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

Circulating Tumor DNA Predicts Conversion Therapy Response and Prognosis in Initially Unresectable Colorectal Liver-Limited Metastases: A Retrospective Study

Aims/Background Effective molecular biomarkers for predicting prognosis and guiding treatment in patients with initially unresectable colorectal liver metastases (CRLMs) undergoing conversion therapy are currently lacking. This study investigated the predictive value of circulating tumor DNA (ctDNA) conversion therapy outcomes in initially unresectable CRLMs. Methods A retrospective analysis was conducted on 81 patients with CRLMs treated at the Sixth Affiliated Hospital, Sun Yat-sen University from January 2017 to April 2021. The relationships between baseline and treatment ctDNA levels and clinical responses were evaluated using group comparisons based on data type. The impact of ctDNA on survival outcomes was analyzed through Cox regression survival analysis. Results Analysis of 81 patients with ctDNA-positive at baseline showed that patients in the ctDNA low-level group had a significantly longer median progression-free survival (mPFS) (p = 0.039). Among 45 patients who underwent ctDNA testing during systemic therapy, the proportion of patients in the ctDNA-negative group receiving local ablative treatment (LAT) was significantly higher (70.0% vs 26.7%, p = 0.006). Furthermore, 50% of patients in the ctDNA-negative group achieved no evidence of disease (NED) status, compared to 6.7% in the ctDNA-positive group (p = 0.004). Both mPFS and median overall survival (mOS) were significantly longer in ctDNA-negative patients compared to ctDNA-positive patients (p < 0.05). Of the 61 patients who underwent LAT, 37 received ctDNA testing at the same time as imaging assessment for NED. The proportion of patients with ctDNA clearance who achieved NED status was markedly higher than that of patients with ctDNA non-clearance (78.6% vs 33.3%, p = 0.036). Patients with ctDNA clearance demonstrated significantly improved mOS compared to those with ctDNA non-clearance (not reached vs 30.1 months, p = 0.036). Conclusion Dynamic changes in ctDNA levels can predict both long-term survival and the effectiveness of conversion therapy in patients with initially unresectable CRLMs.

Prognostic impact of conversion hepatectomy for initially unresectable colorectal liver metastasis

PURPOSE

This study aimed to evaluate the prognostic impact of conversion hepatectomy in patients with initially unresectable colorectal liver metastasis (CRLM) and to identify prognostic factors after conversion hepatectomy.

METHODS

Correlations of conversion hepatectomy with relapse-free survival (RFS) and overall survival (OS) were retrospectively investigated in 554 consecutive patients who underwent hepatectomy for CRLM in 2000-2017. Prognostic factors after conversion hepatectomy were examined in multivariable analysis.

RESULTS

Five hundred and nine patients (92%) had initially resectable CRLM at diagnosis and underwent hepatectomy (primary resection group) and 45 (8%) underwent conversion hepatectomy following chemotherapy (conversion group). The 5-year RFS was 30.0% in the primary resection group and 19.8% in the conversion group (p = 0.042); the respective 5-year OS rates were 62.0% and 52.4% (p = 0.253). Multivariable analysis did not identify conversion hepatectomy as a significant prognostic factor for RFS (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.64-1.37, p = 0.796) or OS (HR 1.12, 95% CI 0.67-1.79, p = 0.667). In the conversion group, multivariable analysis identified the following independent prognostic factors: timing of liver metastases for RFS (synchronous: HR 3.14, 95% CI 1.20-8.24, p = 0.020) and preoperative CEA level for RFS (> 5 ng/ml: HR 3.10, 95% CI 1.45-6.61, p = 0.003) and OS (> 5 ng/ml: HR 3.29, 95% CI 1.18-9.17, p = 0.023).

CONCLUSIONS

RFS and OS rates after conversion hepatectomy were not inferior to those after primary resection in patients with CRLM. Patients with a normal CEA level before hepatectomy can be expected to have good long-term prognosis after conversion hepatectomy.

Intra-arterial therapy for unresectable colorectal liver metastases: A meta-analysis

PURPOSE

To evaluate the efficacy of hepatic arterial infusion (HAI), conventional trans-arterial chemoembolization (cTACE), drug-eluting embolic trans-arterial chemoembolization (DEE-TACE), trans-arterial radioembolization (TARE) and their combinations with systemic chemotherapy (SCT) for unresectable colorectal liver metastases.

METHODS

A search was conducted on EMBASE, Scopus, PubMed and Web of Science for prospective non-randomized studies and randomized controlled trials (RCTs) from inception to 20^th June 2020. Survival data of patients were recovered from original Kaplan-Meier curves by exploiting a graphical reconstructive algorithm. One-stage meta-analyses were conducted for median overall survival (OS), survival rates (SR), and restricted mean survival time (RMST), while two-stage meta-analyses of proportions were conducted to determine response rates (RR) and conversion-to-resection rates (CRR).

RESULTS

71 prospective non-randomized studies and 21 RCTs were identified comprising 6,695 patients. Among patients treated beyond first line, DEE-TACE+SCT (n=152) had the best survival outcomes of median OS of 26.5 (95%-CI: 22.5-29.1) months and 3-year RMST of 23.6 (95%-CI: 21.8-25.5) months. Upon further stratification by publication year, DEE-TACE+SCT appears to consistently have the highest pooled survival rates at 1-year (81.9%) and 2-years (66.1%) in recent publications (2015-2020). DEE-TACE+SCT and HAI+SCT had the highest pooled-RRs of 56.7% (I²=0.90) and 62.6% (I²=0.87) respectively and pooled-CRRs of 35.5% (I²=0.00) and 30.3% (I²=0.80) respectively.

CONCLUSION

Albeit significant heterogeneity, paucity of high-quality evidence and the non-comparative nature of all analyses, the overall evidence suggests that patients treated with DEE-TACE+SCT may have the best oncological outcomes and greatest potential to be converted for resection.

Prognostic factors of hepatectomy in initially unresectable colorectal liver metastasis: Indication for conversion therapy

The aim of the present study was to retrospectively identify prognostic factors for long-term cumulative survival following liver resection in patients with primarily unresectable colorectal cancer who had previously received conversion therapy. A multicentre study was designed to ascertain the appropriate indication for conversion therapy. The study included 34 patients who underwent conversion therapy at 5 university hospitals. Patients' background, operative factors, recurrence rate and survival rate were evaluated, and factors influencing therapy outcomes were identified. The median duration of preoperative chemotherapy was 3 months and the response rate was 39.8%. Upon resection, the median tumour size was 47 mm and the median number of tumours was 4. The recurrence-free and cumulative survival rates 5 years after liver resection were 13.7 and 39.3%, respectively. Postoperative complications developed in 12 patients. A response rate >40% was indicated with regards to the assessed prognostic factors for long-term cumulative survival following liver resection and an absence of postoperative complications was noted. It was revealed that conversion therapy should be considered prior to liver resection, particularly for patients with response rates exceeding 40%. Absence of postoperative complications is also an independent predictor of long-term cumulative survival after liver resection. In light of these findings, it was consisted that an optimal response rate >40% could be used as an indicator for surgical resection in conversion therapy. In addition, meticulous intra- and postoperative managements are important for decreasing postoperative complications and improving long-term cumulative survival.

Modern prospection for hepatic arterial infusion chemotherapy in malignancies with liver metastases

Malignancy with liver metastasis plays an important role in daily oncology practice, especially for primary cancers of the gastrointestinal tract and hepatopancreatobiliary system. On account of the dual vascular supply system and the fact that most metastatic liver tumors are supplied by the hepatic artery, hepatic artery infusion chemotherapy (HAIC) is an appealing method for the treatment of liver metastases. Herein, we summarize recent study results reported in the literature regarding the use of HAIC for metastatic liver tumors, with special focus on colorectal cancer.