Colorectal liver metastases

The impact of Kirsten rat sarcoma (KRAS) status on local tumor progression after surgical ablation of colorectal liver metastases

BACKGROUND

Kirsten rat sarcoma mutation was reported to adversely affect local tumor control after percutaneous ablation of colorectal liver metastasis. Nevertheless, the effect of Kirsten rat sarcoma mutation on surgical ablation has not been investigated in the literature. The aim of this study is to analyze the impact of Kirsten rat sarcoma mutation on local recurrence after surgical ablation of colorectal liver metastasis.

METHODS

This was an institutional review board-approved study of patients who underwent surgical ablation of colorectal liver metastasis between 2005 and 2023 at a single center and underwent Kirsten rat sarcoma testing with ≥1 year follow-up. Local recurrence was analyzed using univariate Kaplan-Meier and multivariate Cox hazard models.

RESULTS

A total of 163 patients with 424 lesions fulfilled inclusion criteria. Fifty (30.7%) patients received radiofrequency ablation and 113 (69.3%) patients received microwave ablation. Fifty-seven patients (32.2%) with 177 lesions were found to have a Kirsten rat sarcoma mutation. Patients with Kirsten rat sarcoma mutation had a larger number of tumors, percentage of posteriorly located tumors, and tumor burden score compared with those with wild-type Kirsten rat sarcoma. Nevertheless, there was no difference between the groups regarding local recurrence per lesion (15% vs 17%, respectively, P = not significant). Independent predictors of local recurrence included tumor size, ablation margin, and blood vessel proximity for radiofrequency ablation compared with tumor size and ablation margin for microwave ablation.

CONCLUSION

There was no effect of Kirsten rat sarcoma mutations on local recurrence after surgical radiofrequency ablation or microwave ablation of colorectal liver metastasis in this study. Tumor size and ablation margin remained as independent predictors.

Pretransplant metabolic tumor volume predicts recurrence following liver transplantation for colorectal metastasis: A multicenter study

Liver transplant (LT) for colorectal cancer liver metastases (CRLM) is increasingly popular, yet the ideal selection criteria remain unknown. Pretransplant positron emission tomography (PET) metabolic tumor volume (MTV) has been described as predicting recurrence, with a proposed cutoff of MTV ≥70 cm 3 . This approach has not been validated. Patients undergoing LT for CRLM at 2 academic transplant centers (January 1, 2017, to December 1, 2023) were included. PET-MTV was calculated by a staff radiologist from the most recent PET-scan before LT using the published protocol. Twenty-six patients were included. Median follow-up was 609 days (IQR 320-1069) and from PET to LT was 1.9 months (1.3-2.6). Nearly all (n=24, 92.3%) received living donor transplantation. Absolute recurrence rate was 30.8% (n=8). Actuarial unadjusted 1- and 2-year recurrence-free survival (RFS) were 83% (n=15/18) and 62% (n=8/13); 1- and 2-year overall survival were 100% (n=18/18) and 85% (n=11/13). The incidence of recurrence-per-year follow-up was 0.35 when MTV ≥70 cm 3 versus 0.10 if MTV <70 cm 3 ( P <0.001). Median RFS using Kaplan-Meier product-estimate was 0.83 years (95% CI: 0.43-1.23) in MTV≥70 cm 3 versus 4.1 years (95% CI: 2.90-5.22) when MTV<70 cm 3 ( p <0.001); this was also associated with improved overall survival ( p =0.003). MTV>70 cm 3 demonstrated HR=2.42 (95% CI: 2.2-62.2, p =0.006) for association with RFS on univariate Cox-proportional hazards analysis, and an AUC=0.771 (95% CI: 0.560-0.981) for predicting recurrence ( p =0.030). Nineteen patients (69.2%) had histologically viable tumors, which were associated with recurrence (43% vs. 0%, p =0.039) and reduced RFS (log-rank p =0.019). PET-MTV was associated with the presence of histologically viable tumor (AUC=0.763, 95% CI: 0.583-0.944). PET-MTV ≥70 cm 3 was associated with reduced RFS and overall survival after LT for CRLM, confirming findings from the Norway group. This is likely due to its ability to identify residual viable tumors, which are independently associated with recurrence. PET-MTV should be a key selection criterion prior to LT for CRLM.

Surgical Management of Colorectal Cancer Liver Metastases

Approximately 50% of colorectal cancer patients develop liver metastases. Hepatic metastases represent the most common cause of colorectal cancer-related mortality. Metastasectomy, if possible, represents the most effective treatment strategy; 20% of patients will be cured and more than 50% survive at least 5 years. Nuances to treatment planning hinge on whether patients present with resectable disease upfront, whether the future liver remnant is adequate, and whether the primary tumor, if present, is colon versus rectal in origin. This article discusses considerations impacting our approach to patients with colorectal liver metastases and the role for various multimodal treatment options.

The histological growth patterns in liver metastases from colorectal cancer display differences in lymphoid, myeloid, and mesenchymal cells

Colorectal liver metastases grow following different histologic growth patterns (HGPs), classified as desmoplastic and nondesmoplastic (dHGP, non-dHGP), being the latter associated with worst prognosis. This study aimed to investigate the tumor microenvironment (TME) between HGPs supporting different survival. Multiplexed immunohistochemical staining was performed with the Opal7 system in a 100-patients cohort to evaluate the tumor-liver interface with three different cell panels: lymphoid, myeloid, and carcinoma-associated fibroblasts. Differences between HGPs were assessed by Mann-Whitney U test with Pratt correction and Holm-Bonferroni multitest adjustment. Cytotoxic T-cells were more abundant in tumoral areas of dHGP, while non-dHGP had higher macrophages infiltration, Th2, CD163+, and Calprotectin+ cells as well as higher pSMAD2 expression. Regarding carcinoma-associated fibroblasts, several subsets expressing COL1A1 were enriched in dHGP, while αSMAlow_single cells were present at higher densities in non-dHGP. Interestingly, Calprotectin+ cells confer better prognoses in non-dHGP, identifying a subgroup of good outcome patients that unexpectedly also show an enrichment in other myeloid cells. In summary, our results illustrate different TME landscapes with respect to HGPs. dHGP presents a higher degree of immunocompetence, higher amounts of Collagen 1 as well as lesser presence of myeloid cell populations, features that might be influencing on the better prognosis of encapsulated metastases.

Intensive locoregional therapy before liver transplantation for colorectal cancer liver metastasis: A novel pretransplant protocol

We describe a novel pre-liver transplant (LT) approach in colorectal liver metastasis, allowing for improved monitoring of tumor biology and reduction of disease burden before committing a patient to transplantation. Patients undergoing LT for colorectal liver metastasis at Cleveland Clinic were included. The described protocol involves intensive locoregional therapy with systemic chemotherapy, aiming to reach minimal disease burden revealed by positron emission tomography scan and carcinoembryonic Ag. Patients with no detectable disease or irreversible treatment-induced liver injury undergo transplant. Nine patients received liver transplant out of 27 who were evaluated (33.3%). The median follow-up was 700 days. Seven patients (77.8%) received a living donor LT. Five had no detectable disease, and 4 had treatment-induced cirrhosis. Pretransplant management included chemotherapy (n = 9) +/- bevacizumab (n = 6) and/or anti-EGFR (n = 6). The median number of pre-LT cycles of chemotherapy was 16 (range 10-40). Liver-directed therapy included Yttrium-90 (n = 5), ablation (n = 4), resection (n = 4), and hepatic artery infusion pump (n = 3). Three patients recurred after LT. Actuarial 1- and 2-year recurrence-free survival were 75% (n = 6/8) and 60% (n = 3/5). Recurrence occurred in the lungs (n = 1), liver graft (n = 1), and lungs+para-aortic nodes (n = 1). Patients with pre-LT detectable disease had reduced RFS ( p = 0.04). All patients with recurrence had histologically viable tumors in the liver explant. Patients treated in our protocol (n = 16) demonstrated improved survival versus those who were not candidates (n = 11) regardless of transplant status ( p = 0.01). A protocol defined by aggressive pretransplant liver-directed treatment and transplant for patients with the undetectable disease or treatment-induced liver injury may help prevent tumor recurrence.

Tumor-derived lactate promotes resistance to bevacizumab treatment by facilitating autophagy enhancer protein RUBCNL expression through histone H3 lysine 18 lactylation (H3K18la) in colorectal cancer

Bevacizumab plays an important role in the first and second line treatment for metastatic colorectal cancer (CRC). And induction of hypoxia and the tumors response to it plays an important role in determining the efficacy of antiangiogenic therapy while the connection between them remains unclear. Here, we found that lactate accumulated in the tumor environment of CRC and acted as substrates for histone lactylation, and this process was further induced by cellular enhanced glycolysis in hypoxia. We determined that CRC patients resistant to bevacizumab treatment presented with elevated levels of histone lactylation and inhibition of histone lactylation efficiently suppressed CRC tumorigenesis, progression and survival in hypoxia. Histone lactylation promoted the transcription of RUBCNL/Pacer, facilitating autophagosome maturation through interacting with BECN1 (beclin 1) and mediating the recruitment and function of the class III phosphatidylinositol 3-kinase complex, which had a crucial role in hypoxic cancer cells proliferation and survival. Moreover, combining inhibition of histone lactylation and macroautophagy/autophagy with bevacizumab treatment demonstrated remarkable treatment efficacy in bevacizumab-resistance patients-derived pre-clinical models. These findings delivered a new exploration and important supplement of metabolic reprogramming-epigenetic regulation, and provided a new strategy for improving clinical efficacy of bevacizumab in CRC by inhibition of histone lactylation.Abbreviations: 2-DG: 2-deoxy-D-glucose; BECN1: beclin 1; CQ: chloroquine; CRC: colorectal cancer; DMOG: dimethyloxalylglycine; H3K18la: histone H3 lysine 18 lactylation; MAP1LC3B/LC3B: microtubule associated protein 1 light chain 3 beta; Nala: sodium lactate; PDO: patient-derived orgnoid; PDX: patient-derived xenograft; RUBCNL/Pacer: rubicon like autophagy enhancer; SQSTM1/p62: sequestosome 1.

The Role of the Multiparametric MRI LiverMultiScanTM in the Quantitative Assessment of the Liver and Its Predicted Clinical Applications in Patients Undergoing Major Hepatic Resection for Colorectal Liver Metastasis

Liver biopsy remains the gold standard for the histological assessment of the liver. With clear disadvantages and the rise in the incidences of liver disease, the role of neoadjuvant chemotherapy in colorectal liver metastasis (CRLM) and an explosion of surgical management options available, non-invasive serological and imaging markers of liver histopathology have never been more pertinent in order to assess liver health and stratify patients considered for surgical intervention. Liver MRI is a leading modality in the assessment of hepatic malignancy. Recent technological advancements in multiparametric MRI software such as the LiverMultiScanTM offers an attractive non-invasive assay of anatomy and histopathology in the pre-operative setting, especially in the context of CRLM. This narrative review examines the evidence for the LiverMultiScanTM in the assessment of hepatic fibrosis, steatosis/steatohepatitis, and potential applications for chemotherapy-associated hepatic changes. We postulate its future role and the hurdles it must surpass in order to be implemented in the pre-operative management of patients undergoing hepatic resection for colorectal liver metastasis. Such a role likely extends to other hepatic malignancies planned for resection.

Circulating Tumor DNA in Colorectal Cancer Liver Metastasis: Analysis of Patients Receiving Liver Resection and Transplant

PURPOSE

Liver metastases occur in about 50% of colorectal cancer cases and drive patient outcomes. Circulating tumor DNA (ctDNA) is emerging as a diagnostic, surveillance, and tumor mutational information tool.

METHODS

Patients with colorectal cancer liver metastasis (CCLM) seen in a multidisciplinary liver tumor clinic from January to August 2022 received ctDNA testing on each visit. ctDNA was obtained using the Guardant360 platform. Tumor mutational burden (TMB) is defined as the number of identified mutations per megabase of genome analyzed.

RESULTS

Fifty-two patients had available ctDNA, with 34 (65%) tested preoperatively and 18 (35%) postoperatively; nine patients had sequential pre- and postoperative testing. The median time to test result was 12 days (IQR, 10-13.5). There were a greater number of somatic mutations identified preoperatively (n = 29 v n = 11) and a greater genomic heterogeneity (P = .0069). The mean TMB score was 12.77 in those without pathologic response to cytotoxic therapy and 6.0 in those with pathologic response (P = .10). All nine patients with sequential testing were positive preoperatively, compared with just three (33.3%) postoperatively (P = .0090). Positive postoperative ctDNA was associated with the increased likelihood of disease recurrence after resection (57%) versus negative ctDNA (0%, P = .0419).

CONCLUSION

Routine ctDNA screening in patients with CCLM is logistically feasible. Liver resection and/or transplant may be associated with clearance of detectable ctDNA and a reduction in TMB or genomic heterogeneity. Persistence of ctDNA alterations postresection appears predictive of disease recurrence. Further studies are necessary to confirm these findings, and longitudinal ctDNA testing is needed to monitor changing tumor biology.

Long-term results of liver-first approach strategy in patients with advanced synchronous liver metastases from colorectal cancer

BACKGROUND

The "liver-first" approach (LFA) is a strategy indicated for advanced synchronous liver metastases (ASLM) from colorectal cancer (CRC). Includes neoadjuvant chemotherapy, resection of the ASLM followed by CRC resection.

METHODS

Retrospective descriptive analysis from a prospective database of hepatectomies from liver metastases (LM) from CRC in two centers. Between 2007-2019, 88 patients with CRC-ASLM were included in a LFA scheme. Bilobar (LM) was present in 65.9%, the mean number of lesions was 5.5 and mean size 42.7 mm. Response to treatment was assessed by RECIST criteria. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier survival curves.

RESULTS

Seventy-five of 88 patients (85.2%) completed the LFA. RECIST evaluation showed partial response in 75.7% and stable disease in 22.8%. Severe morbidity rate (Clavien-Dindo ≥ IIIA) after liver and colorectal surgery was present in 29.4% and 9.3%, respectively. There was no 90-day postoperative mortality in both liver and colorectal surgeries. Recurrence rate was 76%, being the liver the most frequent site, followed by the pulmonary. From the total number of recurrences (106) in 56 patients, surgical with chemotherapy rescue treatment was accomplished in 34 of them (32.1%). The mean PFS was 8.5 and 5-year OS was 53%.

CONCLUSIONS

In patients with CRC-ASLM the LFA allows control of the liver disease beforehand and an assessment of the tumor response to neoadjuvant chemotherapy, optimising the chance of potentially curative liver resection, which influences long-term survival.

Association of Variation in US County-Level Rates of Liver Surgical Resection for Colorectal Liver Metastasis With Poverty Rates in 2010

IMPORTANCE

Among patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM.

OBJECTIVE

To describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates.

DESIGN, SETTING, AND PARTICIPANTS

This ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022.

EXPOSURES

County-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level).

MAIN OUTCOMES AND MEASURES

The primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate.

RESULTS

In the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.

Current status of minimally invasive liver surgery for cancers

Hepatocellular carcinoma (HCC) patients have chronic liver disease with functional deterioration and multicentric oncogenicity. Liver surgeries for the patients should be planned on both oncological effects and sparing liver function. In colorectal patients with post-chemotherapy liver injury and multiple bilateral tumors, handling multiple tumors in a fragile/easy-to-bleed liver is an important issue. Liver surgery for biliary tract cancers is often performed as a resection of large-volume functioning liver with extensive lymphadenectomy and bile duct resection/reconstruction. Minimally invasive liver surgery (MILS) for HCC is applied with the advantages of laparoscopic for cases of cirrhosis or repeat resections. Small anatomical resections using the Glissonian, indocyanine green-guided, and hepatic vein-guided approaches are under discussion. In many cases of colorectal liver metastases, MILS is applied combined with chemotherapy owing to its advantage of better hemostasis. Two-stage hepatectomy and indocyanine green-guided tumor identification for multiple bilateral tumors are under discussion. In the case of biliary tract cancers, MILS with extensive lymphadenectomy and bile duct resection/reconstruction are developing. A robot-assisted procedure for dissection of major vessels and handling fragile livers may have advantages, and well-simulated robot-assisted procedure may decrease the difficulty for biliary tract cancers.

The Number of Intraoperative Intestinal Venous Circulating Tumor Cells Is a Prognostic Factor for Colorectal Cancer Patients

Purpose

To assess the association between intestinal venous blood (IVB) circulating tumor cells (CTCs) and clinicopathological parameters in stage I-III colorectal cancer (CRC) patients.

Methods

Participants were retrospectively retrieved, who were admitted to our hospital or took annual physical exams between December 1, 2015 and December 31, 2018. A negative enrichment-immunofluorescence in situ hybridization (NE-imFISH) technique was used to isolate and identify CTCs. Receiver operating characteristic (ROC) curves and Youden index values were used to determine the critical CTC cutoff value for the diagnosis of CRC. Kaplan-Meier and log-rank methods were used to conduct survival analyses, and multivariate Cox regression analyses were employed for multivariate corrections to comprehensively evaluate the value of CTCs in the diagnosis of CRC. Relationships between IVB CTCs, clinicopathological parameters, and prognosis were then analyzed based upon patient postoperative follow-up data.

Results

In total, we retrieved 282 patients including 48 healthy controls, 72 patients with benign colorectal tumors, and 162 CRC patients. CRC patients exhibited significantly higher numbers of CTCs relative to control patients or those with benign disease. CTC numbers in CRC patient peripheral blood (PB) and IVB were closely associated with tumor node metastasis (TNM) staging (P < 0.01), carbohydrate antigen-125 (CA-125) levels (P < 0.001), and KRAS (Kirsten rat sarcoma virus oncogene) mutation status (P < 0.001). The disease-free survival (DFS) of patients in the CTC-negative group was significantly longer than that of patients in the CTC-positive group (24.60 ± 13.31 months vs. 18.70 ± 10.19 months, P < 0.05), with the same being true with respect to their overall survival (OS) (30.60 ± 12.44 months vs. 35.25 ± 11.57 months, P < 0.05). A multivariate analysis revealed that the detection ≥2 CTCs/3.2 ml was independently associated with poorer DFS and OS. CTC counts were independently predictive of CRC patients TNM staging, CA-125, and KRAS mutation status in both univariate and multivariate Cox proportional hazards regression analyses.

Conclusion

CTCs are valuable biomarkers that can be monitored to predict CRC patient disease progression.

Spatial Immunology in Liver Metastases from Colorectal Carcinoma according to the Histologic Growth Pattern

Simple Summary

In the era of immunotherapy, the tumor microenvironment (TME) has attracted special interest. However, colorectal liver metastases (CRC-LM) present histological peculiarities that could affect the interaction of immune and tumor cells such as fibrotic encapsulation and dense intratumoral stroma. We explored the spatial distribution of lymphocytic infiltrates in CRC-LM in the context of the histologic growth patterns using multispectral digital pathology providing data on three different scenarios, tumor periphery, invasive margin, and central tumoral areas. Our results illustrate a similar poor cell density of CD8⁺ cells between different metastases subtypes in intratumoral regions. However, in encapsulated metastases, cytotoxic cells reach the tumor cells while remaining retained in stromal areas in non-encapsulating metastases. Some aspects are still unresolved, such as understanding the reason why most lymphocytes are largely retained in the capsule.

Abstract

Colorectal cancer liver metastases (CRC-LM) present differential histologic growth patterns (HGP) that determine the interaction between immune and tumor cells. We explored the spatial distribution of lymphocytic infiltrates in CRC-LM in the context of the HGP using multispectral digital pathology. We did not find statistically significant differences of immune cell densities in the central regions of desmoplastic (_dHGP) and non-desmoplastic (_ndHGP) metastases. The spatial evaluation reported that _dHGP-metastases displayed higher infiltration by CD8⁺ and CD20⁺ cells in peripheral regions as well as CD4⁺ and CD45RO⁺ cells in _ndHGP-metastases. However, the reactive stroma regions at the invasive margin (IM) of _ndHGP-metastases displayed higher density of CD4⁺, CD20⁺, and CD45RO⁺ cells. The antitumor status of the TIL infiltrates measured as CD8/CD4 reported higher values in the IM of encapsulated metastases up to 400 μm towards the tumor center (p < 0.05). Remarkably, the IM of _dHGP-metastases was characterized by higher infiltration of CD8⁺ cells in the epithelial compartment parameter assessed with the ratio CD8^epithelial/CD8^stromal, suggesting anti-tumoral activity in the encapsulating lesions. Taking together, the amount of CD8⁺ cells is comparable in the IM of both HGP metastases types. However, in _dHGP-metastases some cytotoxic cells reach the tumor nests while remaining retained in the stromal areas in _ndHGP-metastases.

Effect of tumour size ratio on liver recurrence-free survival of patients undergoing hepatic resection for colorectal liver metastases

Background

The study aimed to assess the impact of size differences of multiple liver metastases on liver recurrence-free survival (RFS) in patients undergoing hepatic resection for colorectal liver metastases (CRLMs).

Methods

Overall, 147 patients with CRLMs who underwent hepatic resection between January 2010 and December 2016 were retrospectively analysed. Tumour size ratio (TSR) was defined as the maximum diameter of the largest liver lesion over the maximum diameter of the smallest liver lesion. The univariate and multivariate analyses were performed to determine independent prognostic risk factors. The prognostic value of the TSR was further explored in each Tumour Burden Score (TBS) zone. Log-rank survival analyses were used to compare liver RFS in the new clinical score and the Fong clinical score.

Results

Based on the TSR, patients were classified into three groups: TSR < 2, 2 ≤ TSR < 4, and TSR ≥ 4. According to the multivariate analysis, TSR of 2–4 (hazard ratio [HR], 2.580; 95% confidence interval [CI] 1.543–4.312; P < 0.001) and TSR < 2 (HR, 4.435; 95% CI 2.499–7.872; P < 0.001) were associated with worse liver RFS. As TSR decreased, liver RFS worsened. TSR could further stratify patients in zones 1 and 2 into different risk groups according to the TBS criteria (zone 1: median liver RFS, 3.2 and 8.9 months for groups 1 and 2, respectively, P = 0.003; zone 2: median liver RFS, 3.5, 5.0, and 10.9 months for groups 1, 2, and 3, respectively, P < 0.05). The predictive ability of the new clinical score, which includes TSR, was superior to that of the Fong clinical score.

Conclusions

TSR, as a prognostic tool, could accurately assess the effect of size differences across multiple liver metastases on liver RFS in patients undergoing hepatectomy for CRLMs.

Trial registration

Retrospectively registered

Microwave ablation for colorectal cancer metastasis to the liver: a single-center retrospective analysis

Background

The purpose of this study is to evaluate the safety and intermediate-term efficacy of percutaneous microwave (MW) ablation for the treatment of colorectal liver metastases (CRLM) at a single institution.

Methods

A retrospective review was performed of all CRLM treated with MW ablation from 3/2011 to 7/2020 (102 tumors; 72 procedures; 57 patients). Mean age was 60 years (range, 36-88) and mean tumor size was 1.8 cm (range, 0.5-5.0 cm). The patient population included 19 patients with extra-hepatic disease. Chemotherapy (pre- and/or post-ablation) was given in 98% of patients. Forty-five sessions were preceded by other focal CRLM treatments including resection, ablation, radiation, and radioembolization. Kaplan-Meier curves were used to estimate local tumor progression-free survival (LTPFS), disease-free survival (DFS), and overall survival (OS) and multivariate analysis (Cox Proportional Hazards model) was used to test predictors of OS.

Results

Technical success (complete ablation) was 100% and median follow-up was 42 months (range, 1-112). There was a 4% major complication rate and an overall complication rate of 8%. Local tumor progression (LTP) rate during the entire study period was 4/98 (4%), in which 2 were retreated with MW ablation for a secondary LTP-rate of 2%. LTP-free survival at 1, 3, and 5 years was 93%, 58%, and 39% and median LTP-free survival was 48 months. OS at 1, 3, and 5 years was 96%, 66%, 47% and median OS was 52 months. There were no statistically significant predictors of OS.

Conclusions

MW ablation of hepatic colorectal liver metastases appears safe with excellent local tumor control and prolonged survival compared to historical controls in selected patients. Further comparative studies with other local treatment strategies appear indicated.

Surgical treatment of colorectal liver metastasis

Liver metastasis is the most common form of distant metastasis in colorectal cancer and is a key factor for prognosis in patients with colorectal cancer. Surgery may be the only way to cure colorectal liver metastases. This paper mainly summarizes the latest progress in surgical treatment of colorectal liver metastases, including how to increase resection rate of liver metastases with neoadjuvant therapy or staged hepatectomy, the effect of surgical margin on the prognosis of patients, the timing of surgery in patients with synchronous colorectal liver metastasis, the impact of laparoscopic hepatectomy of liver metastases, the application of liver transplantation in patients with colorectal liver metastases, etc, with an aim to help develop an optimal treatment for patients with colorectal liver metastases through combination of surgical innovations with individualized treatment, thereby improving patients' disease-free survival and overall survival.

A Single-Center Retrospective Analysis of Periprocedural Variables Affecting Local Tumor Progression after Radiofrequency Ablation of Colorectal Cancer Liver Metastases

Background Local tumor progression (LTP) is associated with poorer survival in patients undergoing radiofrequency ablation (RFA) for colorectal liver metastasis (CLM). An algorithmic strategy to predict LTP may help in selection of patients who would benefit most from RFA for CLM. Purpose To estimate local tumor progression-free survival (LTPFS) following RFA of CLM and develop an algorithmic strategy based on clinical variables. Materials and Methods In this retrospective study, between March 2000 and December 2014, patients who underwent percutaneous RFA for CLM were randomly split into development (60%) and internal validation (40%) data sets. Kaplan-Meier method was used to estimate LTPFS and overall survival (OS) rates. Independent factors affecting LTPFS in the development data set were investigated by using multivariable Cox proportional hazard regression analysis. Risk scores were assigned to the risk factors and applied to the validation data set. Results A total of 365 patients (mean age, 60 years ± 11 [standard deviation]; 259 men) with 512 CLMs were evaluated. LTPFS and OS rates were 85% and 92% at 1 year, 73% and 41% at 5 years, 72% and 30% at 10 years, and 72% and 28% at 15 years, respectively. Independent risk factors for LTP included tumor size of 2 cm or greater (hazard ratio [HR], 3.8; 95% CI: 2.3, 6.2; P < .001), subcapsular tumor location (HR, 1.9; 95% CI: 1.1, 3.1; P = .02), and minimal ablative margin of 5 mm or less (HR, 11.7; 95% CI: 4.7, 29.2; P < .001). A prediction model that used the risk factors had areas under the curve of 0.89, 0.92, and 0.90 at 1, 5, and 10 years, respectively, and it showed significantly better areas under the curve when compared with the model using the minimal ablative margin of 5 mm or less alone. Conclusion Radiofrequency ablation provided long-term control of colorectal liver metastases. Although minimal ablative margin of 5 mm or less was the most dominant factor, the multifactorial approach including tumor size and subcapsular location better predicted local tumor progression-free survival. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Soulen and Sofocleous in this issue.

Surgical Management of Colorectal Cancer Liver Metastases

Approximately 50% of colorectal cancer patients develop liver metastases. Hepatic metastases represent the most common cause of colorectal cancer-related mortality. Metastasectomy, if possible, represents the most effective treatment strategy; 20% of patients will be cured and more than 50% survive at least 5 years. Nuances to treatment planning hinge on whether patients present with resectable disease upfront, whether the future liver remnant is adequate, and whether the primary tumor, if present, is colon versus rectal in origin. This article discusses considerations impacting our approach to patients with colorectal liver metastases and the role for various multimodal treatment options.

Construction and Characterization of KRAS Immune Lipid Magnetic Balls for Colorectal Cancer Circulating Tumor Cells

Objective

The purpose of this study was to prepare and characterize a lipid magnetic ball modified with KRAS antibodies on the surface and to isolate circulating tumor cells of colorectal cancer with KRAS mutations.

Methods

The microemulsion method was used to form lipid bilayers to encapsulate Fe3O4 nanoparticles with superparamagnetism to form lipid magnetic balls, and KRAS antibodies were formed on the surface to form KRAS immune lipid magnetic balls.

Results

Compared with traditional EpCAM antibody-modified lipid magnetic balls, it can effectively improve the capture ability of colorectal cancer circulating tumor cells with KRAS mutation, the capture rate reaches 92.9%, and the capture results are consistent with clinical diagnosis and pathology.

Conclusion

Our results showed that KRAS antibody-modified lipid magnetic balls can be used in the diagnosis and treatment of KRAS colorectal cancer.

Measurement Reliability and Diagnostic Accuracy of Virtual Monoenergetic Dual-Energy CT in Patients with Colorectal Liver Metastases

RATIONALE AND OBJECTIVES

To compare dual-energy CT virtual monoenergetic images (VMI) and standard reconstructions for reliability of quantitative size measurements and diagnostic accuracy for the detection of colorectal liver metastases (CRLM).

MATERIALS AND METHODS

We retrospectively included 98 patients (mean age, 61.1±11.5 years) with colorectal cancer, of whom 49 subjects had CRLM. All patients underwent a portal-venous phase dual-energy CT examination. Standard linearly-blended reformats and 40-keV VMI were reconstructed. For both reconstruction techniques, two blinded readers performed measurements of CRLM twice in a preset sequence. Three additional radiologists independently assessed all liver lesions in terms of dignity (benign vs. malignant). Sensitivity, specificity and diagnostic accuracy were calculated on a per-patient basis using MRI as reference standard. Readers scored the suitability for metric measurements and their diagnostic confidence using 5-point Likert scales. Inter-rater agreement was evaluated using intraclass correlation coefficient (ICC).

RESULTS

Inter-rater agreement for lesion size measurements was higher for 40-keV VMI (ICC, 0.88) compared to standard linearly-blended series (ICC, 0.80). Sensitivity and diagnostic accuracy for the detection of CRLM were significantly higher for VMI at 40-keV compared to standard reconstructions (90.6% vs. 80.6%, and 89.1% vs. 81.3%; p < 0.001). Reader scores indicated that 40-keV VMI were more suitable for metric lesion measurements and provided greater diagnostic confidence compared to standard reformats (median, 5 vs. 3, and 5 vs. 4; both p < 0.001).

CONCLUSION

Low-keV VMI reconstructions improve reliability of quantitative size measurements and diagnostic accuracy for the assessment of CRLM compared to standard linearly-blended images.

Clinical significance of epithelial-mesenchymal transition typing of circulating tumour cells in colorectal cancer

AIM

The aim was to determine the diagnostic value of epithelial-mesenchymal transition typing of circulating tumour cells (CTCs) in colorectal cancer (CRC).

METHOD

Peripheral blood samples were collected from 51 CRC patients before anti-tumour treatment from April 2016 to June 2018 at the Peking University Shenzhen Hospital. The blood samples were analysed using the CanPatrol CTC typing technique (SurExam, Guangzhou, China), which combines nanomembrane enrichment with mRNA in situ hybridization. Based on the marker expression, the CTCs were classified into epithelial, epithelial mesenchymal and mesenchymal (M-CTC) types. The correlation between the CTC counts and clinicopathological characteristics such as gender, age, TNM stage, lymph node metastasis and distant metastasis were analysed by univariate and multivariate Cox regression models. The overall survival and progression-free survival (PFS) of patients demarcated by CTC typing were analysed using the Kaplan-Meier method and log-rank tests.

RESULT

M-CTCs were detected more frequently in patients with lymph node metastasis (N2 81.8%; N1 72.7%; N0 38.9%) as well as distant metastasis (M0 50%; M1a 81.25%; M1b 85.7%) compared to those without metastasis. In addition, the presence of M-CTCs was significantly correlated with distant metastasis (P < 0.01). Univariate analysis showed that lymph node metastasis (P = 0.035), distant metastasis (P < 0.001) and total CTC count ≥ 4 (P = 0.007) and M-CTC count ≥ 1 (P < 0.001) were significantly associated with unfavourable PFS, and lymph node metastasis (P = 0.04), distant metastasis (P = 0.01) and M-CTC count ≥ 1 (P < 0.001) were significantly associated with unfavourable overall survival. Multivariate analysis showed that the presence of M-CTCs was the only independent prognostic factor for poor PFS, and patients with M-CTCs had significantly shorter PFS than those without (P = 0.011).

CONCLUSION

M-CTCs are significantly associated with CRC severity and metastasis, and M-CTC count is an independent predictor of prognosis.

Circulating tumor cells as an independent prognostic factor in advanced colorectal cancer: a retrospective study in 121 patients

PURPOSE

This study aimed to evaluate the prognostic value of circulating tumor cells (CTCs) in advanced colorectal cancer (CRC) patients during chemotherapy course.

METHODS

From January 2016 to September 2017, the clinicopathological variables, such as gender, age, tumor location, tumor de-differentiation, depth of invasion, lymphatic invasion, distant metastasis, TNM stage, CTCs enumeration during 2-6 cycles of chemotherapy, and serum carcinoembryonic antigen (CEA) level during the same period, of 121 newly acquired and histopathologically confirmed CRC patients were collected from the Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine. All patients were followed up for survival until the end of November 2018. Statistical analysis focused on the associations between CTCs counts and clinicopathological variables. Overall survival (OS) and progression-free survival (PFS) among different prognostic factors were calculated using the Kaplan-Meier method, and the differences between the survival curves were compared by using the log-rank test. Factors of prognostic significance were investigated with the multivariate Cox regression analysis.

RESULTS

Here, 71 of 121 patients were CTC-positive, in which CTC-positive rate was positively correlated with the depth of invasion, lymphatic invasion, distant metastasis, TNM stage, and serum CEA level (P < 0.05 for all). However, no significant difference was found between CTC-positive and other clinicopathological variables (P > 0.05 for all), such as gender, age, tumor location, and tumor de-differentiation. CTCs counts gradually increased with the advancement of depth of invasion (P = 0.002), lymphatic invasion (P = 0.004), distant metastasis (P = 0.007), TNM stage (P = 0.001), serum CEA level (P = 0.001), and decreased tumor de-differentiation (P = 0.011). Furthermore, the Kaplan-Meier survival curves showed that patients with CTC-positive had a significantly unfavorable PFS (14 vs. 23 months, P = 0.001) and OS (18 vs. 25 months, P = 0.003). The multivariate Cox regression analyses revealed that the presence of CTCs during chemotherapy was an independent factor for unfavorable PFS (hazard ratio (HR) 2.682, P = 0.017, 95% confidence interval (CI) 1.193-6.029) and OS (HR 2.790, P = 0.048, 95% CI 1.010-7.705) in advanced CRC patients.

CONCLUSIONS

This study provided an evidence that the presence of CTCs may be valuable for predicting survival outcome, and CTCs was associated with unfavorable survival in advanced CRC patients during chemotherapy.

Impact of epidural analgesia on the systemic biomarker response after hepatic resection

Background

Perioperative inflammation is associated with poor oncologic outcomes. Regional analgesia has been shown mitigate some of these inflammatory changes and be associated with better oncologic outcomes in patients with hepatic malignancies. The mechanism for this effect, however, remains unclear. The authors sought to compare systemic biomarker concentrations in a comprehensive and oncologically relevant panel in the perioperative setting between patients undergoing thoracic epidural analgesia (TEA) and intra-venous patient- controlled analgesia (IV-PCA) for resection of hepatic metastatic disease.

Results

Clinicopathologic variables and baseline biomarkers were similar between TEA (n = 46) and IV-PCA (n = 16) groups. Of the biomarkers which were significantly changed from baseline, there was a lower fold change from baseline in the TEA patients compared to IV-PCA including IL-6 (13.5vs19.1), MCP-1 (1.9vs3.0), IL-8 (2.4vs3.0), and Pentraxin-3 (10.8vs15.6). Overall decreased systemic concentrations of TGFb signaling were noted in TEA patients on POD1 TGFb3 (243.2 vs. 86.0, p = 0.005), POD3 TGFb1 (6558.0 vs. 2063.3, p = 0.004), POD3 TGFb2 (468.3 vs. 368.9, p = 0.036), POD3 TGFb3 (132.2 vs. 77.8, p = 0.028), and POD5 TGFb3 (306.5 vs. 92.2, p = 0.032). POD1 IL-12p70 concentrations were significantly higher in TEA patients (8.3 vs. 1.6, p = 0.024).

Conclusion

Epidural analgesia damped the postoperative inflammatory response and systemic immunosuppressive signaling, as well as promoted Th1 systemic signaling early in the post-operative period after hepatic resection for metastatic disease. These differences elaborate on known mechanisms for improved oncologic outcomes with regional anesthesia, and may be considered for biomarker monitoring of effective regional anesthesia in oncologic surgery.

Materials and Methods

Patient data, including clinicopathologic variables were collected for this study from the database of a randomized controlled trial comparing perioperative outcomes in patients undergoing hepatic resection with TEA vs. IV-PCA. Patients undergoing resection for metastatic disease were selected for this study. Plasma concentrations (pg/mL) of well-studied biomarkers (IL-1b/2/4/5/6/7/8/10/12p70/13/17, MCP-1 IFNγ, TNFα, MIP-1b, GM-CSF, G-CSF, VEGF, Resistin, TGFb1, TGFb2, and TGFb3), as well as novel perioperative markers (CXCL12, CXCL10, Omentin-1, sLeptin R, Vaspin, Pentraxin-3, Galactin-3, FGF-23, PON-1, FGF-21) were measured preoperatively, and on postoperative day (POD)1, POD3, and POD5 using multiplex bead assays. Clinicopathologic variables and perioperative variations in these biomarkers were compared between TEA vs IV-PCA groups.

Living donor liver transplantation with two-stage hepatectomy for patients with isolated, irresectable colorectal liver-the LIVER-T(W)O-HEAL study

BACKGROUND

Colorectal cancer is the third most common malignancy worldwide. The occurrence of liver metastases worsens the prognosis of the patient significantly if the tumor burden is not resectable. Liver transplantation might be an option for otherwise irresectable colorectal liver metastases. In this study, we evaluate the role of two-stage hepatectomy in combination with a left-lateral living donor liver transplantation.

METHODS

Patients with irresectable liver metastases having a stable disease or tumor regression after at least 8 weeks of systemic chemotherapy without an extrahepatic tumor burden (except resectable lung metastases) are suitable for study inclusion. A randomization is not planned since the control arm (systemic chemotherapy) is well established and the superiority of the transplantation procedure has to be expected. The surgical treatment consists of two steps: in a first operation, a left hemihepatectomy in the recipient will be performed. At this place, the left lateral liver lobe (segments II and III) of a living donor will be transplanted. To induce a growth of the graft, a portal vein ligation will be performed. Approximately after 2 weeks, the removal of the right hemiliver will be conducted if the control imaging shows a sufficient growth of the graft.

RESULTS

The patient recruitment is ongoing. In total, three patients have been already transplanted with this protocol. Up to now, they are tumor-free and in good clinical health.

DISCUSSION

With the design of the LIVER-T(W)O-HEAL study, it might be possible to offer patients with otherwise irresectable colorectal liver metastases a curative treatment option. The key point of this study will be, most probably, the patient's selection.

TRIAL REGISTRATION

Registered at Clinical Trials; NCT03488953 ; registered on April 5, 2018.

Increased kinetic growth rate during late phase liver regeneration impacts the risk of tumor recurrence after colorectal liver metastases resection

BACKGROUND

Although experimental data strongly support the pro-tumorigenic role of postoperative liver regeneration, this hypothesis has not been clinically investigated. We aimed to examine the impact of liver regeneration determined by volumetric imaging on recurrence following resection of colorectal liver metastasis (CRLM).

METHODS

Resected liver volume was subtracted from total liver volume (TLV) to define postoperative remnant liver volume (RLV_p). Early and late kinetic growth rates (KGR) were defined as the postoperative increases in liver volume within 2-3 and 8-10 months from surgery, respectively, divided by the corresponding time interval.

RESULTS

Median early and late KGR was 2.6%/month (IQR: -0.9 to 12.3) and 1.0%/month (IQR: -0.64 to 2.91), respectively. Late KGR predicted intrahepatic recurrence after 1 year from surgery (AUC 0.677, P = 0.011). Specifically, patients with a late KGR ≥1% had a higher cumulative risk of recurrence compared with patients with a KGR <1% (P = 0.038). In multivariate analysis, KGR ≥1% independently predicted recurrence (P = 0.027).

DISCUSSION

A KGR ≥1% during the late regeneration phase was associated with increased risk of intrahepatic recurrence. These data may inform the timing of adjuvant therapy administration and focus surveillance strategies for high-risk patients.

Hepatotoxicity following systemic therapy for colorectal liver metastases and the impact of chemotherapy-associated liver injury on outcomes after curative liver resection

Patients with colorectal liver metastases (CLM) have remarkably benefited from the advances in medical multimodal treatment and surgical techniques over the last two decades leading to significant improvements in long-term survival. More patients are currently undergoing liver resection following neoadjuvant chemotherapy, which has been increasingly established within the framework of curative-indented treatment strategies. However, the use of several cytotoxic agents has been linked to specific liver injuries that not only impair the ability of liver tissue to regenerate but also decrease long-term survival. One of the most common agents included in modern chemotherapy regimens is oxaliplatin, which is considered to induce a parenchymal damage of the liver primarily involving the sinusoids defined as sinusoidal obstruction syndrome (SOS). Administration of bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF), has been reported to improve response of CLM to chemotherapy in clinical studies, concomitantly protecting the liver from the development of SOS. In this review, we aim to summarize current data on multimodal treatment concepts for CLM, give an in-depth overview of liver damage caused by cytostatic agents focusing on oxaliplatin-induced SOS, and evaluate the role of bevacizumab to improve clinical outcomes of patients with CLM and to protect the liver from the development of SOS.

Borderline operability in hepatectomy patients is associated with higher rates of failure to rescue after severe complications

BACKGROUND/OBJECTIVE

To understand the influence of age and comorbidities, this study analyzed the incidence and risk factors for post-hepatectomy morbidity/mortality in patients with "borderline" (BL) operability, defined by the preoperative factors: age ≥75 years, dependent function, lung disease, ascites/varices, myocardial infarction, stroke, steroids, weight loss >10%, and/or sepsis.

METHODS

All elective hepatectomies were identified in the 2005-2013 ACS-NSQIP database. Predictors of 30-day morbidity/mortality in BL patients were analyzed.

RESULTS

A 3,574/15,920 (22.4%) patients met BL criteria. Despite non-BL and BL patients undergoing similar magnitude hepatectomies (P > 0.4), BL patients had higher severe complication (SC, 23.3% vs. 15.3%) and mortality rates (3.7% vs. 1.2%, P < 0.001). BL patients with any SC experienced a 14.1% mortality rate (vs. 7.3%, non-BL, P < 0.001). Independent risk factors for SC in BL patients included American Society of Anesthesiologists (ASA) score >3 (odds ratio, OR - 1.29), smoking (OR - 1.41), albumin <3.5 g/dl (OR - 1.36), bilirubin >1 (OR - 2.21), operative time >240 min (OR - 1.58), additional colorectal procedure (OR - 1.78), and concurrent procedure (OR - 1.73, all P < 0.05). Independent predictors of mortality included disseminated cancer (OR - 0.44), albumin <3.5 g/dl (OR - 1.94), thrombocytopenia (OR - 1.95), and extended/right hepatectomy (OR - 2.81, all P < 0.01).

CONCLUSIONS

Hepatectomy patients meeting BL criteria have an overall post-hepatectomy mortality rate that is triple that of non-BL patients. With less clinical reserve, BL patients who suffer SC are at greater risk of post-hepatectomy death. J. Surg. Oncol. 2017;115:337-343. © 2016 Wiley Periodicals, Inc.

Tumor Biology Rather Than Surgical Technique Dictates Prognosis in Colorectal Cancer Liver Metastases

INTRODUCTION

The interplay of tumor biology and surgical margin status after resection for colorectal liver metastasis (CRLM) remains controversial. Consequently, we sought to determine the impact of surgical margin status on overall survival (OS) stratified by KRAS mutational status.

MATERIALS AND METHODS

Four hundred eighty-five patients with known KRAS mutational status were identified. Clinicopathologic and long-term survival data were collected and assessed.

RESULTS

On pathology, most patients (n = 380; 78.3 %) had an R0 margin, while 105 (21.7 %) had an R1. Roughly two thirds of tumors were KRAS wild type (wtKRAS) (n = 307, 63.3 %), while 36.7 % (n = 178) had KRAS mutations (mutKRAS). Median and 5-year OS of the entire cohort was 65.8 months and 53.8 %, respectively. An R1 resection was associated with worse 5-year OS compared with R0 (42.4 % vs. 57.1 %; hazard ratio (HR) 1.82, 95 % CI 1.28-2.57; P = 0.001). After controlling for KRAS status, the survival benefit associated with an R0 resection persisted only among patients with wtKRAS tumors (HR 2.16, 95 % CI 1.42-3.30; P < 0.001). In contrast, surgical margin had no impact on OS among patients with mutKRAS tumors (5-year OS R0, 40.7 % vs. R1, 46.7 %; HR 1.34, 95 % CI 0.73-2.48; P = 0.348).

CONCLUSION

The impact of margin status differed by KRAS mutation status. An R0 margin only provided a survival benefit to patients with wtKRAS tumors. Tumor biology and not surgical technique determined prognosis.

Functional imaging in liver tumours

Functional imaging encompasses techniques capable of assessing physiological parameters of tissues, and offers useful clinical information in addition to that obtained from morphological imaging. Such techniques may include magnetic resonance imaging with diffusion-weighted sequences or hepatobiliary contrast agents, perfusion imaging, or molecular imaging with radiolabelled tracers. The liver is of major importance in oncological practice; not only is hepatocellular carcinoma one of the malignancies with steadily rising incidence worldwide, but hepatic metastases are regularly observed with a range of solid neoplasms. Within the realm of hepatic oncology, different functional imaging modalities may occupy pivotal roles in lesion characterisation, treatment selection and follow-up, depending on tumour size and type. In this review, we characterise the major forms of functional imaging, discuss their current application to the management of patients with common primary and secondary liver tumours, and anticipate future developments within this field.

Morbidity and mortality and predictors of outcome following hepatectomy at a Saudi tertiary care center

BACKGROUND

Hepatic resection is a major surgical procedure. Data on outcomes of hepatectomy in Saudi Arabia are scarce.

OBJECTIVE

To measure morbidity and mortality and assess predictors of outcome after hepatectomy.

DESIGN

Descriptive study.

SETTING

Tertiary care center in Saudi Arabia with well established hepatobiliary surgery unit.

PATIENTS AND METHODS

All patients undergoing liver resection in our institute during 2006-2014. Data were analyzed by Kaplan-Meier survival analysis.

MAIN OUTCOMES MEASURE(S)

Postoperative morbidity and 90-day mortality. Secondary outcomes were risk factors associated with increased morbidity and mortality.

RESULTS

Data on 77 resections were collected; 56 patients (72.7%) had a malignant etiology, mainly colorectal liver metastases and hepatocellular carcinoma (45.5% and 14.3% respectively). Complications developed following 30 resections (39.0%), with the majority being Clavien grades I-III. In the univariate analysis, predicting factors were the total bilirubin level preoperatively, operative time, extent of resection (i.e., major resection), use of epidural anesthesia, and postoperative liver dysfunction. In the multivariate analysis, the Schindl liver dysfunction score showed the strongest correlation with the development of complications (P=.006). The 90-day postoperative mortality was 5.2% (4/77 patients); 3 patients fulfilled the 50:50 liver dysfunction criteria. Significant predictors were concurrent intra-abdominal surgery, postoperative liver dysfunction, and multiple complications.

CONCLUSION

Factors that predicted development of complications were elevated total bilirubin level preoperatively, operative time, extent of the resection, use of epidural anesthesia and a postoperative need for blood transfusion. Liver resection is a safe and feasible option at our center.

LIMITATIONS

The small number of indications for resection and consequent reduction in variety of risk factors limited ability to make inferences. Additionally, only a handful of cases were performed laparoscopically.

Isolated hepatic perfusion for unresectable hepatic malignancies: A systematic review and meta-analysis

AIM

To investigate the efficacy and safety of isolated hepatic perfusion (IHP) in the management of unresectable liver malignancies.

METHODS

Studies were identified manually and on-line by using PubMed and EMBASE database. We formulate the eligibility criteria according to the PICOS elements, and accessed the quality of studies using the MINORS instrument. Data from all included studies were carefully investigated. We calculated the pooled response rate and incidences of mortality reported from all eligible studies by using the Meta-Analyst software, and we computed a pooled relative risk (RR) and 95%CI by using the Comprehensive Meta-Analysis software. Heterogeneity was quantified evaluated using I² statistic.

RESULTS

Eight studies, including 502 patients, were selected. Of these, six studies performed IHP, while the other two studies performed percutaneous IHP. The results showed that the pooled response rate was 60.8% (95%CI: 53.1%-68%), I² = 37.1%. The median overall survival was 20 mo (range: 12.1 to 25 mo) following IHP or PIHP. The pooled mortality rate was 5.4% (95%CI: 2.5%-11.2%), I² = 37.5%. Prognostic factors predict the response to IHP or survival, and were reported in six studies. Meta-analysis demonstrated that Gender was not associated with overall survival (RR = 0.877, 95%CI: 0.564-1.365); however, carcino-embryonic antigen ≤ 30 ng/mL was associated with a significant improvement in survival outcomes with colorectal cancer patients (RR = 2.082, 95%CI: 1.371-3.163), and there was no significant heterogeneity.

CONCLUSION

The present systemic review and meta-analysis suggest that IHP and PIHP are potentially efficient and safe techniques for unresectable liver primary and secondary malignancies.

High preoperative serum CA19-9 level is predictive of poor prognosis for patients with colorectal liver oligometastases undergoing hepatic resection

Oligometastasis is defined as a transitional state between localized and widespread systemic metastatic cancers. In colorectal cancer, the prognostic factors and prognostic value of preoperative serum carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) for patients with colorectal liver oligometastases (CLOM) undergoing hepatic resection have not been well explored. Therefore, the present study included 141 patients with CLOM (≤5 liver metastases) who underwent R0 resection from 2005 to 2012. The association of clinicopathological factors including preoperative CA19-9 and CEA levels with overall survival (OS) was analyzed with univariate and multivariate analyses. Kaplan-Meier analysis showed that patients with high CA19-9 levels tended to have poorer OS than those with low levels (median OS 21.5 vs. 64.0 months, P = 0.002). Preoperative CEA levels were not significantly associated with OS (P > 0.05). Univariate and multivariate analyses demonstrated that larger tumor size of liver metastases (HR 1.911; 95 % CI 1.172-3.114; P = 0.009), bilobar distribution (HR 1.776; 95 % CI 1.097-2.873; P = 0.019), and higher preoperative CA19-9 levels (HR 1.954; 95 % CI 1.177-3.242; P = 0.010) were independent predictors of poor OS for patients with CLOM. Our study identified tumor size, distribution, and preoperative CA19-9 levels as independent prognostic factors for OS of patients with CLOM. In particular, measurement of preoperative CA19-9 levels offers an easy tool that could help identify high-risk patients and aid in improving the management of patients with CLOM.

Liver resection for non-colorectal non-neuroendocrine metastases

OBJECTIVE

Liver resections for non-colorectal non-neuroendocrine liver metastases (NCNELM) are gaining popularity. This study examines the outcomes of liver resections in patients with NCNELM in an Australian hospital.

METHOD

A database search identified 21 attempted liver resections on 20 patients (12 men, eight women, mean age: 63.1) from 1998 to 2013. A retrospective analysis considered patient demographics and primary malignancy details. Complication rates were compared to those for colorectal metastases at the same institution. Kaplan-Meier curves were used to plot overall survival.

RESULTS

Complete resection was achieved in 16 of the 21 operations with 13 cases having proven metastases (three cases were benign lesions on final histology). Primary cancers were gastric (n = 4), gall bladder/bile duct (n = 3), renal (n = 3), soft tissue sarcoma (n = 3), melanoma (n = 2), pancreatic (n = 2), anal (n = 2), breast (n = 1) and unknown (n = 1). Primary histology types were adenocarcinoma (n = 10), sarcoma (n = 3), renal cell (n = 3), squamous cell (n = 2), melanoma (n = 2) and gastrointestinal stromal tumour (n = 1). There was no peri-operative mortality. Significant post-operative complications (Clavien-Dindo Grade III or more) occurred in six patients (28.5%). Overall survival at 2 and 5 years was 46.2% and 30.8%, respectively, for all 21 cases of attempted resection, and 51.9% and 34.6%, respectively, for the 13 cases of complete resection of malignant metastases.

CONCLUSIONS

This study produced comparable 5-year survival rates to those reported after liver resection for colorectal metastases and in other studies on NCNELM. Complication rates were comparable to those for colorectal liver metastasis resection at the same institution.

Analysis of circulating tumor cells in colorectal cancer liver metastasis patients before and after cryosurgery

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.

Bevacizumab plus FOLFOX or FOLFIRI regimens on patients with unresectable liver-only metastases of metastatic colorectal cancer

Background:

The present study was aimed to evaluate the efficacy and safety of at least three cycles of Bevacizumab in combination with chemotherapy regimens, FOLFIRI or FOLFOX to treat liver metastatic colorectal cancer and improved response rates in these patients.

Materials and Methods:

In this non-randomized clinical trial, 38 patients were enrolled and followed for 12-weeks period of chemotherapy. Fifteen patients under treated with FOLOFX (Group I), 15 patients under treated with FOLOFIRI (Group II), 4 patients under treated with FOLOFX + Bevacizumab (Group III), and 34 patients under treated with FOLOFIRI + Bevacizumab (Group IV). Response to treatment was assessed in all patients as main endpoint. Patients in groups I and II, who did not response to treatment after 12 weeks of chemotherapy, were followed by groups III and IV regimens, respectively, for 12 weeks.

Results:

Overall response rate was 35% (19 of 54), and complete response (CR), partial response (PR), progressive disease (PD), and stable disease (SD) rates in all patients were 18%, 17%, 35%, and 30%. PR, SD, and PD were different among groups, but no statistical significance was noted among groups (P-value >0.05). No patient achieved a CR in groups III and IV, although CR was observed in 4 patients (27%) and 6 patients (40%) in groups I and II, respectively. The rare of CR was statistically significant among studied groups (P-value = 0.013).

Conclusion:

Results showed that adding Bevacizumab to chemotherapy regimens, in patients who did not response to FOLFIRI or FOLFOX regimen, did not increase CR in these patients.

Negative surgical margin improved long-term survival of colorectal cancer liver metastases after hepatic resection: a systematic review and meta-analysis

OBJECTIVE

The need to achieve a tumor-free margin of ≥1 mm (R0) for colorectal liver metastases (CRLM) after hepatic resection has been questioned recently. This study conducted a meta-analysis to determine whether status of the surgical margin still influenced the long-term outcome of survival and recurrence rate.

METHODS

Eligible trials that compared survival and recurrence rates of R0 versus the tumor-free margin <1 mm (R1) were identified from Embase, PubMed, the Web of Science, and the Cochrane Library since their inception to 1 March 2015. The study outcomes included long-term outcome of survival and recurrence rate. Hazard ratio (HR) with a 95 % confidence interval was used to measure the pooled effect according to a random-effects model or fixed-effects model, depending on the heterogeneity among the included studies. The heterogeneity among these trials was statistically evaluated using the χ(2) and I(2) tests. Sensitivity analyses and publication bias were also carried out.

RESULTS

A total of 18 studies containing 6790 patients were included. The comparison between R1 and R0 revealed that a pooled HR for 5-year overall survival was 1.603 (95 % CI; 1.464-1.755; p = 0.000; I(2) = 31.2 %, p = 0.141). For patients received modern chemotherapy; a pooled HR of R1 resection for 5-year overall survival was 1.924 (95 % CI; 1.567-2.361, p = 0.000; I(2) = 20.5 %, p = 0.273). The pooled HR for 5-year OS of ≥1 cm in the included studies calculated using the random-effects model was 0.819 (95 % CI; 0.715-0.938, p = 0.004; I(2) = 0 %, p = 0.492).

CONCLUSIONS

R1 resections decreased long-term survival, and modern chemotherapy did not alter an adverse outcome. Surgeons should attempt to obtain a 1-cm margin.

Aggressive Surgical Management for Metastatic Liver Tumors From Squamous Cell Carcinomas: Report of Three Cases

The use of hepatectomy for the treatment of metastatic liver tumors (MLTs) arising from squamous cell carcinomas (SCCs) has not been well investigated. The use of hepatectomy for MLTs from SCCs, especially in advanced cases, needs further investigation. Three patients with SCC-derived MLTs underwent hepatectomy. On clinicopathologic examination, the primary lesions were found to be oral cancer, lung cancer, and oropharyngeal cancer, with synchronous metastasis in 2 patients and metachronous metastasis in 1 patient. One case also involved adrenal metastasis, and another involved direct invasion of the diaphragm and lung. In all cases, surgery was performed to eliminate any residual tumor tissue. After the hepatectomy, 1 patient died (22 months postoperatively) of an unrelated disease, 1 remains alive (30 months postoperatively) with a recurrent tumor, and 1 remains alive (60 months postoperatively) without recurrence. For the patients with solitary MLT derived from SCC, hepatectomy gives a chance for a cure. Thus, aggressive hepatectomy is an important modality in the multidisciplinary approach for controlling SCC-derived MLTs.

Complex Surgical Strategies to Improve Resectability in Borderline-Resectable Disease

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.

Surgical management of hepatic metastases of colorectal cancer

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.