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Ghanie A, Formica MK, Dhir M. Systematic review and meta-analysis of 90-day and 30-day mortality after liver resection in the elderly. Surgery 2022; 172:1164-1173. [PMID: 35973874 DOI: 10.1016/j.surg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 05/22/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND With the aging population worldwide, the number of elderly patients presenting for liver resection because of liver malignancies is increasing. Data on the perioperative mortality in this population are limited and contradictory. We performed a systematic review and meta-analysis to determine the mortality of elderly patients after hepatectomy. METHODS Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines, we searched 3 databases to identify studies that investigated 30-day and 90-day mortality after hepatectomy for patients ≥65 years of age. We categorized the patients by age into 4 groups (≥65, ≥70, ≥75, and ≥80 years), which were analyzed separately for mortality. All analyses were conducted with IBM SPSS Statistics for Windows version 28. RESULTS Using PubMed, Embase, and Scopus, we identified 441 articles. After study selection and quality assessment, we included 66 studies consisting of 29,998 patients in the final meta-analysis. The pooled estimates for 30-day and 90-day mortality in the ≥65, ≥70, ≥75, and ≥80 age groups years were 1.3% (95% confidence interval 0.59%-2.06%), 2.8% (95% confidence interval 1.80%-3.69%), 3.0% (95% confidence interval 1.68%-4.30%), and 1.7% (95% confidence interval 1.22%-2.20%) and 2.7% (95% confidence interval 1.45%-3.87%), 2.8% (95% confidence interval 1.49%-4.02%), 5.1% (95% confidence interval 2.76%-7.42%), and 2.4% (95% confidence interval 0.60%-4.16%), respectively. CONCLUSION This meta-analysis summarizes the 30-day and 90-day mortality rates after liver resection in the elderly patients. Liver resection in this population selected for surgery appears to be relatively safe. Advanced age alone may not be a sufficient exclusion criterion for surgery. These age-specific mortality data can be used to educate patients at the time of preoperative counseling.
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Affiliation(s)
- Amanda Ghanie
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY. http://www.twitter.com/GhanieAmanda
| | - Margaret K Formica
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Mashaal Dhir
- Department of Surgery, Division of Surgical Oncology, SUNY Upstate Medical University, Syracuse, NY.
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2
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Chen Q, Zhang Y, Deng Y, Huang Z, Zhao H, Cai J. Outcomes of simultaneous resection for elderly patients with colorectal liver metastasis: A propensity score matching analysis. Cancer Med 2022; 11:4913-4926. [PMID: 35608250 PMCID: PMC9761077 DOI: 10.1002/cam4.4826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 05/04/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Evidence on simultaneous resection for elderly patients (age ≥ 70 years) with colorectal liver metastasis (CRLM) is lacking. METHODS Four hundred and eighty-two CRLM patients treated by simultaneous resection were categorised into young group (age < 70 years) and elderly group (age ≥ 70 years). Propensity score matching (PSM1) was performed to adjust for differences in baseline characteristics and compare short-term outcomes. An additional propensity score matching (PSM2) including short-term outcomes was performed to analyse survival. Subgroup analysis was performed in patients stratified by the Clinical Risk Score (CRS). RESULTS After PSM1, 87 young group patients were matched to 50 elderly group patients. Patients in the elderly group had a significantly higher rate of overall post-operative complications (68.0% vs. 46.0%, p = 0.013). After PSM2, 89 young group patients were matched to 47 elderly group patients. Progression-free survival (PFS) was comparable between the two groups (median 11.0 months vs. 9.8 months, p = 0.346). Age ≥ 70 independently predicted worse overall survival (OS) (Hazard ratio, HR = 2.57, 95% confidence interval, CI 1.37-4.82) in multivariate analysis. In the subgroup multivariate analysis of patients with CRS score 3-5, age ≥ 70 was independently associated with worse PFS (HR = 1.62, 95% CI 1.01-2.62) and OS (HR = 2.34, 95% CI 1.26-4.35). CONCLUSIONS Simultaneous resection for elderly CRLM patients is acceptable. Further studies are required to determine the optimal treatment for elderly CRLM patients with high CRS scores.
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Affiliation(s)
- Qichen Chen
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yizhou Zhang
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yiqiao Deng
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhen Huang
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Hong Zhao
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jianqiang Cai
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Yoshino K, Hamzaoui Y, Yoh T, Ftériche FS, Aussilhou B, Beaufrère A, Belghiti J, Soubrane O, Cauchy F, Dokmak S. Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications. Langenbecks Arch Surg 2021; 406:1543-1552. [PMID: 34057599 DOI: 10.1007/s00423-021-02210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. METHODS Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. RESULTS The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. CONCLUSIONS Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.
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Affiliation(s)
- Kenji Yoshino
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Yanis Hamzaoui
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Tomoaki Yoh
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Fadhel Samir Ftériche
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Aurélie Beaufrère
- Department of Pathology, University of Paris, Hôpital Beaujon, AP-HP, Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France.
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4
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Nassabein R, Mansour L, Richard C, Vandenbroucke-Menu F, Aubin F, Ayoub JP, Dagenais M, Lapointe R, Letourneau R, Plasse M, Roy A, Turcotte S, Tehfe M. Outcomes of Older Patients with Resectable Colorectal Liver Metastases Cancer (CRLM): Single Center Experience. ACTA ACUST UNITED AC 2021; 28:1899-1908. [PMID: 34069871 PMCID: PMC8161835 DOI: 10.3390/curroncol28030176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/22/2022]
Abstract
Surgery is the only potential curative option of CRLM if resectable. The curative approach in patients over 70 years old is challenging mainly because of comorbidities and other geriatric syndromes. Herein, we report outcomes of older patients with resectable CRLM in our center. We retrospectively analyzed characteristics and outcomes of older patients with CRLM operated at "Centre Hospitalier de l'Université de Montréal" (CHUM) between 2010 and 2019. We identified 210 patients aged ≥70 years with a median age of 76 (range: 70-85). CRLM were synchronous in 56% of patients. Median disease-free survival (DFS) was 41.3 months. Median overall survival (OS) was 62.2 months and estimated 5-year survival rate was 51.5% similar to those of younger counterparts. Patients with metachronous CRLM had a trend to a higher OS compared to those with synchronous disease (67.2 vs. 58.7 months; p = 0.42). Factors associated with lower survival in the multivariate analysis were right-sided tumors and increased Charlson Comorbidity index (CCI). Survival outcomes of patients aged ≥70 years were comparable to those of younger patients and those reported in the literature. Age should not be a limiting factor in the curative management of older patients with resectable CRLM.
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Affiliation(s)
- Rami Nassabein
- Department of Medicine, Hematology-Oncology Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (R.N.); (L.M.); (F.A.); (J.-P.A.)
| | - Laura Mansour
- Department of Medicine, Hematology-Oncology Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (R.N.); (L.M.); (F.A.); (J.-P.A.)
| | - Corentin Richard
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC H2X 0A9, Canada;
| | - Franck Vandenbroucke-Menu
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Francine Aubin
- Department of Medicine, Hematology-Oncology Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (R.N.); (L.M.); (F.A.); (J.-P.A.)
| | - Jean-Pierre Ayoub
- Department of Medicine, Hematology-Oncology Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (R.N.); (L.M.); (F.A.); (J.-P.A.)
| | - Michel Dagenais
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Real Lapointe
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Richard Letourneau
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Marylène Plasse
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - André Roy
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Simon Turcotte
- Department of Surgery, Hepatopancreatobiliary Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (F.V.-M.); (M.D.); (R.L.); (R.L.); (M.P.); (A.R.); (S.T.)
| | - Mustapha Tehfe
- Department of Medicine, Hematology-Oncology Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC H2X 0C1, Canada; (R.N.); (L.M.); (F.A.); (J.-P.A.)
- Correspondence: ; Tel.: +1-(514)-890-8000 (ext. 20688)
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5
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Alabraba E, Gomez D. Systematic Review of Treatments for Colorectal Metastases in Elderly Patients to Guide Surveillance Cessation Following Hepatic Resection for Colorectal Liver Metastases. Am J Clin Oncol 2021; 44:210-223. [PMID: 33710135 DOI: 10.1097/coc.0000000000000803] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging. METHODS There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases. RESULTS Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited. DISCUSSION The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.
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Affiliation(s)
- Edward Alabraba
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust
| | - Dhanny Gomez
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust
- NIHR Nottingham Digestive Disease Biomedical Research Unit, University of Nottingham, Nottingham, UK
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Bruera G, D'Andrilli A, Simmaco M, Guadagni S, Rendina EA, Ricevuto E. Relevance of Pharmacogenomics and Multidisciplinary Management in a Young-Elderly Patient With KRAS Mutant Colorectal Cancer Treated With First-Line Aflibercept-Containing Chemotherapy. Front Oncol 2020; 10:1155. [PMID: 32850329 PMCID: PMC7417602 DOI: 10.3389/fonc.2020.01155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/08/2020] [Indexed: 01/24/2023] Open
Abstract
Introduction: Intensive oncological treatment integrated with resection of metastases raised the clinical outcome of metastatic colorectal cancer (MCRC). In clinical practice, complex evaluation of clinical (age, performance status, comorbidities), and biological (tumoral genotype, pharmacogenomic) parameters addresses tailored, personalized multidisciplinary treatment strategies. Patients with MCRC unsuitable for first-line intensive medical treatments are prevalent and showed worse clinical outcome. After progression to oxaliplatin-based chemotherapy, aflibercept/FOLFIRI significantly improved clinical outcome, even if no survival benefit was reported in adjuvant fast relapsers by aflibercept addition. The case reported a young-elderly (yE) patient with KRAS mutant colorectal cancer rapidly progressing to adjuvant chemotherapy, unfit owing to comorbidities, with multiple pharmacogenomic alterations, who gained long-term survival in clinical practice by multidisciplinary treatment strategy consisting of first-line and re-introduction of aflibercept-containing chemotherapy and two-stage lung metastasectomies. Case presentation: A 71-years-old yE patient, unfit for intensive oncological treatments owing to Cumulative Illness Rating Scale (CIRS) stage secondary, affected by KRAS c.35 G>T mutant colorectal cancer, rapidly progressing with lung metastases after adjuvant XelOx chemotherapy, reached long-term survival 66 months with no evidence of disease after first-line and re-introduction of tailored, modulated aflibercept (4 mg/kg) d1,15-irinotecan (120 mg/m2) d1,15-5-fluorouracil (750 mg/m2/day) dd1–4, 15–18; and secondary radical bilateral two-stage lung metastasectomies. Safety profile was characterized by limiting toxicity syndrome at multiple sites (LTS-ms), requiring 5-fluorouracil discontinuation and aflibercept reduction (2 mg/kg), because of G2 hand-foot syndrome (HFS) for >2 weeks, and G3 hypertension. Pharmacogenomic analyses revealed multiple alterations of fluoropyrimidine and irinotecan metabolism: severe deficiency of fluorouracil degradation rate (FUDR), single nucleotide polymorphisms of UGT1A1*28 variable number of tandem repeats (VNTR) 7R/7R homozygote, ABCB1 c.C3435T, c.C1236T, MTHFR c.C667T homozygote, DPYD c.A166G, TSER 28bp VNTR 2R/3R heterozygote. Conclusions: In clinical practice, a complex management evaluating clinical parameters and RAS/BRAF genotype characterizing an individual patient with MCRC, particularly elderly and/or unfit owing to comorbidities, is required to properly address tailored, multidisciplinary medical and surgical treatment strategies, integrated with careful monitoring of superimposing toxicity syndromes, also related to pharmacogenomic alterations, to gain optimal activity, and long-term efficacy.
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Affiliation(s)
- Gemma Bruera
- Oncology Territorial Care, S. Salvatore Hospital, Oncology Network ASL1 Abruzzo, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio D'Andrilli
- Thoracic Surgery, S. Andrea Hospital, Faculty of Medicine and Psychology, University La Sapienza, Rome, Italy
| | | | - Stefano Guadagni
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Universitary General Surgery, S. Salvatore Hospital, Oncology Network ASL1 Abruzzo, University of L'Aquila, L'Aquila, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery, S. Andrea Hospital, Faculty of Medicine and Psychology, University La Sapienza, Rome, Italy
| | - Enrico Ricevuto
- Oncology Territorial Care, S. Salvatore Hospital, Oncology Network ASL1 Abruzzo, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Bajwa R, Madoff DC, Kishore SA. Embolotherapy for Hepatic Oncology: Current Perspectives and Future Directions. DIGESTIVE DISEASE INTERVENTIONS 2020; 4:134-147. [PMID: 32832829 DOI: 10.1055/s-0040-1712146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractPrimary and secondary liver cancers are a major cause of mortality worldwide. Transarterial liver-directed therapy, or embolotherapy, represents an important locoregional treatment strategy for primary and secondary liver tumors. Embolotherapeutic modalities include bland embolization (transarterial embolization), chemoembolization (transarterial chemoembolization), and radioembolization or selective internal radiotherapy. A brief technical overview of embolotherapeutic modalities as well as supportive evidence for the treatment of most common primary and secondary liver tumors will be discussed in this review. Several potential future applications, including synergy with systemic therapy, interventional theranostics, and artificial intelligence will also be reviewed briefly.
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Affiliation(s)
- Raazi Bajwa
- Memorial Sloan Kettering Cancer Center, Department of Radiology, Division of Interventional Radiology, New York, NY, USA
| | - David C Madoff
- Yale University School of Medicine, Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, New Haven, CT, USA
| | - Sirish A Kishore
- Memorial Sloan Kettering Cancer Center, Department of Radiology, Division of Interventional Radiology New York, NY, USA
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de’Angelis N, Baldini C, Brustia R, Pessaux P, Sommacale D, Laurent A, Le Roy B, Tacher V, Kobeiter H, Luciani A, Paillaud E, Aparicio T, Canuï-Poitrine F, Liuu E. Surgical and regional treatments for colorectal cancer metastases in older patients: A systematic review and meta-analysis. PLoS One 2020; 15:e0230914. [PMID: 32320417 PMCID: PMC7176093 DOI: 10.1371/journal.pone.0230914] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
Objective The present study explored the existing literature to describe the outcomes of surgical and regional treatments for colorectal cancer metastases (mCRC) in older patients. Methods A literature search was conducted in PubMed, EMBASE, Cochrane and ClinicalTrials.gov for studies published since 2000 that investigated the short- and long-term outcomes of regional treatments (surgical or non-surgical) for mCRC in patients aged ≥65 years. Pooled data analyses were conducted by calculating the risk ratio (RR), mean differences (MD) and hazard ratio (HR) between older and younger patients or between two different approaches in older patients. Results After screening 266 articles, 29 were included in this review. These studies reported the outcomes of surgery (n = 19) and non-surgical local ablation treatments (n = 3) for CRC metastases in older vs. younger patients or compared the outcomes of different interventions in older patients (n = 7). When comparing older vs. younger patients undergoing liver surgery for mCRC, pooled data analysis showed higher postoperative mortality [RR = 2.53 (95%CI: 2.00–3.21)] and shorter overall survival [HR = 1.17 (95%CI: 1.07–1.18)] in older patients, whereas no differences in operative outcomes, postoperative complications and disease-free survival were found. When comparing laparoscopy vs. open surgery for liver resection in older mCRC patients, laparoscopy was associated with fewer postoperative complications [RR = 0.27 (95%CI: 0.10–0.73)]. Conclusion Liver resection for mCRC should not be disregarded a priori in older patients, who show similar operative and postoperative outcomes as younger patients. However, clinicians should consider that they are at increased risk of postoperative mortality and have a worse overall survival, which may reflect comorbidities and frailty.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
- * E-mail:
| | - Capucine Baldini
- Drug Development Department, Gustave Roussy Cancer Campus, University Paris-Saclay, Villejuif, France
| | - Raffaele Brustia
- Department of Hepato-biliary and Liver Transplantation Surgery, Pitié-Salpêtrière University Hospital, APHP, Paris, France
| | - Patrick Pessaux
- Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Université de Strasbourg, and U1110 Inserm, Institute of Viral and Liver Disease, Strasbourg, France
| | - Daniele Sommacale
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Alexis Laurent
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Vania Tacher
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Hicham Kobeiter
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Alain Luciani
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Elena Paillaud
- Hopital Europeen Georges Pompidou, Department of Geriatrics, Paris, France
| | - Thomas Aparicio
- Gastroenterology and Digestive Oncology Department, Saint Louis Hospital, AP-HP, and University of Paris, Paris, France
| | - Florence Canuï-Poitrine
- Department of Epidemiology and Biostatistics, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Evelyne Liuu
- Department of Geriatrics, CHU La Milétrie, Poitiers University Hospital, Grand Poitiers, France
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9
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Rosati G, Cordio S, Reggiardo G, Aprile G, Butera A, Avallone A, Tucci A, Novello G, Blanco G, Caputo G, Bilancia D, Bordonaro R. Oxaliplatin-Based Chemotherapy in Patients with Metastatic Colorectal Cancer Aged at Least 75 Years: A Post-Hoc Subgroup Analysis of Three Phase II Trials. Cancers (Basel) 2019; 11:cancers11040578. [PMID: 31022922 PMCID: PMC6521155 DOI: 10.3390/cancers11040578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/17/2019] [Accepted: 04/21/2019] [Indexed: 12/21/2022] Open
Abstract
Patients older than 75 years of age are usually excluded from metastatic colorectal cancer studies based on a combination chemotherapy containing oxaliplatin. Our group conducted three phase II trials in elderly patients in recent years. A post-hoc subgroup analysis of 67 patients aged at least 75 years was included in this study. Oxaliplatin was combined with capecitabine in two trials and with uracil-tegafur (UFT) plus folinic acid in the third trial. In one study, bevacizumab was also added to chemotherapy. The median age of patients was 77 years, and all had a good performance status (0 to 1). The observed overall response rate was 45%, comparable to younger patients (51%, p = 0.49). The estimated median progression-free survival (PFS) time and overall survival (OS) time were 8.7 and 19.3 months, respectively. These results did not significantly differ from those in younger patients (8.0 months for PFS (p = 0.58) and 19.7 months for OS (p = 0.94), respectively). The most common grade 3–4 adverse events included diarrhea (13%), fatigue (13%), peripheral neuropathy (10%), and neutropenia (7%). Moreover, the toxicity was never statistically different from that in younger patients. The efficacy of oxaliplatin-based combination was maintained in fit elderly patients ≥75 years.
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Affiliation(s)
- Gerardo Rosati
- U.O. Oncologia Medica, Azienda Ospedaliera S. Carlo, 85100 Potenza, Italy.
| | - Stefano Cordio
- Struttura Complessa di Oncologia Medica, Ospedale Garibaldi, 95122 Catania, Italy.
| | - Giorgio Reggiardo
- Biostatistics and Data Management Unit, Medi Service S.r.l., 16149 Genova, Italy.
| | - Giuseppe Aprile
- Dipartimento di Oncologia Clinica, Ospedale San Bortolo, AULSS8, 36100 Vicenza, Italy.
| | - Alfredo Butera
- U.O. Oncologia Medica, Ospedale S. Giovanni di Dio, 92100 Agrigento, Italy.
| | - Antonio Avallone
- Struttura Complessa di Oncologia Clinica Sperimentale Addome, Dipartimento Assistenziale e di Ricerca dei Percorsi Oncologici del Distretto Addominale, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131 Napoli, Italy.
| | - Aniello Tucci
- U.O. Oncologia Medica, ASL NA3 Sud, 80035 Nola (NA), Italy.
| | - Giuseppe Novello
- U.O. Oncologia Medica, Azienda Ospedaliero-Universitaria "Vittorio Emanuele", 95124 Catania, Italy.
| | - Giuseppina Blanco
- U.O. Oncologia Medica, Istituto Oncologico del Mediterraneo, 95029 Viagrande (CT), Italy.
| | - Giuseppe Caputo
- U.O. Oncologia Medica, Azienda Ospedaliera Gravina, 95041 Caltagirone, Italy.
| | - Domenico Bilancia
- U.O. Oncologia Medica, Azienda Ospedaliera S. Carlo, 85100 Potenza, Italy.
| | - Roberto Bordonaro
- Struttura Complessa di Oncologia Medica, Ospedale Garibaldi, 95122 Catania, Italy.
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Tufo A, Dunne DFJ, Manu N, Lacasia C, Jones L, de Liguori Carino N, Malik HZ, Poston GJ, Fenwick SW. Changing outlook for colorectal liver metastasis resection in the elderly. Eur J Surg Oncol 2019; 45:635-643. [DOI: 10.1016/j.ejso.2018.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/01/2018] [Accepted: 11/30/2018] [Indexed: 12/14/2022] Open
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Yue M, Li S, Yan G, Li C, Kang Z. Short- and long-term outcomes of laparoscopic hepatectomy for colorectal liver metastases in elderly patients. Cancer Manag Res 2018; 10:2581-2587. [PMID: 30127644 PMCID: PMC6089117 DOI: 10.2147/cmar.s156379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose This study aimed to evaluate the short- and long-term outcomes of laparoscopic hepatectomy (LH) for colorectal liver metastases (CRLM) in elderly patients. Patients and methods Between January 2009 and January 2016, LH was performed for 241 consecutive patients who were ≥60 years old and had CRLM. Based on their age at the LH, the patients were divided into an elderly group (≥70 years old, 78 patients) and a middle-aged group (60–69 years old, 163 patients). The short- and long-term outcomes were compared between the two groups. Results Compared to the middle-aged group, the elderly group had higher values for Charlson comorbidity index, proportion of preoperative chemotherapy, and American Society of Anesthesiologists score. No other significant differences were observed in the preoperative characteristics. The elderly group had a higher conversion rate, compared to the middle-aged group, although no significant differences were observed in the surgical procedures, surgical times, intraoperative blood losses, numbers and severities of postoperative 90-day complications, postoperative 90-day mortality rates, pathology results, and other short-term outcomes. Long-term follow-up revealed similar rates of recurrence, disease-free survival, and overall survival in the two groups. Multivariable analysis revealed that age did not independently predict overall survival or disease-free survival. Conclusion Similar short- and long-term outcomes were observed after LH for CRLM in elderly and middle-aged patients. Thus, advanced age is not a contraindication for LH treatment in this setting.
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Affiliation(s)
- Meng Yue
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Shiquan Li
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Guoqiang Yan
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Chenyao Li
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Zhenhua Kang
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
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12
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Bruera G, Russo A, Galvano A, Rizzo S, Ricevuto E. Clinical parameters to guide decision-making in elderly metastatic colorectal CANCER patients treated with intensive cytotoxic and anti-angiogenic therapy. Oncotarget 2018; 8:37875-37883. [PMID: 28053287 PMCID: PMC5514958 DOI: 10.18632/oncotarget.14333] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 11/24/2016] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Bevacizumab addiction to triplet chemotherapy, according to FIr-B/FOx schedule, as first-line treatment in young-elderly metastatic colorectal CANCER (MCRC) patients may be more effective. Tailored treatments show worse clinical outcome in unfit patients. METHODS Elderly patients were clinically evaluated according to age and comorbidity (Cumulative Illness Rating Scale) to select FIr-B/FOx regimen in fit or tailored treatments in unfit elderly. Limiting toxicity syndromes (LTS) were evaluated. RESULTS At 17 months follow-up, in 28 young-elderly patients treated with first line FIr-B/FOx: objective response rate (ORR) 79%, progression-free survival (PFS) 11 months, overall survival (OS) 21 months. Clinical outcome was not significantly different according to KRAS genotype. G3-4 toxicities were diarrhea 21%, mucositis 11%, neutropenia 11%. LTS were 46%, significantly more multiple than single site. At 8 months follow-up, in 37 unfit patients: ORR 37%, PFS 7 months, OS 13 months. PFS was significantly different in KRAS wild-type compared to mutant patients, while not OS. PFS and OS were significantly worse in KRAS c.35 G > A compared to wild-type and/or other mutant. CONCLUSIONS Careful decision-making process including evaluation of patient's fitness, and individual safety should be included to select FIr-B/FOx intensive first line regimen in young-elderly MCRC patients. KRAS, and specifically c.35 G > A mutant genotype, may significantly affect clinical outcome in patients unfit for FIr-B/FOx.
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Affiliation(s)
- Gemma Bruera
- Oncology Territorial Care, S. Salvatore Hospital, Oncology Network ASL1 Abruzzo, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Russo
- Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Antonio Galvano
- Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Sergio Rizzo
- Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Enrico Ricevuto
- Oncology Territorial Care, S. Salvatore Hospital, Oncology Network ASL1 Abruzzo, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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13
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Synchronous colorectal liver metastases: focus on the elderly. Langenbecks Arch Surg 2017; 402:1223-1232. [DOI: 10.1007/s00423-017-1611-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 07/20/2017] [Indexed: 12/14/2022]
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14
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Leal JN, Sadot E, Gonen M, Lichtman S, Kingham TP, Allen PJ, DeMatteo RP, Jarnagin WR, D’Angelica MI. Operative morbidity and survival following hepatectomy for colorectal liver metastasis in octogenarians: a contemporary case matched series. HPB (Oxford) 2017; 19:162-169. [PMID: 27914765 PMCID: PMC5608029 DOI: 10.1016/j.hpb.2016.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/11/2016] [Accepted: 09/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical outcomes of octogenarians undergoing hepatectomy for colorectal liver metastases (CRLM) are poorly characterized. The current study evaluated operative morbidity, mortality and survival outcomes among a contemporary cohort of octogenarians. METHODS Patients undergoing their first hepatectomy for CRLM were identified from institutional databases and those ≥80 years old (y) were matched 1:1 to a group of patients <80 y. Data pertaining to surgical morbidity/mortality and survival were compared using standard statistical methods. RESULTS From 2002 to 2012, 1391 hepatectomies were performed for CRLM, 55 (4%) in patients ≥80 y. Major complications occurred twice as frequently among patients ≥80 y [10 (19%) ≥80 y versus 5 (9%) <80 y, (p = 0.270)]. No matched patient <80 y. died within 90 d of operation, whereas, 4 (7%) patients ≥80 y did, p = 0.125. Median follow-up was significantly longer for the <80 y group [44 (1-146) versus. 23 (0-102) mths, p = 0.006]. Probability of disease recurrence was not different between groups (p = 0.123) nor was the cumulative incidence of death from disease (p = 0.371). However, patients ≥80 y had significantly higher incidence of non-cancer related death (p = 0.012). CONCLUSIONS Hepatectomy for CRLM among well-selected octogenarians is reasonable with cancer related survival outcomes similar to those observed in younger patients. However, it is associated with clinically significant morbidity/mortality and continued efforts directed at optimizing perioperative care are necessary to improve early outcomes among octogenarians.
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Affiliation(s)
- Julie N. Leal
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Eran Sadot
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Mithat Gonen
- Department of Epidemiology/Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Stuart Lichtman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center
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15
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Nachmany I, Pencovich N, Zohar N, Goykhman Y, Lubezky N, Nakache R, Klausner JM. Resection of colorectal liver metastases in the elderly-Is it justified? J Surg Oncol 2016; 113:485-8. [DOI: 10.1002/jso.24188] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/17/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Ido Nachmany
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Niv Pencovich
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Nitzan Zohar
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Yaacov Goykhman
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Nir Lubezky
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Richard Nakache
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
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16
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Xie M, Zhu J, He X, Yang Z, Chen X, Lan P, Lian L. Liver Metastasis from Colorectal Cancer in the Elderly: Is Surgery Justified? Dig Dis Sci 2015; 60:3525-35. [PMID: 26173502 DOI: 10.1007/s10620-015-3789-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The elderly population with liver metastasis from colorectal cancer has been increasing. As the potentially curative treatment, the role of liver resection in the elderly remains undetermined. AIMS This study provides a meta-analysis on the outcome of liver resection of colorectal liver metastasis in patients aged over 70. METHODS PubMed, Embase, Ovid, Web of Science, and Cochrane databases from the years 2000 to 2015 were searched for eligible studies. Data on perioperative mortality, postoperative complications, and survival were collected. RESULTS Twelve retrospective studies with a total of 11,285 patients (2498 elderly patients and 8787 younger patients) were identified. The elderly (>70 years old) were associated with a similar overall complication rate (30.5 vs. 28.0%; OR 1.08; 95% CI 0.91-1.28; p = 0.39) and a higher 30-day mortality (OR 1.92; 95% CI 1.12-3.31; p = 0.02) after liver resection of colorectal liver metastasis (CRLM). The overall survival showed a significant difference in favor of the younger patients (HR 0.76; 95% CI 0.65-0.89; p = 0.0007). However, with regard to disease-free survival, there was no significant difference between elderly and younger patients (HR 0.93; 95% CI 0.82-1.06; p = 0.30). CONCLUSION Liver resection of CRLM is relatively safe in carefully selected elderly patients. Liver resection should be offered to selected elderly patients with CRLM.
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Affiliation(s)
- Minghao Xie
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jinling Zhu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xiaosheng He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zihuan Yang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xinlin Chen
- Department of Preventive Medicine and Biostatistics, Basic Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Abstract
The surgical procedure of two-thirds partial hepatectomy (PH) in rodents was first described more than 80 years ago by Higgins and Anderson. Nevertheless, this technique is still a state-of-the-art method for the community of liver researchers as it allows the in-depth analysis of signalling pathways involved in liver regeneration and hepatocarcinogenesis. The importance of PH as a key method in experimental hepatology has even increased in the last decade due to the increasing availability of genetically-modified mouse strains. Here, we propose a standard operating procedure (SOP) for the implementation of PH in mice, which is based on our experience of more than 10 years. In particular, the SOP offers all relevant background information on the PH model and provides comprehensive guidelines for planning and performing PH experiments. We provide established recommendations regarding optimal age and gender of animals, use of appropriate anaesthesia and biometric calculation of the experiments. We finally present an easy-to-follow step-by-step description of the complete surgical procedure including required materials, critical steps and postoperative management. This SOP especially takes into account the latest changes in animal welfare rules in the European Union but is still in agreement with current international regulations. In summary, this article provides comprehensive information for the legal application, design and implementation of PH experiments.
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Affiliation(s)
- Y A Nevzorova
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - R Tolba
- Institute for Laboratory Animal Science & Experimental Surgery, RWTH Aachen University, Aachen, Germany
| | - C Trautwein
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - C Liedtke
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany
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Major Hepatectomy for Colorectal Metastases in the Elderly: A Tertiary Center Experience. Int Surg 2015. [DOI: 10.9738/intsurg-d-14-00155.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this retrospective study was to investigate whether patients over 70 years old are at significantly higher risk for worse outcomes following major liver resection. Hepatic resection is the only treatment offering long-term survival for patients with colorectal liver metastases. As the population considered for metastasectomy is aging, there are still controversial published results regarding the safety of major hepatectomy in elderly patients. Between December 2002 and April 2010, 327 patients underwent major liver resection for colorectal liver metastasis. Patients were stratified into 2 groups: group A, <70 years old; and group B, ≥70 years old. Recorded, analyzed, and compared data across groups included the following: (1) patient characteristics including age, sex, American Society of Anesthesiologists performance status, primary tumor site and stage, adjuvant chemotherapy, number and size of metastatic lesions; (2) perioperative data including extent of resection, in-hospital mortality, postoperative morbidity, length of hospital stay, length of intensive treatment unit stay and blood loss; and (3) overall survival. The patients' characteristics were similar as were the characteristics of their tumors. There was no difference in overall morbidity (25% versus 22%) or postoperative mortality (2.6% versus 2.9%) (P = 0.44 and 0.57, respectively). The overall survival was 67% versus 62% in group A and B, respectively (P = 0.09). Elderly patients can safely undergo major liver resection for colorectal liver metastases with short- and long-term outcomes comparable with younger patients.
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Phan K, An VVG, Ha H, Phan S, Lam V, Pleass H. Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta-analysis. ANZ J Surg 2015; 85:815-22. [DOI: 10.1111/ans.13211] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Kevin Phan
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
- St Vincent's Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Vincent Vinh Gia An
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
| | - Hakeem Ha
- St Vincent's Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Steven Phan
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Vincent Lam
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
| | - Henry Pleass
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
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Liu DM, Thakor AS, Baerlocher M, Alshammari MT, Lim H, Kos S, Kennedy AS, Wasan H. A review of conventional and drug-eluting chemoembolization in the treatment of colorectal liver metastases: principles and proof. Future Oncol 2015; 11:1421-8. [PMID: 25602287 DOI: 10.2217/fon.15.3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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21
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Abstract
BACKGROUND With the increase in average life expectancy in recent decades, the proportion of elderly patients requiring liver surgery is rising. The aim of the meta-analysis reported here was to evaluate the safety and efficacy of hepatectomy in elderly patients. METHODS An extensive electronic search was performed for relevant articles that compare the outcomes of hepatectomy in patients ≥70 years of age with those in younger patients prior to October 2012. Analysis of pooled data was performed with RevMan 5.0. RESULTS Twenty-eight observational studies involving 15,480 patients were included in the analysis. Compared with the younger patients, elderly patients experienced more complications (31.8 vs 28.7 %; P = 0.002), mainly as a result of increased cardiac complications (7.5 vs 1.9 %; P < 0.001) and delirium (11.7 vs 4.5 %; P < 0.001). Postoperative major surgical complications (12.6 vs 11.3 %; P = 0.55) and mortality (3.6 vs 3.3 %; P = 0.68) were comparable between elderly and younger patients. For patients with malignancies, both the 5-year disease-free survival (26.5 vs 26.3 %; P = 0.60) and overall survival (39.5 vs 40.7 %; P = 0.29) did not differ significantly between the two groups. CONCLUSIONS Postoperative major surgical complications, mortality, and long-term results in elderly patients seem to be comparable with those in younger patients, suggesting that age alone should not be considered a contraindication for hepatectomy.
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Fernandes AI, Tralhão JG, Abrantes A, Hoti E, Alexandrino H, Oliveiros B, Ferreira M, Botelho MF, Sousa FC. Functional hepatocellular regeneration in elderly patients undergoing hepatectomy. Liver Int 2015; 35:1116-23. [PMID: 24325556 DOI: 10.1111/liv.12433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 12/03/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS More than 50% of liver tumours occur in patients aged 65 years or more. Assessment of functional liver regeneration capacity is crucial to minimize postoperative liver failure. We aimed to study functional hepatocellular regeneration, through scintigraphic quantification of Mebrofenin hepatic extraction fraction (HEF), after partial hepatectomy, comparing elderly patients with younger ones. METHODS One hundred and two patients undergoing partial hepatectomy for primary or secondary hepatic lesions were prospectively included and divided in two groups: Group A - 58 patients aged <65 years (33 men, 53.9 ± 8.7 years), Group B - 44 patients aged ≥65 years (32 men, 71 ± 5 years). Groups were comparable in several aspects except for the presence of cirrhosis (more common in Group B, all patients Child-Pugh score A) and the initial diagnosis (Group B - primary lesions, Group A - metastases). The scintigraphic evaluation of Mebrofenin-HEF was performed before surgery, on the 5th and 30th day post-hepatectomy. RESULTS Mortality and morbidity were 3.4 and 12.1%, respectively, in Group A and 2.3 and 11.4% in Group B (n.s.). HEF values (%), T1/2 (min) and Tmax (min) showed no significant differences between the two groups: Group A (preoperative: HEF = 99.2 ± 1.5%, T1/2 = 36.7 ± 21.3, Tmax = 15 ± 6. Day 5: HEF = 96.3 ± 10.8%, T1/2 = 76.4 ± 75.9; Tmax = 13.3 ± 4.9. Day 30: HEF = 98.4 ± 5.5%, T1/2 = 38.6 ± 7.7, Tmax = 12.8 ± 3.6) and Group B (preoperative: HEF = 95.3 ± 13%, T1/2 = 38.1 ± 24.1; Tmax = 15.9 ± 9.4. Day 5: HEF = 98.4 ± 2.6%, T1/2 = 106.6 ± 131.7; Tmax = 15.1 ± 6.2. Day 30: HEF = 99 ± 2.1%, T1/2 = 40.5 ± 27; Tmax = 15.5 ± 6.7). CONCLUSION Our results suggest that functional hepatocellular regeneration is early, fast and similar between elderly and younger patients. Thus, age alone, does not appear to represent an absolute contraindication to hepatectomy.
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Sulpice L, Rayar M, Campillo B, Pery C, Guillaud A, Meunier B, Boudjema K. Advanced age remains an achilles heel for liver resections. World J Surg 2014; 38:918-26. [PMID: 24337318 DOI: 10.1007/s00268-013-2367-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly. METHODS Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60-74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis. RESULTS Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60-74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5-15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2-6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044). CONCLUSIONS Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population.
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Affiliation(s)
- Laurent Sulpice
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, Rennes, France,
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Yang S, Alibhai SMH, Kennedy ED, El-Sedfy A, Dixon M, Coburn N, Kiss A, Law CHL. Optimal management of colorectal liver metastases in older patients: a decision analysis. HPB (Oxford) 2014; 16:1031-42. [PMID: 24961482 PMCID: PMC4487755 DOI: 10.1111/hpb.12292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 04/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients. METHODS A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters. RESULTS In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age. CONCLUSIONS HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.
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Affiliation(s)
- Simon Yang
- Division of General Surgery, University of TorontoToronto, ON
| | - Shabbir MH Alibhai
- Department of Medicine, University Health NetworkToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON
| | - Erin D Kennedy
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Mount Sinai HospitalToronto, ON
| | - Abraham El-Sedfy
- Department of Surgery, Saint Barnabas Medical CenterLivingston, NJ
| | - Matthew Dixon
- Department of Surgery, Maimonides Medical CenterBrooklyn, NY
| | - Natalie Coburn
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON
| | - Alex Kiss
- Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Institute for Clinical Evaluative SciencesToronto, ON
| | - Calvin HL Law
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON,Correspondence, Calvin H.L. Law, Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite T2-025, Toronto, Ontario, Canada M4N 3M5. Tel: +1 416 480 4825. Fax: +1 416 480 5804. E-mail:
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Vargas GM, Parmar AD, Sheffield KM, Tamirisa NP, Brown KM, Riall TS. Impact of liver-directed therapy in colorectal cancer liver metastases. J Surg Res 2014; 191:42-50. [PMID: 24990539 DOI: 10.1016/j.jss.2014.05.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/20/2014] [Accepted: 05/23/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy. METHODS We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization. RESULTS We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age >85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period. CONCLUSIONS Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.
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Affiliation(s)
- Gabriela M Vargas
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas.
| | - Abhishek D Parmar
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kristin M Sheffield
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Nina P Tamirisa
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kimberly M Brown
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
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Bruera G, Cannita K, Giordano AV, Vicentini R, Ficorella C, Ricevuto E. Prognostic relevance of KRAS genotype in metastatic colorectal cancer patients unfit for FIr-B/FOx intensive regimen. Int J Oncol 2014; 44:1820-30. [PMID: 24715238 PMCID: PMC4063538 DOI: 10.3892/ijo.2014.2369] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/07/2014] [Indexed: 11/06/2022] Open
Abstract
First-line triplet chemotherapy plus bevacizumab (FIr-B/FOx) can improve efficacy of metastatic colorectal cancer (MCRC), KRAS wild-type and mutant. Prognostic relevance of KRAS genotype was evaluated in patients unfit for FIr-B/FOx, treated with conventional medical treatments. Consecutive MCRC patients not eligible for FIr-B/FOx regimen due to age (≥75 years) and/or comorbidities were treated with tailored conventional first-line treatments. KRAS codon 12/13 mutations were screened by direct sequencing. Activity and efficacy were evaluated and compared according to medical treatments, age (non-elderly and elderly≥65 years), comorbidity stage (Cumulative Illness Rating Scale), metastatic extension (liver-limited and other/multiple metastatic), and KRAS genotype, using log-rank. Selected first line treatments were medical in 37 patients (92.5%), and surgical in 3 patients (7.5%). Medical treatment regimens: triplet, 18 (45%); doublet, 15 (37.5%); mono-therapy, 4 (10%). At median follow-up of 8 months, objective response rate (ORR) was 37%, median progression-free survival (PFS) 7 months, liver metastasectomies 8% (liver-limited disease 37.5%), median overall survival (OS) 13 months. Triplet regimens failed to significantly affect clinical outcome, compared to doublet. According to KRAS genotype, ORR, PFS and OS were, respectively: wild-type 50%, 8 months, 13 months; mutant 25%, 6 months, 9 months. KRAS genotype wild-type compared to mutant significantly affected PFS, while not OS. KRAS c.35 G>A mutation (G12D) significantly affected worse PFS and OS compared to wild-type and/or other mutations. KRAS genotype, specifically the c.35 G>A KRAS mutation, may indicate poor prognosis in MCRC patients unfit for intensive medical treatments.
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Affiliation(s)
- Gemma Bruera
- Medical Oncology, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
| | - Katia Cannita
- Medical Oncology, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
| | - Aldo Victor Giordano
- Radiology, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
| | - Roberto Vicentini
- Hepatobiliar-Pancreatic Surgery, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
| | - Corrado Ficorella
- Medical Oncology, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
| | - Enrico Ricevuto
- Medical Oncology, S. Salvatore Hospital, University of L'Aquila, I-67100 L'Aquila, Italy
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Effectiveness and safety of intensive triplet chemotherapy plus bevacizumab, FIr-B/FOx, in young-elderly metastatic colorectal cancer patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:143273. [PMID: 24307987 PMCID: PMC3838846 DOI: 10.1155/2013/143273] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/31/2013] [Accepted: 09/13/2013] [Indexed: 12/30/2022]
Abstract
Four-drug regimens, such as FIr-B/FOx schedule, can improve efficacy of first-line treatment of metastatic colorectal cancer (MCRC) patients. The present study specifically evaluates feasibility of FIr-B/FOx first-line intensive regimen in fit young-elderly MCRC patients, representing approximately 40% of overall MCRC patients. Activity, efficacy, and safety were equivalent to overall MCRC patients, not significantly different according to KRAS genotype. Clinical outcome was significantly prolonged in liver-limited compared to other/multiple metastatic disease. Safety evaluation of the individual young-elderly patient showed that limiting toxicity syndromes (LTS) in multiple sites were significantly increased, compared to LTS in single site, with respect to non-elderly patients.
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Rosati G. Combination therapy for older men with colorectal cancer: are two drugs better than one? Expert Rev Anticancer Ther 2013; 13:1013-6. [PMID: 24053200 DOI: 10.1586/14737140.2013.826984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Gerardo Rosati
- Medical Oncology Unit, S. Carlo Hospital, Via P. Petrone, 1, 85100 Potenza, Italy +39 0971 612273 +39 0971 613000
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Orcutt ST, Artinyan A, Li LT, Silberfein EJ, Berger DH, Albo D, Anaya DA. Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population-level analysis of 4026 patients. HPB (Oxford) 2012; 14:863-70. [PMID: 23134189 PMCID: PMC3521916 DOI: 10.1111/j.1477-2574.2012.00577.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 08/23/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases. METHODS A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge). RESULTS A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11). CONCLUSIONS Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.
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Affiliation(s)
- Sonia T Orcutt
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA
| | - Avo Artinyan
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Operative Care Line, Michael E. DeBakey Veterans Affairs Medical CenterHouston, TX, USA
| | - Linda T Li
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
| | - Eric J Silberfein
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,General Surgery, Ben Taub General HospitalHouston, TX, USA
| | - David H Berger
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
| | - Daniel Albo
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA
| | - Daniel A Anaya
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
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Cook EJ, Welsh FKS, Chandrakumaran K, John TG, Rees M. Resection of colorectal liver metastases in the elderly: does age matter? Colorectal Dis 2012; 14:1210-6. [PMID: 22251850 DOI: 10.1111/j.1463-1318.2012.02946.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases decreases dramatically in the elderly. Is this referral or selection bias justified? METHOD A prospective database of resection for colorectal liver metastases at a single centre was retrospectively analysed to compare the outcome in patients aged ≥75 years (group E) with those aged <75 years (group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling. RESULTS Of 1443 resections, 151 (10.5%) in group E were compared with 1292 (89.5%) in group Y. The two groups were matched apart from higher American Society of Anesthesiology scores (P=0.001) and less use of chemotherapy (P=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5%vs 21.2%, P=0.02, and 7.3%vs 1.3%, P=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from that of the younger patients [n=2/76 (2.6%) vs n=9/559 (1.6%); P=0.063]. The 5-year survival was similar in groups E and Y for cancer-specific (41.4%vs 41.6%, P=0.917), overall (37.0%vs 38.2%) and median (44.1 months vs 43.6 months, P=0.697) survival respectively. CONCLUSION In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.
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Affiliation(s)
- E J Cook
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Foundation Trust, Basingstoke, Hampshire, UK
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Surgical treatment of perihilar cholangiocarcinoma in octogenarians: a single center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 20:324-31. [DOI: 10.1007/s00534-012-0529-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Approximately 20-25% of patients with colorectal cancer present with liver metastases at the time of diagnosis. Traditionally, resection of the primary tumor has been advocated in order to prevent complications of the primary tumor colorectal cancer in patients with synchronous liver metastases. The published data concerning long-term prognosis in this group of patients are discordant. Although some of the reports show survival benefits from resection of the primary tumor, these studies are retrospective with small number of patients and using single drug chemotherapy. For patients with resectable liver metastases, new studies indicate that progression-free survival is best in patients receiving perioperative chemotherapy. In patients with synchronous nonresectable liver metastases and colorectal cancer, there is no published prospective randomized study comparing initial surgery of the primary tumor with neoadjuvant chemotherapy. However, recent publications show that in patients receiving chemotherapy based on oxaliplatin or irinotecan combined with targeted treatments, the complications associated with the primary tumor are less than 10%. The conclusion should be that today prophylactic surgery of asymptomatic primary colorectal cancer in patients with liver metastases cannot be recommended.
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Affiliation(s)
- Bengt Gustavsson
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Göteborg, Sweden.
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Kulik U, Framke T, Grosshennig A, Ceylan A, Bektas H, Klempnauer J, Lehner F. Liver resection of colorectal liver metastases in elderly patients. World J Surg 2011; 35:2063-72. [PMID: 21717239 DOI: 10.1007/s00268-011-1180-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection remains the only curative therapy; data evaluating the outcome in this age group is limited. Aim of the present study was to determine if postoperative morbidity, mortality, and other independent predictors influence survival in patients ≥ 70 years undergoing liver resection for CLM. METHODS Clinical data on primary tumor and metastases of 939 patients after liver resection for CLM between 1994 and 2008 were retrospectively collected and subdivided in three age-groups (≥ 70, 40-69, <40). Independent predictors of survival were evaluated with overall and age-specific univariate and multivariate Cox regression models. RESULTS A total of 939 patients underwent liver resection for CLM, 20.3% aged ≥ 70 years. Overall postoperative mortality and morbidity were 1.08 and 14.82%, revealing no age-related differences. With 5-year survival of 31.8% in the elderly and 37.5% in the mid-age population, age ≥ 70 years was linked with decreased survival (Hazard Ratio [HR] = 1.305; P = 0.0186). Multivariate overall analyses showed size of CLM > 50 mm (HR = 1.376; P = 0.0060), a high amount of transfusion during surgery (HR = 1.676; P = 0.0110), duration of surgery >210 min (HR = 1.241; P = 0.0322), primary UICC (International Union Against Cancer) stage IV (HR = 2.297; P < 0.0001), and performance of repeat resections (HR = 0.652; P = 0.0107) as independent predictors of survival. In the elderly group, effects of UICC IV (HR = 3.260; P = 0.0148) and high numbers of transfusions (HR = 3.647; P = 0.0129) were confirmed; the others did not show statistical significance. CONCLUSIONS Resection of CLM at older age is feasible with morbidity and mortality rates similar to those in younger patients. Although age ≥ 70 was shown to be associated with poorer overall outcome, reasonable 5-year survival was observed.
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Affiliation(s)
- U Kulik
- Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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Abstract
Cancer incidence and mortality rise exponentially in the elderly. With the aging of the population there is an urgent need to address this issue with evidence-based guidelines. Delayed diagnosis and incomplete workup and treatment are well documented in this population. Incorporation of a geriatric evaluation in oncology practice should be routinely implemented to prevent adverse outcomes. Treatment decisions in the elderly should not be based solely on survival gains but should also take quality of life into consideration. Cancer treatment is safe and effective in the elderly population. Social issues and other comorbidities should be addressed to improve compliance and outcome. Many unanswered questions regarding the optimal management of elderly cancer patients can be addressed only with the new clinical trials. Eliminating age bias among health care providers by providing education will help achieve optimal care for the elderly with cancer.
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Affiliation(s)
- Deepak Kilari
- Department of Medicine, Hematology/Oncology, James P. Wilmot Cancer Center, University of Rochester, Rochester, NY 14642, USA
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Sánchez-Hidalgo JM, Naranjo A, Ciria R, Ranchal I, Aguilar-Melero P, Ferrín G, Valverde A, Rufián S, López-Cillero P, Muntané J, Briceño J. Impact of age on liver regeneration response to injury after partial hepatectomy in a rat model. J Surg Res 2011; 175:e1-9. [PMID: 22341343 DOI: 10.1016/j.jss.2011.11.1022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 10/12/2011] [Accepted: 11/17/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND Liver resection is a feasible treatment for multiple liver diseases. There is no evidence about the impact of age on liver regeneration. OBJECTIVE To assess the effect of age on liver regeneration in an experimental in vivo animal model of 70%-partial hepatectomy. METHODS Forty young (Y) and old (O) Wistar male rats (n = 80) were distributed into four groups [controls (C), sham operated (SO), hepatectomy 6 h (H6), and 48 h (H48)]. Different morphometric and biochemical factors, oxidative and nitrosative stress, lipid peroxidation, cytokines kinetics, and histopathologic tissular parameters were determined. RESULTS Early postoperative mortality was higher in aged rats (P = 0.049). Morphometric determinations, liver regeneration index, and total volume weight were favorable to young rats. Serum transaminase levels were higher in aged rats. Parameters of necrosis (measured by histopathologic injury [HI: 0-I-II-III]), regeneration (measured by bromodeoxyuridine-BrdU incorporation) and apoptosis (determined by the TDT-mediated dUTP nick end labeling-TUNEL) were well-synchronized in young rats. Parameters of oxidative stress such as reduced (GSH), oxidized (GSSG) glutathione and lipid peroxidation (measured by hepatic malondialdehyde -MDA-) were lower in young animals throughout the studied period. Nitrosative stress measured by nitric oxide (NO) end-products was higher in late stages in resected old rats. Pro-inflammatory cytokines (TNF- α) reached higher and earlier levels in aged rats while pro-regenerative cytokines (IL-6) were significantly higher in early stages for young rats and in late stages for aged rats. The levels of TGF-β were higher in young rats. CONCLUSION Liver regeneration is delayed and reduced in aged animals submitted to liver resection.
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Reddy SK, Clary BM. A New Era in Defining Indications for Resectability of Colorectal Cancer Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2010. [DOI: 10.1007/s11888-010-0049-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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de Haas RJ, Wicherts DA, Salloum C, Andreani P, Sotirov D, Adam R, Castaing D, Azoulay D. Long-term outcomes after hepatic resection for colorectal metastases in young patients. Cancer 2010; 116:647-58. [PMID: 19998351 DOI: 10.1002/cncr.24721] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Long-term outcomes after hepatectomy for colorectal liver metastases in relatively young patients are still unknown. The aim of the current study was to evaluate long-term outcomes in patients < or = 40 years old, and to compare them with patients >40 years old. METHODS All consecutive patients who underwent hepatectomy for colorectal liver metastases at the authors' hospital between 1990 and 2006 were included in the study. Patients < or = 40 years old were compared with all other patients treated during the same period. Overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS) rates were determined, and prognostic factors were identified. RESULTS In total, 806 patients underwent hepatectomy for colorectal liver metastases, of whom 56 (7%) were aged < or = 40 years. Among the young patients, more colorectal liver metastases were present at diagnosis, and they were more often diagnosed synchronous with the primary tumor. Five-year OS was 33% in young patients, compared with 51% in older patients (P = .12). Five-year PFS was 2% in young patients, compared with 16% in older patients (P < .001). DFS rates were comparable between the groups (17% vs 23%, P = .10). At multivariate analysis, age < or = 40 years was identified as an independent predictor of poor PFS. CONCLUSIONS In young patients, colorectal liver metastases seem to be more aggressive, with a trend toward lower OS, more disease recurrences, and a significantly shorter PFS after hepatectomy. However, DFS rates were comparable between young and older patients, owing to an aggressive multimodality treatment approach, consisting of chemotherapy and repeat surgery. Therefore, physicians should recognize the poor outcome of colorectal liver metastases in young patients and should consider an aggressive approach to diagnosis and early treatment.
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Affiliation(s)
- Robbert J de Haas
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Adam R, Frilling A, Elias D, Laurent C, Ramos E, Capussotti L, Poston GJ, Wicherts DA, de Haas RJ. Liver resection of colorectal metastases in elderly patients. Br J Surg 2010; 97:366-76. [DOI: 10.1002/bjs.6889] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
This study evaluated the outcome of liver surgery for colorectal metastases (CLM) in patients over 70 years old in a large international multicentre cohort.
Methods
Among 7764 patients who had resection of CLM, 999 (12·9 per cent) were aged 70–75 years, 468 (6·0 per cent) were aged 75–80 years and 157 (2·0 per cent) were at least 80 years old. Elderly patients were compared with the younger population.
Results
Multinodular and bilateral metastases were less common in elderly than in younger patients (P < 0·001). Preoperative chemotherapy was used less frequently and more limited surgery was performed (P < 0·001). Sixty-day postoperative mortality and morbidity rates were 3·8 and 32·3 per cent respectively, compared with 1·6 and 28·7 per cent in younger patients (both P < 0·001). Three-year overall survival was 57·1 per cent in elderly and 60·2 per cent in younger patients (P < 0·001), and was similar among patients aged 70–75, 75–80 or at least 80 years (57·8, 55·3 and 54·1 per cent respectively; P = 0·160). Independent predictors of survival were more than three metastases, bilateral metastases, concomitant extrahepatic disease and no postoperative chemotherapy.
Conclusion
Liver resection for CLM in elderly patients can achieve a reasonable 3-year survival rate, with an acceptable morbidity rate. There should be no upper age limit but risk factors may help predict potential benefit.
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Affiliation(s)
- R Adam
- Hepatobiliary Centre, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, University Paris-Sud, Unité Mixte de Recherche S 776, France
| | - A Frilling
- Department of Surgery, Essen University Hospital, Essen, Germany
| | - D Elias
- Department of Surgery, Institute Gustave Roussy, Villejuif, France
| | - C Laurent
- Department of Surgery, Hôpital Saint André, Bordeaux, France
| | - E Ramos
- Department of Surgery, University Hospital Bellvitge, Barcelona, and Hospital de Girona, Girona, Spain
| | - L Capussotti
- Department of Hepato-Biliary-Pancreatic and Digestive Surgery, Ospedale Mauriziano Umberto I, Torino, Italy
| | - G J Poston
- Department of Surgery, University Hospital Aintree, Liverpool, UK
| | - D A Wicherts
- Hepatobiliary Centre, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, University Paris-Sud, Unité Mixte de Recherche S 776, France
| | - R J de Haas
- Hepatobiliary Centre, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, University Paris-Sud, Unité Mixte de Recherche S 776, France
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Pallis AG, Papamichael D, Audisio R, Peeters M, Folprecht G, Lacombe D, Van Cutsem E. EORTC Elderly Task Force experts' opinion for the treatment of colon cancer in older patients. Cancer Treat Rev 2009; 36:83-90. [PMID: 19944536 DOI: 10.1016/j.ctrv.2009.10.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 10/28/2009] [Accepted: 10/29/2009] [Indexed: 02/07/2023]
Abstract
As a result of an increasing life expectancy, the incidence of colon cancer in the older population is rising. As a consequence oncologists and their older patients commonly face the dilemma of whether or not to give/receive treatment for colon cancer. However, the paucity of large, well conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The current evidence supports the safety and efficacy of treatment for colon cancer in fit older patients and demonstrates that treatment outcome can be similar to that of their younger counterparts. However, it should be noted that these data are derived from retrospective studies which are likely to suffer from selection bias. Despite a growing body of data, further work is still needed to establish optimal strategies to care for this special population and prospective specific trials for older colon cancer patients are clearly needed.
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Affiliation(s)
- A G Pallis
- EORTC Headquarters, EORTC-Elderly Task Force, Brussels, Belgium.
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Spiliotis J, Datsis AC, Vaxevanidou A, Lambropoulou E, Voutsina A, Chrysanthopoulos K, Zacharis G. Role of age on the outcome of liver surgery. A single institution experience. SURGICAL PRACTICE 2009. [DOI: 10.1111/j.1744-1633.2009.00437.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Mitry E, Rougier P. Review article: benefits and risks of chemotherapy in elderly patients with metastatic colorectal cancer. Aliment Pharmacol Ther 2009; 29:161-71. [PMID: 18945257 DOI: 10.1111/j.1365-2036.2008.03867.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although metastatic colorectal cancer (mCRC) is largely a disease of older individuals, our understanding of disease processes and their optimal treatment has been gained through trials with populations largely confined to younger individuals. AIM To identify through a review issues specific to geriatric patients with mCRC (physiological changes associated with aging, burden of coexisting illnesses, altered drug pharmacokinetics and functional impairment) and assess challenges to elderly patients posed by malignancy and exposure to cytotoxic medication. METHODS Our literature search for indexed articles published between 2000 and May 2008 employed terms including irinotecan, oxaliplatin, elderly, mCRC, targeted agents and biologicals. RESULTS Underrepresentation of older patients in clinical trials makes it difficult to extrapolate findings to older age groups. However, some trials have demonstrated that elderly patients can achieve survival benefits and toxicity comparable to younger patients, although dosage modifications may be required. CONCLUSIONS Currently, benefits with pharmacological therapy are suggested but not proven in the elderly population. Although concurrent illnesses and disabilities can complicate treatment decision making, chronological age alone should not disqualify these patients with mCRC from receiving optimal treatment similar to that offered to their younger cohorts.
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Affiliation(s)
- E Mitry
- UFR Médecine Paris Ile de France Ouest, Université Versailles Saint-Quentin, EA4340, Hôpital Ambroise Paré, APHP, Boulogne, France.
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Abstract
BACKGROUND AND AIMS As the mean life expectancy rises, the incidence of patients 75 years of age and older who present with colorectal liver metastases continues to increase. The purpose of our study was to evaluate the outcome of major hepatic resections in the elderly population. PATIENT AND METHODS From April 1998 to December 2006, 572 consecutive patients with colorectal liver metastases were treated at our Institution. Of these, 59 were 75 years or older. There was an intent to proceed with major liver resections in all cases. Data were analyzed according to diagnosis, comorbidities, extent of liver resection, postoperative complications, overall survival, and disease-free survival. RESULTS Surgical treatment included right hepatectomies (n = 8), left hepatectomies (n = 4), and sectionectomies (more than three segments; n = 33). Fourteen (n = 14) patients received an explorative laparotomy alone. Morbidity and hospital mortality were 10% and 3%, respectively. Overall survival of 1, 3, and 5 years was 90%, 64%, and 33%, respectively. The corresponding disease-free survival was 74%, 42%, and 32%. Resection margin (R class) was the only predictor of survival by both uni- and multivariate analyses. CONCLUSION Hepatic resections can be performed safely in selected patients 75 years of age or older.
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Poston GJ, Figueras J, Giuliante F, Nuzzo G, Sobrero AF, Gigot JF, Nordlinger B, Adam R, Gruenberger T, Choti MA, Bilchik AJ, Van Cutsem EJD, Chiang JM, D'Angelica MI. Urgent need for a new staging system in advanced colorectal cancer. J Clin Oncol 2008; 26:4828-33. [PMID: 18711170 DOI: 10.1200/jco.2008.17.6453] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite recent advances in the medical treatment of metastatic colorectal cancer (mCRC), which include irinotecan- and oxaliplatin-based first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the increasing use of targeted monoclonal antibodies, 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with CRC liver metastases, liver resection remains the only chance of cure, with 5-year survival rates ranging from 25% to 40%. However, 80% to 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. The rapid expansion in the use of improved combination chemotherapy regimens plus or minus biologics, to render initially unresectable metastases resectable has increased the percentage of patients eligible for potentially curative surgery. However, the current staging criteria for CRC patients with metastatic disease do not reflect these recent changes or the fact that there is also a large variation in the survival of patients with stage IV CRC. For example the survival for a patient with a solitary, resectable liver metastasis is better than that for a patient with stage III disease. A new staging system is therefore needed that acknowledges both the improvements that have been made in surgical techniques for resectable metastases and the impact of modern chemotherapy on rendering initially unresectable CRC liver metastases resectable, while at the same time distinguishing between patients with a chance of cure at presentation and those for whom only palliative treatment is possible.
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Affiliation(s)
- Graeme J Poston
- Department of Surgery, University Hospital Aintree, Liverpool, L9 7AL, United Kingdom.
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Grothey E, Gibson TB, Chu E. Highlights from: The 2008 American Society of Clinical Oncology Gastrointestinal Cancers Symposium; Orlando, FL; January 25-27, 2008. Clin Colorectal Cancer 2008. [DOI: 10.1016/s1533-0028(11)70415-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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González HD, Figueras J. Practical questions in liver metastases of colorectal cancer: general principles of treatment. HPB (Oxford) 2007; 9:251-8. [PMID: 18345300 PMCID: PMC2215392 DOI: 10.1080/13651820701457992] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Indexed: 12/12/2022]
Abstract
Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.
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Affiliation(s)
- Héctor Daniel González
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital Josep TruetaGironaSpain
| | - Joan Figueras
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital Josep TruetaGironaSpain
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