The Effects of Multidisciplinary Team Meetings on Clinical Practice for Colorectal, Lung, Prostate and Breast Cancer: A Systematic Review

Simple Summary

Multidisciplinary team meetings have increasingly been implemented in cancer care worldwide to ensure timely, accurate and evidence-based diagnosis, and treatment plans. Nowadays, multidisciplinary team meetings are generally considered indispensable. However, they are considered time-consuming and expensive, while the effects of multidisciplinary team meetings are not yet fully understood. The aim of this systematic review is to update and summarize the literature and create an overview of the existing knowledge. Cancer types such as colorectal, lung, prostate and breast cancer with rapidly increasing incidence rates will inevitably impact the workload of clinicians. Understanding the effects of the widely implemented multidisciplinary team meetings in oncology care is fundamental in order to optimize care pathways and allocate resources in the rapidly diversifying landscape of cancer therapies.

Abstract

Objective: The aim of our systematic review is to identify the effects of multidisciplinary team meetings (MDTM) for lung, breast, colorectal and prostate cancer. Methods: Our systematic review, performed following PRISMA guidelines, included studies examining the impact of MDTMs on treatment decisions, patient and process outcomes. Electronic databases PUBMED, EMBASE, Cochrane Library and Web of Science were searched for articles published between 2000 and 2020. Risk of bias and level of evidence were assessed using the ROBINS-I tool and GRADE scale. Results: 41 of 13,246 articles were selected, evaluating colorectal (21), lung (10), prostate (6) and breast (4) cancer. Results showed that management plans were changed in 1.6–58% of cases after MDTMs. Studies reported a significant impact of MDTMs on surgery type, and a reduction of overall performed surgery after MDTM. Results also suggest that CT and MRI imaging significantly increased after MDTM implementation. Survival rate increased significantly with MDTM discussions according to twelve studies, yet three studies did not show significant differences. Conclusions: Despite heterogeneous data, MDTMs showed a significant impact on management plans, process outcomes and patient outcomes. To further explore the impact of MDTMs on the quality of healthcare, high-quality research is needed.

Improved Overall Survival of Colorectal Cancer under Multidisciplinary Team: A Meta-Analysis

Purpose

The purpose of the current meta-analysis was to evaluate whether multidisciplinary team improved overall survival of colorectal cancer.

Methods

PubMed, EMBASE, and Cochrane Library database were searched from inception to October 25, 2020. The hazard ratio (HR) and 95% confidence (CI) of overall survival (OS) were calculated.

Results

A total of 11 studies with 30814 patients were included in this meta-analysis. After pooling the HRs, the MDT group was associated with better OS compared with the non-MDT group (HR = 0.81, 95% CI 0.69-0.94, p = 0.005). In subgroup analysis of stage IV colorectal cancer, the MDT group was associated with better OS as well (HR = 0.73, 95% CI 0.59-0.90, p = 0.004). However, in terms of postoperative mortality, no significant difference was found between MDT and non-MDT groups (OR = 0.84, 95% CI 0.44-1.61, p = 0.60).

Conclusion

MDT could improve OS of colorectal cancer patients.

The Effect of Multidisciplinary Team Discussion Intervention on the Prognosis of Advanced Colorectal Cancer

Purpose: The effects of multidisciplinary team discussion intervention on the treatment and prognosis of advanced colorectal cancer are still controversial. Large sample size studies to evaluate the efficacy in patients with advanced colorectal cancer are lacking. Materials and Methods: We statistically analyzed the data of surgical patients diagnosed with advanced colorectal cancer from 2008 to 2014 by retrospective analysis. Patients were divided into two groups according to whether or not they received multidisciplinary team discussion intervention. After at least 3 years of follow up, differences between two groups were compared with respect to treatment process and patient prognosis. Results: The time to treatment in intervention group was shorter (9.6 ± 4.2 days vs 10.7 ± 5.6 days; p= 0.002). There were no significant differences in recurrence and metastasis rate between the two groups. Multivariate survival analysis suggested that multidisciplinary team discussion intervention reduced the risk of death (HR = 0.677; p = 0.006). And it had significant interaction with tumor invasion and tumor stage, and especially had beneficial effects in the tumor stage IV subgroup (p=0.005) and tumor invasion T4 subgroup (p<0.001). Conclusion: Multidisciplinary team discussion intervention accelerated the treatment process and reduced the death risk of patients with advanced colorectal cancer, especially improved the overall survival of stage IV and invasion T4 patients. The clinical characteristics of tumor invasion and tumor stage must be the primary considerations when judging whether patients need to conduct multidisciplinary team discussions.

Chances, challenges and outcomes of patients with complex bilobar colorectal liver metastases approached by a combined multimodal therapy with liver resection and local ablative therapy

BACKGROUND AND OBJECTIVES

In treatment of colorectal liver metastases (CRC-LM), liver surgery combined with systemic therapies and local ablation (LAT) allows improved survival. This study aims at the outcomes of patients with complex bilobar CRC-LM who were intended to undergo multimodal therapy with liver resection and LAT.

METHODS

Forty-three CRC-LM patients with recommendation for multimodal treament were extracted from 5878 tumor board decisions between 2014 and 2017. Outcome variables included patient survival, as well as completion of hepatic clearance. Prognostic factors were identified by correlation and a Cox proportional hazards model.

RESULTS

Out of 43 patients only 23 achieved complete clearance of CRC-LM. One- and 3-year overall survival of patients with cleared liver disease was 100% and 91.7%, respectively, as compared to 83.8% and 12.1%. Incomplete hepatic clearance was the strongest independent risk factor for overall survival (hazards ratio [HR], 5.86; p = .009). Risk factors for incomplete clearance were higher age (r = .34; p = .026), comorbidities (r = .40; p = .008), major complications (r = .34; p = .024), and prolonged intensive care unit stay (r = .41; p = .017).

CONCLUSION

Completion of hepatic clearance is crucial to achieve long-term survival in patients with complex bilobar CRC-LM. Careful patient selection and treatment planning should avoid treatment failure before completing the intended therapy plan when multimodal treatments are planned.

A National Assessment of Optimal Oncologic Surgery for Distal Pancreatic Adenocarcinomas

OBJECTIVES

The objective of this study was to create a composite measure, optimal oncologic surgery (OOS), for patients undergoing distal pancreatectomy for pancreatic adenocarcinoma and identify factors associated with OOS.

METHODS

Adult patients undergoing distal pancreatectomy were identified from the National Cancer Database between 2010 and 2016. Patients were stratified based on receipt of OOS. Criteria for OOS included 90-day survival, no 30-day readmission, length of stay ≤7 days, negative resection margins, ≥12 lymph nodes harvested, and receipt of chemotherapy. Multivariate logistic regression was performed to identify predictors of OOS. Survival curves and a Cox proportional hazards model were created to compare survival and identify risk factors for mortality.

RESULTS

Three thousand five hundred forty-six patients were identified. The rate of OOS was 22.3%. Diagnosis after 2012, treatment at an academic medical center, and a minimally invasive surgical approach (MIS) were associated with OOS. Survival was superior for patients undergoing OOS. Decreasing age at diagnosis, fewer comorbidities, surgery at an academic medical center, MIS, and lower pathologic stage were also associated with improved survival on multivariate analysis.

CONCLUSIONS

Rates of OOS for distal pancreatectomy are low. Time trends show increasing rates of OOS that may be related to increasing MIS, adjuvant chemotherapy, and referrals to academic medical centers.

Colorectal liver metastases: Current management and future perspectives

The liver is the commonest site of metastatic disease for patients with colorectal cancer, with at least 25% developing colorectal liver metastases (CRLM) during the course of their illness. The management of CRLM has evolved into a complex field requiring input from experienced members of a multi-disciplinary team involving radiology (cross sectional, nuclear medicine and interventional), Oncology, Liver surgery, Colorectal surgery, and Histopathology. Patient management is based on assessment of sophisticated clinical, radiological and biomarker information. Despite incomplete evidence in this very heterogeneous patient group, maximising resection of CRLM using all available techniques remains a key objective and provides the best chance of long-term survival and cure. To this end, liver resection is maximised by the use of downsizing chemotherapy, optimisation of liver remnant by portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and combining resection with ablation, in the context of improvements in the functional assessment of the future remnant liver. Liver resection may safely be carried out laparoscopically or open, and synchronously with, or before, colorectal surgery in selected patients. For unresectable patients, treatment options including systemic chemotherapy, targeted biological agents, intra-arterial infusion or bead delivered chemotherapy, tumour ablation, stereotactic radiotherapy, and selective internal radiotherapy contribute to improve survival and may convert initially unresectable patients to operability. Currently evolving areas include biomarker characterisation of tumours, the development of novel systemic agents targeting specific oncogenic pathways, and the potential re-emergence of radical surgical options such as liver transplantation.

The impact of multidisciplinary team management on outcome of hepatic resection in liver-limited colorectal metastases

Hepatic resection is the gold standard treatment for patients affected by liver-limited colorectal metastases. Reports addressing the impact of multidisciplinary team (MDT) evaluation on survival are controversial. The aim of this study was to evaluate the benefit of MDT management in these patients in our Institution experience. The objective of the analysis was to compare survivals of patients managed within our MDT (MDT cohort) to those of patients referred to surgery from other hospitals without MDT discussion (non-MDT cohort). Of the 523 patients, 229 were included in the MDT cohort and 294 in the non-MDT cohort. No difference between the two groups was found in terms of median overall survival (52.5 vs 53.6 months; HR 1.13; 95% CI, 0.88-1.45; p = 0.344). In the MDT cohort there was a higher number of metastases (4.5 vs 2.7; p < 0.0001). The median duration of chemotherapy was lower in MDT patients (8 vs 10 cycles; p < 0.001). Post-operative morbidity was lower in the MDT cohort (6.2 vs 21.5%; p < 0.001). One hundred and ninety-seven patients in each group were matched by propensity score and no significant difference was observed between the two groups in terms of OS and DFS. Our study does not demonstrate a survival benefit from MDT management, but it allows surgery to patients with a more advanced disease. MDT assessment reduces the median duration of chemotherapy and post-operative morbidities.

Shanghai international consensus on diagnosis and comprehensive treatment of colorectal liver metastases (version 2019)

The liver is the most common anatomical site for hematogenous metastases from colorectal cancer. Therefore effective treatment of liver metastases is one of the most challenging elements in the management of colorectal cancer. However, there is rare available clinical consensus or guideline only focusing on colorectal liver metastases. After six rounds of discussion by 195 clinical experts of the Shanghai International Consensus Expert Group on Colorectal Liver Metastases (SINCE) from 29 countries or regions, the Shanghai Consensus has been finally completed, based on current research and expert experience. The consensus emphasized the principle of multidisciplinary team, provided detailed diagnosis approaches, and guided precise local and systemic treatments. This Shanghai Consensus might be of great significance to standardized diagnosis and treatment of colorectal liver metastases all over the world.

The Role of p53-Mediated Signaling in the Therapeutic Response of Colorectal Cancer to 9F, a Spermine-Modified Naphthalene Diimide Derivative

Colorectal cancer (CRC) is one of the most prevalent cancers due to its frequency and high rate of mortality. Polyamine-vectorized anticancer drugs possess multiple biological properties. Of these drugs, 9F has been shown to inhibit tumor growth and the metastasis of hepatocellular carcinoma. This current study aims to investigate the effects of 9F on CRC and determine its molecular mechanisms of action. Our findings demonstrate that 9F inhibits CRC cell growth by inducing apoptosis and cell cycle arrest, and suppresses migration, invasion and angiogenesis in vitro, resulting in the inhibition of tumor growth and metastasis in vivo. Based on RNA-seq data, further bioinformatic analyses suggest that 9F exerts its anticancer activities through p53 signaling, which is responsible for the altered expression of key regulators of the cell cycle, apoptosis, the epithelial-to-mesenchymal transition (EMT), and angiogenesis. In addition, 9F is more effective than amonafide against CRC. These results show that 9F can be considered as a potential strategy for CRC treatment.

Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery

PURPOSE

There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking.

METHODS

The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification.

RESULTS

Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons.

CONCLUSIONS

The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres.

LEVEL OF EVIDENCE

Expert opinion, Level V.

Impact of multidisciplinary tumor boards on patients with rectal cancer

Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.

The Impact of a Hepatobiliary Multidisciplinary Team Assessment in Patients with Colorectal Cancer Liver Metastases: A Population-Based Study

BACKGROUND

Assessing patients with colorectal cancer liver metastases (CRCLM) by a liver multidisciplinary team (MDT) results in higher resection rates and improved survival. The aim of this study was to evaluate the potentially improved resection rate in a defined cohort if all patients with CRCLM were evaluated by a liver MDT.

PATIENTS AND METHODS

A retrospective analysis of patients diagnosed with colorectal cancer during 2008 in the greater Stockholm region was conducted. All patients with liver metastases (LM), detected during 5-year follow-up, were re-evaluated at a fictive liver MDT in which previous imaging studies, tumor characteristics, medical history, and patients' own treatment preferences were presented. Treatment decisions for each patient were compared to the original management. Odds ratios (ORs) and 95% confidence intervals were estimated for factors associated with referral to the liver MDT.

RESULTS

Of 272 patients diagnosed with LM, 102 patients were discussed at an original liver MDT and 69 patients were eventually resected. At the fictive liver MDT, a further 22 patients were considered as resectable/potentially resectable, none previously assessed by a hepatobiliary surgeon. Factors influencing referral to liver MDT were age (OR 3.12, 1.72-5.65), American Society of Anaesthesiologists (ASA) score (OR 0.34, 0.18-0.63; ASA 2 vs. ASA 3), and number of LM (OR 0.10, 0.04-0.22; 1-5 LM vs. >10 LM), while gender (p = .194) and treatment at a teaching hospital (p = .838) were not.

CONCLUSION

A meaningful number of patients with liver metastases are not managed according to best available evidence and the potential for higher resection rates is substantial.

IMPLICATIONS FOR PRACTICE

Patients with liver metastatic colorectal cancer who are assessed at a hepatobiliary multidisciplinary meeting achieve higher resection rates and improved survival. Unfortunately, patients who may benefit from resection are not always properly referred. In this study, the potential improved resection rate was assessed by re-evaluating all patients with liver metastases from a population-based cohort, including patients with extrahepatic metastases and accounting for comorbidity and patients' own preferences towards treatment. An additional 12.9% of the patients were found to be potentially resectable. The results highlight the importance of all patients being evaluated in the setting of a hepatobiliary multidisciplinary meeting.

Is MRI of the Liver Needed During Routine Preoperative Workup for Colorectal Cancer?

BACKGROUND

The clinical efficacy of gadoxetic acid-enhanced liver MRI as a routine preoperative procedure for all patients with colorectal cancer remains unclear.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of preoperative gadoxetic acid-enhanced liver MRI for the diagnosis of liver metastasis in patients with colorectal cancer.

DESIGN

This was a retrospective analysis from a prospective cohort database.

SETTINGS

All of the patients were from a subspecialty practice at a tertiary referral hospital.

PATIENTS

Patients who received preoperative gadoxetic acid-enhanced liver MRI after CT and attempted curative surgery for colorectal cancer were included.

MAIN OUTCOME MEASURES

The number of equivocal hepatic lesions based on CT and gadoxetic acid-enhanced liver MRI and diagnostic use of the gadoxetic acid-enhanced liver MRI were measured.

RESULTS

We reviewed the records of 690 patients with colorectal cancer. Equivocal hepatic lesions were present in 17.2% of patients based on CT and in 4.5% based on gadoxetic acid-enhanced liver MRI. Among 496 patients with no liver metastasis based on CT, gadoxetic acid-enhanced liver MRI detected equivocal lesions in 15 patients and metastasis in 3 patients. Among 119 patients who had equivocal liver lesions on CT, gadoxetic acid-enhanced liver MRI indicated hepatic lesions in 103 patients (86.6%), including 90 with no metastasis and 13 with metastasis. Among 75 patients who had liver metastasis on CT, gadoxetic acid-enhanced liver MRI indicated that the hepatic lesions in 2 patients were benign, in contrast to CT findings. The initial surgical plans for hepatic lesions according to CT were changed in 17 patients (3%) after gadoxetic acid-enhanced liver MRI.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

The clinical efficacy of gadoxetic acid-enhanced liver MRI as a routine preoperative procedure for all patients with colorectal cancer is low, in spite of its high diagnostic value for detecting liver metastasis. However, this study showed gadoxetic acid-enhanced liver MRI was helpful in characterizing equivocal hepatic lesions identified in CT and could lead to change in treatment plans for some patients. See Video Abstract at http://links.lww.com/DCR/A420.

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting

OBJECTIVES

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting (MDM).

STUDY DESIGN

Retrospective analysis of the association of MDM discussion with survival.

METHODS

All newly diagnosed cancer patients from 2009 to 2012, presenting to a large regional cancer service in South West Victoria, Australia (620 colorectal, 657 breast, 593 lung and 511 haematological) were recorded and followed up to 5 years after diagnosis. Treatment patterns and survival of patients whose treatment was discussed at an MDM compared to those who were not, were explored.

RESULTS

The proportion of patients presented to an MDM within 60 days after diagnosis was 56% (n = 366) for breast cancer, 59% (n = 363) for colorectal cancer, 27% (n = 137) for haematological malignancies and 60% (n = 355) for lung cancer. Seventy-three percent (n = 886) of patients discussed at an MDM had their tumour stage recorded in their medical records while only 52% (n = 604) of patients not discussed had their tumour stage recorded (P < 0.01). We found for haematological and lung cancer patients that those presented to an MDM prior to treatment had a significant reduction in mortality (lung cancer hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.50-0.76, P < 0.01) (haematological cancer HR 0.58, 95% CI 0.35-0.96, P = 0.03) compared to patients whose cases were not discussed at an MDM after adjusting for the potential cofounders of age, stage, comorbidities and treatment. This was not the case for colorectal and breast cancer patients where there was no significant difference.

CONCLUSION

MDM discussion has been recommended as best practice in the management of cancer patients, however, from a public health perspective this creates potential issues around access and resources. It is likely that MDM presentation patterns and outcomes across tumour streams are linked in complex ways. We believe that our data would demonstrate that these patterns differ across tumour streams and that more detailed work is required to better allocate relatively scarce and potentially costly MDM resources to tumour streams and patient groups that may get the most benefit.

Contemporary surgical management of synchronous colorectal liver metastases

Historically, the 5-year survival rates for patients with stage 4 (metastatic) colorectal cancer were extremely poor (5%); however, with advances in systemic chemotherapy combined with an ability to push the boundaries of surgical resection, survival rates in the range of 25–40% can be achieved. This multimodal approach of combining neo-adjuvant strategies with surgical resection has raised a number of questions regarding the optimal management and timing of surgery. For the purpose of this review, we will focus on the treatment of stage 4 colorectal cancer with synchronous liver metastases.

Serum CA125 concentration as a predictor of peritoneal dissemination of colorectal cancer in men and women

Peritoneal dissemination (PD) of cancer is difficult to diagnose. Previous reports have shown that carbohydrate antigen 125 (CA125) is a sensitive marker of PD of gastric cancer. However, CA125 has not been evaluated as a marker of colorectal cancer (CRC), and its accuracy in men is controversial. The aim of this study was to compare the ability of CA125 and carcinoembryonic antigen (CEA) to predict PD of CRC in men and women.Preoperative CA125 and CEA concentrations were measured in 853 people (510 men, 343 women) over 10 years. PD was confirmed intraoperatively in 57 patients. The predictive ability was compared between CA125 and CEA.Compared with CEA, CA125 concentration had a lower sensitivity, higher specificity, and diagnostic accuracy, and significantly greater area under the curve. Further analysis of CA125's sensitivity and specificity among CEA-negative group (n = 514) showed acceptable sensitivity (57.1%) and good specificity (92.0%). In men and women, CA125 concentration did not increase with stage from I to IV unless PD was present (P < 0.001). CEA concentration was increased in women with metastasis with PD (P < 0.001) or without PD (P < 0.001), but was increased only in men with metastasis without PD (P < 0.01). CA125 concentration correlated with PD grade for men and women, but CEA concentration correlated with grade only in women.When analyzed according to the primary tumor site, CA125 concentration in men did not differ between patients with the primary site in the right or left colon, or the rectum, regardless of PD status. By contrast, CA125 concentration differed between PD-positive and PD-negative patients with cancer in the right (P < 0.001) or left (P < 0.001) colon but not in the rectum. CEA concentration in men did not differ according to the primary site or PD status. In women, CA125 and CEA concentrations differed significantly between the PD-positive and PD-negative groups in patients with the primary tumor in the right (P < 0.001) or left (P < 0.001) colon; tumor sites did not differ between the PD-positive and PD-negative groups.These findings suggest that CA125 is a better tumor marker than CEA for predicting PD of CRC in both men and women.

Treatment sequence of synchronously (liver) metastasized colon cancer

No standards for staging, systemic therapy or the timing of an operation are defined for patients newly diagnosed with synchronous metastases and a primary in the colon. An expert group of radiologists, medical, radiation and surgical oncologists therefore came together to discuss staging and treatment sequence for these patients and came up with a recommendation based on current evidence of potential therapeutic options. The discussion was organized to debate recommendations centred on 5 topics and therefore the position paper is built upon these titles and their subtitles.