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Ilyas MIM. Epidemiology of Stage IV Colorectal Cancer: Trends in the Incidence, Prevalence, Age Distribution, and Impact on Life Span. Clin Colon Rectal Surg 2024; 37:57-61. [PMID: 38322602 PMCID: PMC10843881 DOI: 10.1055/s-0043-1761447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Colorectal cancer is a common malignancy in men and women. Historically, stage IV colorectal cancer has 10 to 15% five-year survival. Developments in the management of colorectal metastatic disease have helped improve the overall survival of stage IV colorectal cancers from 12 to 30 months with some patients achieving disease-free survival.
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Lehtomäki K, Soveri LM, Osterlund E, Lamminmäki A, Uutela A, Heervä E, Halonen P, Stedt H, Aho S, Muhonen T, Ålgars A, Salminen T, Kallio R, Nordin A, Aroviita L, Nyandoto P, Kononen J, Glimelius B, Ristamäki R, Isoniemi H, Osterlund P. Resectability, Resections, Survival Outcomes, and Quality of Life in Older Adult Patients with Metastatic Colorectal Cancer (the RAXO-Study). J Clin Med 2023; 12:jcm12103541. [PMID: 37240646 DOI: 10.3390/jcm12103541] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Older adults are underrepresented in metastatic colorectal cancer (mCRC) studies and thus may not receive optimal treatment, especially not metastasectomies. The prospective Finnish real-life RAXO-study included 1086 any organ mCRC patients. We assessed repeated centralized resectability, overall survival (OS), and quality of life (QoL) using 15D and EORTC QLQ-C30/CR29. Older adults (>75 years; n = 181, 17%) had worse ECOG performance status than adults (<75 years, n = 905, 83%), and their metastases were less likely upfront resectable. The local hospitals underestimated resectability in 48% of older adults and in 34% of adults compared with the centralized multidisciplinary team (MDT) evaluation (p < 0.001). The older adults compared with adults were less likely to undergo curative-intent R0/1-resection (19% vs. 32%), but when resection was achieved, OS was not significantly different (HR 1.54 [CI 95% 0.9-2.6]; 5-year OS-rate 58% vs. 67%). 'Systemic therapy only' patients had no age-related survival differences. QoL was similar in older adults and adults during curative treatment phase (15D 0.882-0.959/0.872-0.907 [scale 0-1]; GHS 62-94/68-79 [scale 0-100], respectively). Complete curative-intent resection of mCRC leads to excellent survival and QoL even in older adults. Older adults with mCRC should be actively evaluated by a specialized MDT and offered surgical or local ablative treatment whenever possible.
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Grants
- 2016, 2018, 2019, 2020, 2021, 2022, 2023 Finska Läkaresällskapet
- 2019-2020, 2021, 2022-23 Finnish Cancer Foundation
- 2023 Swedish Cancer Society
- 2022-2023 Radium Hemmets Research Funds
- 2020-2022 Relander's Foundation
- 2016, 2017, 2018, 2019, 2020, 2021,2022, 2023 Competitive State Research Financing of the Expert Responsibility Area of Tampere, Helsinki and Turku
- Tukisäätiö 2019, 2020; OOO 2020 Tampere University Hospital
- 2019, 2020, 2021, 2022 Helsinki University Hospital
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Affiliation(s)
- Kaisa Lehtomäki
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Leena-Maija Soveri
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Home Care, Joint Municipal Authority for Health Care and Social Services in Keski-Uusimaa, 05850 Hyvinkää, Finland
| | - Emerik Osterlund
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Annamarja Lamminmäki
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Aki Uutela
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Eetu Heervä
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Päivi Halonen
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Hanna Stedt
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Sonja Aho
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Timo Muhonen
- Department of Oncology, South Carelia Central Hospital, Valto Käkelän Katu 1, 53130 Lappeenranta, Finland
| | - Annika Ålgars
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Tapio Salminen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Raija Kallio
- Department of Oncology, Oulu University Hospital, Kajaanintie 50, 90220 Oulu, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Laura Aroviita
- Department of Oncology, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland
| | - Paul Nyandoto
- Department of Oncology, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Juha Kononen
- Docrates Cancer Centre, Docrates Hospital, Saukonpaadenranta 2, 00180 Helsinki, Finland
- Department of Oncology, Central Finland Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Raija Ristamäki
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Helena Isoniemi
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Pia Osterlund
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Department of Gastrointestinal Oncology, Tema Cancer, Karolinska Universitetssjukhuset, Eugeniavägen 3, 17176 Solna, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solnavägen 1, 17177 Solna, Sweden
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Fonseca AL, Payne IC, Wong SL, Tan MCB. Surgical Resection of Colorectal Liver Metastases: Attitudes and Practice Patterns in the Deep South. J Gastrointest Surg 2022; 26:782-790. [PMID: 34647225 DOI: 10.1007/s11605-021-05159-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/04/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Metastatic disease is the leading cause of mortality in colorectal cancer. Resection of colorectal liver metastases, when possible, is associated with improved long-term survival and the possibility of cure. However, nationwide studies suggest that liver resection is under-utilized in the treatment of colorectal liver metastases. This study was undertaken to understand attitudes and practice patterns among medical oncologists in the Deep South. METHODS A survey of medical oncologists in the states of Alabama, Mississippi, and the Florida panhandle was performed. Respondents were queried regarding perceptions of resectability and attitudes towards surgical referral. RESULTS We received 63 responses (32% response rate). Fifty percent of respondents reported no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic metastatic disease (72%), presence of > 4 metastases (72%), bilobar metastases (61%), and metastases > 5 cm (46%). Bilobar metastatic disease was perceived as a contraindication more frequently by non-academic medical oncologists (70% vs. 33%, p = 0.03). CONCLUSIONS Wide variations exist in perceptions of resectability and referral patterns for colorectal liver metastases among surveyed medical oncologists. There is a need for wider dissemination of resectability criteria and more liver surgeon involvement in the management of patients with colorectal liver metastases.
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Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, University of South Alabama, 2451 USA Medical Center Drive, Mobile, AL, 36617, USA.
| | - Isaac C Payne
- Department of Surgery, University of South Alabama, 2451 USA Medical Center Drive, Mobile, AL, 36617, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth - Hitchcock Medical Center, Lebanon, NH, USA
| | - Marcus C B Tan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Raoof M, Jutric Z, Haye S, Ituarte PHG, Zhao B, Singh G, Melstrom L, Warner SG, Clary B, Fong Y. Systematic failure to operate on colorectal cancer liver metastases in California. Cancer Med 2020; 9:6256-6267. [PMID: 32687265 PMCID: PMC7476837 DOI: 10.1002/cam4.3316] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/18/2020] [Accepted: 07/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Despite evidence that liver resection improves survival in patients with colorectal cancer liver metastases (CRCLM) and may be potentially curative, there are no population‐level data examining utilization and predictors of liver resection in the United States. Methods This is a population‐based cross‐sectional study. We abstracted data on patients with synchronous CRCLM using California Cancer Registry from 2000 to 2012 and linked the records to the Office of Statewide Health Planning Inpatient Database. Quantum Geographic Information System (QGIS) was used to map liver resection rates to California counties. Patient‐ and hospital‐level predictors were determined using mixed‐effects logistic regression. Results Of the 24 828 patients diagnosed with stage‐IV colorectal cancer, 16 382 (70%) had synchronous CRCLM. Overall liver resection rate for synchronous CRCLM was 10% (county resection rates ranging from 0% to 33%) with no improvement over time. There was no correlation between county incidence of synchronous CRCLM and rate of resection (R2 = .0005). On multivariable analysis, sociodemographic and treatment‐initiating‐facility characteristics were independently associated with receipt of liver resection after controlling for patient disease‐ and comorbidity‐related factors. For instance, odds of liver resection decreased in patients with black race (OR 0.75 vs white) and Medicaid insurance (OR 0.62 vs private/PPO); but increased with initial treatment at NCI hospital (OR 1.69 vs Non‐NCI hospital), or a high volume (10 + cases/year) (OR 1.40 vs low volume) liver surgery hospital. Conclusion In this population‐based study, only 10% of patients with liver metastases underwent liver resection. Furthermore, the study identifies wide variations and significant population‐level disparities in the utilization of liver resection for CRCLM in California.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Zeljka Jutric
- Department of Surgery, University of California Irvine, Irvine, CA, USA
| | - Sidra Haye
- Department of Economics, University of California Irvine, Irvine, CA, USA
| | - Philip H G Ituarte
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Beiqun Zhao
- Department of Surgery, University of San Diego, San Diego, CA, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Bryan Clary
- Department of Surgery, University of San Diego, San Diego, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Engstrand J, Strömberg C, Nilsson H, Freedman J, Jonas E. Synchronous and metachronous liver metastases in patients with colorectal cancer-towards a clinically relevant definition. World J Surg Oncol 2019; 17:228. [PMID: 31878952 PMCID: PMC6933908 DOI: 10.1186/s12957-019-1771-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
Background Approximately 25% of patients with colorectal cancer (CRC) will have liver metastases classified as synchronous or metachronous. There is no consensus on the defining time point for synchronous/metachronous, and the prognostic implications thereof remain unclear. The aim of the study was to assess the prognostic value of differential detection at various defining time points in a population-based patient cohort and conduct a literature review of the topic. Methods All patients diagnosed with CRC in the counties of Stockholm and Gotland, Sweden, during 2008 were included in the study and followed for 5 years or until death to identify patients diagnosed with liver metastases. Patients with liver metastases were followed from time of diagnosis of liver metastases for at least 5 years or until death. Different time points defining synchronous/metachronous detection, as reported in the literature and identified in a literature search of databases (PubMed, Embase, Cochrane library), were applied to the cohort, and overall survival was calculated using Kaplan-Meier curves and compared with log-rank test. The influence of synchronously or metachronously detected liver metastases on disease-free and overall survival as reported in articles forthcoming from the literature search was also assessed. Results Liver metastases were diagnosed in 272/1026 patients with CRC (26.5%). No statistically significant difference in overall survival for synchronous vs. metachronous detection at any of the defining time points (CRC diagnosis/surgery and 3, 6 and 12 months post-diagnosis/surgery) was demonstrated for operated or non-operated patients. In the literature search, 41 publications met the inclusion criteria. No clear pattern emerged regarding the prognostic significance of synchronous vs. metachronous detection. Conclusion Synchronous vs. metachronous detection of CRC liver metastases lacks prognostic value. Using primary tumour diagnosis/operation as standardized cut-off point to define synchronous/metachronous detection is semantically correct. In synchronous detection, it defines a clinically relevant group of patients where individualized multimodality treatment protocols will apply.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden.
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Nilsson
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden
| | - Eduard Jonas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
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Affiliation(s)
- Bengt Glimelius
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Engstrand J, Kartalis N, Strömberg C, Broberg M, Stillström A, Lekberg T, Jonas E, Freedman J, Nilsson H. The Impact of a Hepatobiliary Multidisciplinary Team Assessment in Patients with Colorectal Cancer Liver Metastases: A Population-Based Study. Oncologist 2017; 22:1067-1074. [PMID: 28550028 PMCID: PMC5599196 DOI: 10.1634/theoncologist.2017-0028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Assessing patients with colorectal cancer liver metastases (CRCLM) by a liver multidisciplinary team (MDT) results in higher resection rates and improved survival. The aim of this study was to evaluate the potentially improved resection rate in a defined cohort if all patients with CRCLM were evaluated by a liver MDT. PATIENTS AND METHODS A retrospective analysis of patients diagnosed with colorectal cancer during 2008 in the greater Stockholm region was conducted. All patients with liver metastases (LM), detected during 5-year follow-up, were re-evaluated at a fictive liver MDT in which previous imaging studies, tumor characteristics, medical history, and patients' own treatment preferences were presented. Treatment decisions for each patient were compared to the original management. Odds ratios (ORs) and 95% confidence intervals were estimated for factors associated with referral to the liver MDT. RESULTS Of 272 patients diagnosed with LM, 102 patients were discussed at an original liver MDT and 69 patients were eventually resected. At the fictive liver MDT, a further 22 patients were considered as resectable/potentially resectable, none previously assessed by a hepatobiliary surgeon. Factors influencing referral to liver MDT were age (OR 3.12, 1.72-5.65), American Society of Anaesthesiologists (ASA) score (OR 0.34, 0.18-0.63; ASA 2 vs. ASA 3), and number of LM (OR 0.10, 0.04-0.22; 1-5 LM vs. >10 LM), while gender (p = .194) and treatment at a teaching hospital (p = .838) were not. CONCLUSION A meaningful number of patients with liver metastases are not managed according to best available evidence and the potential for higher resection rates is substantial. IMPLICATIONS FOR PRACTICE Patients with liver metastatic colorectal cancer who are assessed at a hepatobiliary multidisciplinary meeting achieve higher resection rates and improved survival. Unfortunately, patients who may benefit from resection are not always properly referred. In this study, the potential improved resection rate was assessed by re-evaluating all patients with liver metastases from a population-based cohort, including patients with extrahepatic metastases and accounting for comorbidity and patients' own preferences towards treatment. An additional 12.9% of the patients were found to be potentially resectable. The results highlight the importance of all patients being evaluated in the setting of a hepatobiliary multidisciplinary meeting.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Nikolaos Kartalis
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Mats Broberg
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Anna Stillström
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Jonas
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
| | - Jacob Freedman
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Henrik Nilsson
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Cost evaluation of gadoxetic acid-enhanced magnetic resonance imaging in the diagnosis of colorectal-cancer metastasis in the liver: Results from the VALUE Trial. Eur Radiol 2016; 26:4121-4130. [PMID: 26905871 PMCID: PMC5052297 DOI: 10.1007/s00330-016-4271-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the costs of diagnostic workup and surgery of three strategies for patients with colorectal cancer liver-metastases (CRCLM): gadoxetic-acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast-media (ECCM-MRI) or contrast-enhanced MDCT (CE-MDCT). METHODS The within-trial cost evaluation was modelled as a decision-tree to calculate the cost of diagnosis and surgery. The model used clinical outcomes and resource utilization data from a prospective randomized multicentre study. Analyses were performed for the 354-patient safety population from eight participating countries. RESULTS The diagnostic workup cost using Gd-EOB-DTPA-MRI upfront resulted in savings compared to ECCM-MRI in all countries except Thailand (difference <2 %). Compared to CE-MDCT, initial imaging with Gd-EOB-DTPA-MRI was less costly in all countries except Korea and Spain (differences 4 and 8 %, respectively). Significantly more patients in the Gd-EOB-DTPA-MRI group were eligible for surgery (39.3 % (48/122) vs. 31.0 % (36/116) and 26.7 % (31/116) for ECCM-MRI and CE-MDCT, respectively), allowing more patients to undergo potentially curative surgery, but resulting in higher treatment costs for the strategy starting with Gd-EOB-DTPA-MRI. CONCLUSIONS The benefits of Gd-EOB-DTPA-MRI due to less additional imaging and similar diagnostic workup costs in the three groups suggest that Gd-EOB-DTPA-MRI should be the preferred initial imaging procedure to evaluate hepatic resectability in patients with CRCLM. KEY POINTS • Diagnostic imaging cost to evaluate resectability was similar among the groups • Cost for imaging was rather small compared to the cost of surgery • Significantly more patients in the Gd-EOB-DTPA-MRI arm were eligible for surgery • Gd-EOB-DTPA-MRI is recommended for evaluating hepatic resectability in patients with CRCLM.
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Lédel F, Stenstedt K, Hallström M, Ragnhammar P, Edler D. HER3 expression in primary colorectal cancer including corresponding metastases in lymph node and liver. Acta Oncol 2015; 54:480-6. [PMID: 25601452 DOI: 10.3109/0284186x.2014.983654] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The human epidermal growth factor receptor complex (EGFR-1, HER2, HER3 and HER4) plays an important role in pathogenesis of solid tumours. We have previously reported high expression of HER3 in 70% of primary colorectal cancer (CRC) and that high expression were linked to a worse clinical outcome. The purpose of this study is to evaluate the HER3 expression in primary CRC and metastases. MATERIAL AND METHODS Tissue samples from primary CRC, corresponding lymph node metastases and liver metastases from 107 patients were analysed by immunohistochemistry. RESULTS Of 107 patients, 80% showed high HER3 expression in primary CRC tumours and 81% of the stage III patients presented high expression in the lymph node metastases. All patients had liver metastases and 82% presented high HER3 expression. HER3 expression in primary tumour correlated with expression in the corresponding lymph node metastases (r = 0.65, p < 0.001) and in the liver metastases (r = 0.45, p < 0.001). A correlation between HER3 expression in corresponding lymph node and liver metastases (r = 0.65, p < 0.001) was seen. CONCLUSION High HER3 expression is seen in about 80% of primary CRC, corresponding lymph node metastases and liver metastases. There is a correlation between HER3 expression in primary tumour and metastases in CRC.
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Affiliation(s)
- Frida Lédel
- Institution of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
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Welinder C, Jansson B, Lindell G, Wenner J. Cytokeratin 20 improves the detection of circulating tumor cells in patients with colorectal cancer. Cancer Lett 2015; 358:43-6. [DOI: 10.1016/j.canlet.2014.12.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 12/26/2022]
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Krell RW, Regenbogen SE, Wong SL. Variation in hospital treatment patterns for metastatic colorectal cancer. Cancer 2015; 121:1755-61. [PMID: 25640016 DOI: 10.1002/cncr.29253] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/26/2014] [Accepted: 12/24/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are many treatment options for metastatic colorectal cancer (CRC). However, to the authors' knowledge, national treatment patterns for metastatic CRC, and the stability of hospital treatment patterns over time, have not been well described. METHODS Data from the 2006 through 2011 National Cancer Data Base were used to study adults with newly diagnosed metastatic CRC (84,161 patients from 1051 hospitals). Using hierarchical models, the authors characterized hospital volume in the use of different treatment modalities (primary site resection, metastatic site resection, chemotherapy, and palliative care). The authors then assessed variation in the receipt of treatment according to the hospitals' relative volume of services used. Finally, the extent to which hospital treatment patterns changed over the past decade was examined. RESULTS Overall use of volume of services varied widely (5.0% in the hospitals with low volumes of service to 22.3% in the hospitals with high volumes of service). As hospitals' volumes of services increased, adjusted rates of metastatic site surgery (6.6% to 30.8%; P<.001) and multiagent chemotherapy (37.8% to 57.4%; P<.001) use increased, but primary site resection demonstrated little variation (56.8% vs 59.5%; P = .024). It is interesting to note that use of palliative care also increased (8.1% to 11.3%; P = .002). Hospital treatment patterns did not change over time, with hospitals with high volumes of service consistently using more metastatic site resection and multiagent chemotherapy than hospitals with low volumes of service. CONCLUSIONS There is wide variation in hospital treatment patterns for patients with metastatic CRC, and these patterns have been stable over time. It appears that much of the approach for metastatic CRC treatment depends on the hospital in which the patient presents.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Sandra L Wong
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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12
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Krell RW, Reames BN, Hendren S, Frankel TL, Pawlik TM, Chung M, Kwon D, Wong SL. Surgical Referral for Colorectal Liver Metastases: A Population-Based Survey. Ann Surg Oncol 2015; 22:2179-94. [PMID: 25582739 DOI: 10.1245/s10434-014-4318-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical resection is underutilized for patients with colorectal liver metastases (CLM). Although the causes of underutilization are poorly understood, provider attitudes towards surgical referral may be contributory. We sought to understand medical oncologists' perspectives on referral for CLM. METHODS Medical oncologists who treat colorectal cancer in the US state of Michigan were surveyed. We characterized respondents' attitudes regarding clinical and tumor-related contraindications to liver resection for CLM, as well as referral and treatment preferences using case-based scenarios. We then evaluated practice characteristics and treatment preferences between physicians. RESULTS A total of 112 eligible responses were received (46 % response rate). Nearly 40 % of respondents reported having no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic disease (80.3 %), poor performance status (77.7 %), the presence of >4 metastases (62.5 %), bilobar metastases (43.8 %), and metastasis size >5 cm (40.2 %). Compared with high-referring physicians, low-referring physicians were just as likely to refer a patient with very low recurrence risk (89.3 vs. 98.3 %; p = 0.099), but much less likely to refer a patient with moderate risk (0 vs. 82.8 %; p < 0.001). High-referring physicians were more likely to consider resection for scenarios consistent with higher recurrence risk (31.0 vs. 10.7 %; p = 0.05). CONCLUSIONS We found wide variation in surgical referral patterns for CLM. Many felt that bilobar disease and tumor size were contraindications to liver-directed therapy despite a lack of supporting data. These findings suggest an urgent need to increase dissemination of evidence and guidance regarding management for CLM, perhaps through increased specialist participation in tumor boards.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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Hackl C, Neumann P, Gerken M, Loss M, Klinkhammer-Schalke M, Schlitt HJ. Treatment of colorectal liver metastases in Germany: a ten-year population-based analysis of 5772 cases of primary colorectal adenocarcinoma. BMC Cancer 2014; 14:810. [PMID: 25369977 PMCID: PMC4230526 DOI: 10.1186/1471-2407-14-810] [Citation(s) in RCA: 239] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Purpose of this study was to analyse the surgical management and long-term clinical outcome of patients diagnosed with colorectal liver metastases (CLM) over a period of 10 years using data from a German tumour registry. METHODS Retrospective analysis of 5772 patients diagnosed with colorectal adenocarcinoma between 2002 and 2007. Follow-up was continued until 2012. RESULTS 1426 patients (24.7%) had CLM; 1019 patients (71%) had synchronous, 407 patients (29%) developed metachronous CLM. Hepatic resection was performed in 374 of the 1426 CLM patients (26%). A significant increase in liver resection rate from 16.6% for the 2002 cohort to 32% in later cohorts was observed. In centers specialized in liver surgery, CLM resection rates reached 46.6%. However, up to 52% of patients diagnosed with three or less CLM did not undergo liver surgery, although, if resected, patients with 1 CLM show a similar long-time survival as CRC patients who do not develop any CLM. Univariate and multivariate analyses adjusted for age, sex, year of resection, time of CLM diagnosis and number of CLM revealed a significant survival benefit for CLM resection (HR =0.355; CI 0.305-0.414). Furthermore, significant impact on OS was seen for age at diagnosis, perioperative chemotherapy and number of CLM. CONCLUSIONS We here present the first long-term, population-based analysis of the surgical management of CLM in Germany. Significant increase in hepatic resection rates, translating to a significant benefit in OS, was seen over years. However, we still see a striking potential for further improvements in interdisciplinary CLM management.
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Affiliation(s)
- Christina Hackl
- Department of Surgery, University Hospital Regensburg, Franz-Josef Strauss Allee 11, 93053 Regensburg, Germany.
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Stenstedt K, Hallstrom M, Lédel F, Ragnhammar P, Ingelman-Sundberg M, Johansson I, Edler D. The expression of CYP2W1 in colorectal primary tumors, corresponding lymph node metastases and liver metastases. Acta Oncol 2014; 53:885-91. [PMID: 24625228 DOI: 10.3109/0284186x.2014.887224] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Metastatic disease is a major cause of death in patients with colorectal cancer (CRC). We have previously investigated expression of an orphan cytochrome P450 (CYP) enzyme, CYP2W1, and found high expression in about one third of colorectal tumors. CYP2W1 has proven to metabolize duocarmycin analogs into cytotoxic substances, compounds that in xenografts of CRC cells expressing CYP2W1 completely inhibit tumor growth. This study was designed to evaluate whether the enzyme is expressed in primary CRC and corresponding metastases. MATERIAL AND METHODS Samples from primary tumors, corresponding lymph node metastases and liver metastases from 96 patients were collected and analyzed by immunohistochemistry. Data regarding patient's demographics, tumor characteristics and survival were also collected. RESULTS Out of 96 patients, 25 (26%) had high CYP2W1 expression in the primary tumor and 46 (48%) showed high levels in the liver metastasis. In total 59 patients had lymph node metastases, and 31% of them had high CYP2W1 expression. When comparing the expression in primary tumor with that of the first liver metastasis, the increase in expression was statistically significant (p = 0.005). CONCLUSION High CYP2W1 expression is seen in 26% of primary CRC and in 48% of corresponding liver metastases. This opens possibilities for new targeted therapies to metastatic CRC in the future.
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Affiliation(s)
- Kristina Stenstedt
- Center of Surgical Gastroenterology, Karolinska University Hospital , Stockholm , Sweden
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A multiple microwave ablation strategy in patients with initially unresectable colorectal cancer liver metastases - A safety and feasibility study of a new concept. Eur J Surg Oncol 2014; 40:1488-93. [PMID: 24933395 DOI: 10.1016/j.ejso.2014.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 05/04/2014] [Accepted: 05/10/2014] [Indexed: 02/08/2023] Open
Abstract
AIMS Resection for colorectal cancer liver metastases is indicated when an R0 resection with preservation of a sufficient future liver remnant (FLR) is achievable. Multimodality conversion of initially unresectable patients to resectable is possible in some patients. We present results of a downstaging strategy using microwave ablation (MWA). PATIENTS AND METHODS In patients where resection was precluded by absence of a tumour-free FLR due to the extent of segmental tumour engagement, but with the potential to clear the whole liver with multiple local ablations, MWA was performed at laparotomy using ultrasound guidance or computer-assisted navigation. Mortality and morbidity was recorded and the overall and disease-free survival of the ablated patients was compared to data of two historic cohorts. RESULTS Ten of twenty treated patients were alive at median follow-up 25 months. There was no perioperative mortality, with MWA-associated complications being mild to moderate. The MWA group showed a 4-year overall survival of 41%, compared to 70% for a historic cohort of primarily resected patients and 4% for patients with palliative treatment. CONCLUSION Results of the multiple ablation strategy in the defined population suggest a survival benefit, compared to palliative chemotherapy alone with acceptable associated morbidity and no perioperative mortality.
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Liver resections of isolated liver metastasis in breast cancer: results and possible prognostic factors. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2014; 2014:893829. [PMID: 24550602 PMCID: PMC3914465 DOI: 10.1155/2014/893829] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 11/27/2013] [Accepted: 11/28/2013] [Indexed: 01/08/2023]
Abstract
Background. Breast cancer liver metastasis is a hematogenous spread of the primary tumour. It can, however, be the expression of an isolated recurrence. Surgical resection is often possible but controversial. Methods. We report on 29 female patients treated operatively due to isolated breast cancer liver metastasis over a period of six years. Prior to surgery all metastases appeared resectable. Liver metastasis had been diagnosed 55 (median, range 1–177) months after primary surgery. Results. Complete resection of the metastases was performed in 21 cases. The intraoperative staging did not confirm the preoperative radiological findings in 14 cases, which did not generally lead to inoperability. One-year survival rate was 86% in resected patients and 37.5% in nonresected patients. Significant prognostic factors were R0 resection, low T- and N-stages as well as a low-grade histopathology of the primary tumour, lower number of liver metastases, and a longer time interval between primary surgery and the occurrence of liver metastasis. Conclusions. Complete resection of metastases was possible in three-quarters of the patients. Some of the studied factors showed a prognostic value and therefore might influence indication for resection in the future.
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Peloso A, Franchi E, Canepa MC, Barbieri L, Briani L, Ferrario J, Bianco C, Quaretti P, Brugnatelli S, Dionigi P, Maestri M. Combined use of intraoperative ultrasound and indocyanine green fluorescence imaging to detect liver metastases from colorectal cancer. HPB (Oxford) 2013; 15:928-34. [PMID: 23458105 PMCID: PMC3843610 DOI: 10.1111/hpb.12057] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 12/21/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Surgical excision is the standard strategy for managing liver metastases from colorectal carcinoma. The achievement of negative (R0) margins is a major determinant of disease-free survival in these patients. Current imaging techniques are of limited value in achieving this goal. A new approach to the intraoperative detection of colorectal liver metastatic tissue based on the emission of indocyanine green (ICG) fluorescence was evaluated. METHODS A total of 25 consecutive patients with liver metastases from primary colorectal cancers who were eligible for liver resection received a bolus of ICG (0.5 mg/kg body weight) 24 h before surgery. During surgery, ICG fluorescence, which accumulates around lesions as a result of defective biliary clearance, was detected with a near-infrared camera system, the Photodynamic Eye (PDE). Numbers of lesions detected by, respectively, PDE + ICG, intraoperative ultrasound (IOUS) and preoperative computed tomography (CT) were recorded. RESULTS The near-infrared camera plus ICG revealed a total of 77 metastatic liver nodules. Preoperative CT demonstrated 45 (58.4%) and IOUS showed 55 (71.4%). Preoperative CT and IOUS alone were inferior to the combined use of PDE + ICG and IOUS in the detection of lesions of ≤ 3 mm in size. CONCLUSIONS This experience suggests that PDE + ICG, combined with IOUS, may represent a safe and effective tool for ensuring the complete surgical eradication of liver metastases from colorectal cancer.
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Affiliation(s)
- Andrea Peloso
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Eloisa Franchi
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Maria C Canepa
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Letizia Barbieri
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Laura Briani
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Jacopo Ferrario
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Carolina Bianco
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Pietro Quaretti
- Interventional Radiology, Fondazione IRCCS Policlinico San Matteo PaviaPavia, Italy
| | - Silvia Brugnatelli
- Oncology and Immunohaematology, Fondazione IRCCS Policlinico San Matteo PaviaPavia, Italy
| | - Paolo Dionigi
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
| | - Marcello Maestri
- General Surgery, Fondazione IRCCS Policlinico San Matteo Pavia and University of PaviaPavia, Italy
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Laparoscopic Ultrasound for Hepatocellular Carcinoma and Colorectal Liver Metastasis. Surg Laparosc Endosc Percutan Tech 2013; 23:135-44. [DOI: 10.1097/sle.0b013e31828a0b9a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Wei AC, Sandhu L, Devitt KS, Gagliardi AR, Kennedy ED, Urbach DR, Gallinger S, Baxter NN. Practice patterns for the management of hepatic metastases from colorectal cancer: a mixed methods analysis. Ann Surg Oncol 2012; 20:1567-74. [PMID: 23124860 DOI: 10.1245/s10434-012-2698-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE The optimal management of colorectal cancer liver metastases (CRC-LM) has changed during the past two decades. However, clinical practice lags behind best evidence recommendations. We sought to characterize the gap between current practice and best evidence for the management of these patients and to identify barriers that hamper effective utilization of metastasectomy. METHODS A mixed-methods approach was used. A survey was mailed to all general surgeons (GS) and medical oncologists (MO) in Ontario, Canada. Domains examined included: physician/practice characteristics, indications for hepatectomy, use of multi-modality therapy and referral patterns. Physician focus groups were conducted that explored issues relating to access to care. RESULTS The survey was mailed to 942 physicians with a response rate of 68 % (n = 348; GS n = 295, 69 %; MO n = 53, 63 %). Current practice patterns demonstrated that 97 % of physicians refer patients with low tumor burden (e.g., solitary CRC-LM), but referral rates for hepatectomy decreased as the tumor burden increased. Physicians still consider extrahepatic disease as a strong contraindication to metastasectomy. Barriers to care included: economic, time, and resource constraints; lack of physician engagement, local medical expertise, and high-quality guidelines. Multidisciplinary cancer conferences were identified as an enabler of clinical care and a potential platform for the acquisition of new medical knowledge. CONCLUSIONS Current management of CRC-LM does not reflect best evidence. Patients who may benefit from surgery are not being referred for metastasectomy. We have identified an evidence-practice gap at the level of physician, which should be targeted with novel quality improvement strategies.
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Affiliation(s)
- Alice C Wei
- Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.
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A population-based analysis on the rate and surgical management of colorectal liver metastases in Southern Germany. Int J Colorectal Dis 2011; 26:1475-81. [PMID: 21748289 DOI: 10.1007/s00384-011-1278-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE Early detection and multidisciplinary treatment of colorectal liver metastases (CLM), preferably resection, can significantly prolong the survival of colorectal cancer patients. The purpose of this study was to analyze the incidence, management and long-term clinical outcome of CLM patients using data from a regional German tumour registry. METHODS We conducted a retrospective analysis of 884 patients diagnosed with colorectal adenocarcinoma in the year 2002 and documented in a regional tumor registry in Southern Germany. RESULTS Two hundred thirty-six patients (26.7%) had or developed CLM, 132 patients (14.9%) had synchronous CLM and 104 patients (11.8%) developed metachronous CLM. At diagnosis of CLM, 86 patients (36.4%) had 3 or less documented lesions, 6 patients (2.5%) had 4 to 6 lesions and 89 patients (37.7%) showed multiple, diffuse metastases; for 55 patients (23.3%), the number of lesions was not specified. CLM patients (19.1%) (5.1% of all patients) underwent liver resection; a higher resection rate (28.3%) was observed in a subgroup of patients treated in two academic centres. Patients without CLM had a significantly better 5-year survival rate than patients with liver metastases (65.5% versus 16.3%). CLM patients with up to 3 liver metastases (i.e., potentially resectable) who underwent liver resection (n=34) showed a significantly higher 5-year survival than non-resected (n=52) patients (40% versus 5%). CONCLUSIONS The present study is the first population-based analysis of the surgical management and outcome of CLM in Southern Germany. The percentage of liver resections was lower than expected, particularly for patients with three or less metastases. The present data suggest that relevant undertreatment of CLM patients may occur which may have a negative impact on survival.
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Clinical Risk Score Can be Used to Select Patients for Staging Laparoscopy and Laparoscopic Ultrasound for Colorectal Liver Metastases. World J Surg 2010; 34:2141-5. [DOI: 10.1007/s00268-010-0630-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Shah AJ, Callaway M, Thomas MG, Finch-Jones MD. Contrast-enhanced intraoperative ultrasound improves detection of liver metastases during surgery for primary colorectal cancer. HPB (Oxford) 2010; 12:181-7. [PMID: 20590885 PMCID: PMC2889270 DOI: 10.1111/j.1477-2574.2009.00141.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Computed tomography (CT) is the most common staging investigation in colorectal cancer (CRC). Up to 25% of patients are found to have previously undetected hepatic lesions when intraoperative ultrasound (IOUS) of the liver is used during CRC resection. We aimed to assess the ability of IOUS to detect additional liver lesions/metastases at primary colorectal resection, and to evaluate whether contrast-enhanced IOUS (CE-IOUS) improves the detection and characterization of hepatic lesions. METHODS We performed a single-centre, prospective pilot study. At CRC resection, patients underwent IOUS of the liver. Contrast-enhanced IOUS of the liver was undertaken using i.v. sulphur hexafluoride micro-bubbles (SonoVue, 4.8 ml). Findings of CT, non-enhanced IOUS and CE-IOUS were compared. Changes in staging or management were noted. Additional lesions were corroborated with iron oxide magnetic resonance imaging (MRI). RESULTS Among 21 patients, IOUS demonstrated additional lesions in seven (33%). Contrast altered the diagnosis of non-enhanced IOUS in four (20%) and changed the management strategy in three (14%) patients. Thus, IOUS in combination with the contrast agent altered the intraoperative or postoperative management plan in four patients. CONCLUSIONS In the first study of its kind, early results suggest that the ability of IOUS to detect additional metastases is improved by CE-IOUS, and that this may impact on surgical staging and management.
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Affiliation(s)
- Ankur J Shah
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal InfirmaryBristol, UK
| | - Mark Callaway
- Department of Radiology, Bristol Royal InfirmaryBristol, UK
| | - Michael G Thomas
- Department of Colorectal Surgery, Bristol Royal InfirmaryBristol, UK
| | - Meg D Finch-Jones
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal InfirmaryBristol, UK
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Bower M, Metzger T, Robbins K, Tomalty D, Válek V, Boudný J, Andrasina T, Tatum C, Martin RCG. Surgical downstaging and neo-adjuvant therapy in metastatic colorectal carcinoma with irinotecan drug-eluting beads: a multi-institutional study. HPB (Oxford) 2010; 12:31-6. [PMID: 20495642 PMCID: PMC2814401 DOI: 10.1111/j.1477-2574.2009.00117.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 07/03/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy for potentially resectable metastatic colorectal cancer (MCC) is becoming a more common treatment algorithm. The aim of the present study was to evaluate the efficacy of precision hepatic arterial Irinotecan therapy in unresectable MCC. METHODS An open-label, multi-centre, multi-national single arm study of MCC patients, who received hepatic arterial irinotecan. Primary endpoints were safety, tolerance and metastatic tumour resection. RESULTS Fifty-five patients with metastatic colorectal to the liver underwent a total of 90 hepatic arterial irinotecan treatments. The extent of liver involvement was < 25% in 75% of the patients (n= 41), between 26 and 50% in 15% of the patients (n= 11) and >50% in 10% of the patients (n= 24). The median number of hepatic lesions was four (range 1-20), with a median total size of all target lesions of 9 cm (range 5.5-28 cm) with 50% of patients having bilobar tumour distribution. The median number of irinotecan treatments was two (range 1-5). The median treatment dose was 100 mg (range 100-200) with a median total hepatic treatment of 200 mg (range 200-650). The majority of treatments (86%) were performed as lobar infusion treatments, and 30% of patients were treated with concurrent simultaneous chemotherapy. Eleven (20%) patients demonstrated significant response and downstage of their disease or demonstrated stable disease without extra-hepatic disease progression allowing resection, ablation or resection and ablation. There were no post-operative deaths. Post-operative complications morbidity occurred in 18% of patients, with none of them hepatic related. Non-tumorous liver resected demonstrated no evidence of steatohepatitis from the irinotecan arterial infusion. CONCLUSIONS Hepatic arterial infusion irinotecan drug-eluting beads is safe and effective in pre-surgical therapy and helpful in evaluating the biology of metastatic colorectal cancer to the liver prior to planned hepatic resection.
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Affiliation(s)
- Matthew Bower
- University of Louisville School of Medicine Division of Surgical OncologyLittle Rock, AR
| | - Tiffany Metzger
- University of Louisville School of Medicine Division of Surgical OncologyLittle Rock, AR
| | | | | | - Vlatimil Válek
- Department of Radiology, FN Brno a LF MU BrnoCzech republic
| | - Jean Boudný
- Department of Radiology, FN Brno a LF MU BrnoCzech republic
| | | | - Cliff Tatum
- Norton Healthcare RadiologyLouisville, KY, USA
| | - Robert CG Martin
- University of Louisville School of Medicine Division of Surgical OncologyLittle Rock, AR
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Transarterial Chemoembolization of Metastatic Colorectal Carcinoma with Drug-Eluting Beads, Irinotecan (DEBIRI): Multi-Institutional Registry. JOURNAL OF ONCOLOGY 2009; 2009:539795. [PMID: 19888427 PMCID: PMC2771155 DOI: 10.1155/2009/539795] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 08/10/2009] [Accepted: 09/30/2009] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to evaluate the patient tolerance and efficacy of delivering locoregional chemotherapy to metastatic colorectal (MC) hepatic metastases via hepatic trans-arterial approach using irinotecan loaded drug eluting beads. This open-label, multi-center, single arm study included 30 MC patients, who had failed first line therapy. Of the 57 total embolization sessions, 12 (21% of sessions) were associated with adverse reactions during or after the treatment. After a median followup of 9 months, response rates by modified RECIST were 75% at 3 months and 66% at 6 months. Hepatic trans-arterial therapy using Irinotecan loaded DC Bead(TM) was safe and effective in the treatment of MCC as demonstrated by a minimal complication rate and acceptable tumor response.
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Segelman J, Singnomklao T, Hellborg H, Martling A. Differences in multidisciplinary team assessment and treatment between patients with stage IV colon and rectal cancer. Colorectal Dis 2009; 11:768-74. [PMID: 18662241 DOI: 10.1111/j.1463-1318.2008.01648.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE At diagnosis, 14-27% of patients with colorectal cancer (CRC) have distant metastases (stage IV) and a poor prognosis. Today, treatment decisions for CRC patients are often made at multidisciplinary team (MDT) conferences. The aim of this study was to evaluate the effects of development and implementation of MDT assessment and treatment in patients with stage IV colon cancer (CC) and rectal cancer (RC) in a large population. METHOD All 1449 patients who had stage IV CRC at the time of diagnosis and were registered in the regional quality registry of Stockholm from 1995 to 2004 were included. Patients with CC and RC were grouped according to treatment and their characteristics were analysed separately. RESULTS In total, 1000 patients with CC and 449 patients with RC had stage IV disease. Of these, 689 (68.9%) CC patients and 352 (78.4%) RC patients were assessed by a MDT and the proportion increased over the study period (P < 0.001). Surgery for metastases was undertaken on 39 (3.9%) CC patients and 38 (8.5%) RC patients (P < 0.001). CRC patients selected for metastasis surgery had 37% 5-year survival when compared with 2% in patients who were not selected for metastasis surgery (P < 0.001). CONCLUSION Patients with CC were less often assessed by a MDT and less often had metastasis surgery than RC patients. The proportion of patients with CC and RC assessed by a MDT increased during the study period, as did the proportion who had surgery for metastases. MDT assessment opens up the opportunity for more aggressive treatment with better outcomes.
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Affiliation(s)
- J Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Radiofrequency ablation vs. resection for hepatic colorectal metastasis: therapeutically equivalent? J Gastrointest Surg 2009; 13:486-91. [PMID: 18972167 DOI: 10.1007/s11605-008-0727-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Accepted: 10/06/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The role of ablation for hepatic colorectal metastases (HCM) continues to evolve as ablation technology changes and systemic chemotherapy improves. Our aim was to evaluate the therapeutic efficacy of radiofrequency ablation (RFA) of HCM compared to surgical resection. METHODS A retrospective review of our 1,105 patient prospective hepatic database from August 1995 to July 2007 identified 192 patients with only hepatic resection or only ablation for HCM. RESULTS Patients who underwent RFA were similar to resection patients based on a similar Fong score (1.8 vs. 2.1 p = 0.28), presence of extrahepatic disease (15% vs. 9% p = 0.19), mean number of hepatic lesions (2.8 vs. 2.1 p = 0.14), and prior chemotherapy (67% vs. 60% p = 0.33). Median time to recurrence was shorter with ablation than resection (12.2 vs. 31.1 months; p < 0.001). Recurrence at the ablation-resection site was more common with ablation than resection occurring 17% vs. 2% (p < or = 0.001) of the time, respectively. Distant recurrence in the liver was also more common with ablation occurring in 33% of patients vs. 14% for resection (p = 0.002). CONCLUSIONS Surgical resection is associated with a lower chance of recurrence and a longer disease-free interval than RFA and should remain the treatment of choice in resectable HCM.
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Survival and symptomatic benefit from palliative primary tumor resection in patients with metastatic colorectal cancer: a review. Int J Colorectal Dis 2008; 23:559-68. [PMID: 18330581 DOI: 10.1007/s00384-008-0456-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Patients with metastatic colorectal cancer have a limited life expectancy and are at risk for life-threatening tumor-related obstruction, perforation, and hemorrhage. Though surgical resection is performed frequently in this setting, its true benefit is not well-established. MATERIALS AND METHODS We reviewed the medical literature from 1996-2006 using the search terms metastatic colorectal cancer and primary resection to find studies that evaluated the management of primary tumors in metastatic colorectal cancer. All search results were included in our analysis and were assessed on the basis of methodologic quality. RESULTS/FINDINGS Twelve relevant studies were identified; ten were single-institution retrospective reviews and two were population-based studies using National Cancer Institute's Surveillance, Epidemiology, and End-Results database. No prospective or randomized studies were identified. Approximately 70% of patients diagnosed with metastatic colorectal cancer in the USA undergo primary tumor resection; only a minority have this done for tumor-related symptoms or as part of potentially curative resection. The postoperative mortality ranged from 9.0-11.2% in large cancer registries but was often lower in major cancer centers. Resection of asymptomatic primary tumors was frequently associated with prolonged survival but was not found to reduce significantly the incidence of life-threatening tumor-related complications. INTERPRETATION/CONCLUSION Retrospective data suggest that non-curative resection of asymptomatic colorectal primary tumors may prolong survival; however, selection bias and unaccounted clinical factors may explain this observation. Prospective, randomized surgical trials are needed to test the role of primary tumor resection in this setting, especially because of its current widespread use, and its associated cost, morbidity, and high postoperative mortality.
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de Jong GM, Aarts F, Hendriks T, Boerman OC, Bleichrodt RP. Animal models for liver metastases of colorectal cancer: research review of preclinical studies in rodents. J Surg Res 2008; 154:167-76. [PMID: 18694579 DOI: 10.1016/j.jss.2008.03.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 03/04/2008] [Accepted: 03/25/2008] [Indexed: 01/20/2023]
Abstract
Liver metastases of colorectal carcinoma occur in about 50-60% of patients. To improve survival of these patients, there is an urgent need for new treatment strategies. For this purpose, the availability of a preclinical model to develop and test such treatments is mandatory. An ideal animal model for studying liver metastases of colorectal origin should mimic all aspects of the metastatic development in humans and be practical, predictable, and optimal in terms of ethical considerations. Thus far, no model has been developed which satisfies all these conditions. As a consequence, choosing an animal model for the study of liver metastases requires compromises and choices about the necessary characteristics that depend on the purpose of the intended experiments. This overview addresses the advantages and disadvantages of different animal models used for research on experimental liver metastases of colorectal origin. Based on data available in literature, we conclude that heterotopic injection of undifferentiated syngeneic tumor cells in immunocompetent rodents covers most of the desired characteristics. Both subcapsular as well as intraportal injection will yield suitable models and the eventual choice will depend on the aim of the study.
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Affiliation(s)
- Gabie M de Jong
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Can contrast-enhanced ultrasonography replace multidetector-computed tomography in the detection of liver metastases from colorectal cancer? Eur J Radiol 2007; 69:308-13. [PMID: 18068925 DOI: 10.1016/j.ejrad.2007.10.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Revised: 10/10/2007] [Accepted: 10/31/2007] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare the sensitivity and specificity of contrast-enhanced ultrasonography (CEUS) and 4-slice multidetector-computed tomography (MDCT) in the detection of liver metastases in patients with colorectal cancer (CRC). MATERIALS AND METHODS Candidates for this prospective study were 461 consecutive patients referred to the Department of Colorectal Surgery, Aarhus University Hospital with primary or local recurrence of CRC. The patients underwent liver ultrasonography (US), CEUS, MDCT and intraoperative ultrasonography (IOUS). Fine-needle biopsy was performed on all suspicious lesions. The examinations were interpreted blindly and the combination of US, CEUS, biphasic MDCT, IOUS, follow up and biopsy was the gold standard. RESULTS Three hundred and sixty-five patients were included. All patients had undergone preoperative US, CEUS and MDCT and 65.5% had received IOUS. The gold standard found liver metastases in 54 patients (14.8%). Multidetector CT found significantly more metastases than CEUS in 15 (28%) of the patients (p=0.02). In a patient-by-patient analysis MDCT had a non-significantly higher sensitivity in the detection of liver metastases compared to CEUS (0.89 versus 0.80, p=0.06). The specificity of CEUS (0.98) was slightly better than that of MDCT (0.94) (p=0.02). CONCLUSION Multidetector CT found significant more metastases than CEUS, and MDCT had in patient-by-patient analysis a non-significant better sensitivity (p=0.06) in detecting liver metastases in patients with CRC.
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Søndenaa K, Nesvik I, Eiriksson K, Vetrhus M. The result of liver resection for colorectal metastases in a small volume hospital in western Norway. Eur J Surg Oncol 2007; 33 Suppl 2:S105-10. [DOI: 10.1016/j.ejso.2007.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Accepted: 09/26/2007] [Indexed: 11/26/2022] Open
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Dede K, Mersich T, Nagy P, Baranyai Z, Zaránd A, Ifj Besznyák I, Faludi S, Jakab F. [The role of laparoscopy assessing the resectability of hepatic malignancies]. Magy Seb 2007; 60:248-52. [PMID: 17984015 DOI: 10.1556/maseb.60.2007.5.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Regarding the prognosis of hepatic malignancies, surgical resection can provide a 40% 5-year survival, however liver transplantation (OLTX) shows even better results. Unfortunately, many patients have non-resectable disease due to either the number and the position of the tumours or its distant spread. It is relatively frequent that it turns out only at the time of the surgical exploration that the patient is inoperable. Hence, in addition to preoperative clinical evaluation and imaging, laparoscopy can be valuable in further staging and assessment of resectability in selected cases. METHODS AND PATIENTS 310 patients underwent hepatic resection between 1 January 2000 and 31 March 2006. A retrospective analysis was carried out of 39 patients, who underwent laparoscopy prior to the planned hepatectomy. 22 patients (56%) were diagnosed with hepatocellular carcinoma (HCC), while 17 patients (44%) had hepatic metastases. RESULTS Altogether 70% of the patients were found to have non-resectable tumour on laparoscopy. However, when these patients underwent laparotomy, non-resectable disease was found in 50% of them. Laparoscopy was helpful to demonstrate non-resectability of the tumour when carcinosis peritonei or multifocal lesions were present, but central or venous invasion could not be assessed adequately with this technique. CONCLUSION Laparoscopy can be an important component of the preoperative staging of malignant hepatic tumours. Further, it can help to avoid unnecessary laparotomies. However, this procedure is recommended in selected patients only, and its general use is not indicated.
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Affiliation(s)
- Kristóf Dede
- Fovárosi Onkormányzat Uzsoki utcai Kórház, Sebészeti-Ersebészeti Osztály, 1145 Budapest, Uzsoki u. 29.
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Vetrhus M, Søndenaa K. Hospital volume does not affect clinical outcome. Eur J Surg Oncol 2007; 33:1049-51. [PMID: 17521850 DOI: 10.1016/j.ejso.2007.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2007] [Accepted: 04/05/2007] [Indexed: 11/29/2022] Open
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Mann CD, Neal CP, Metcalfe MS, Pattenden CJ, Dennison AR, Berry DP. Clinical Risk Score predicts yield of staging laparoscopy in patients with colorectal liver metastases. Br J Surg 2007; 94:855-9. [PMID: 17380479 DOI: 10.1002/bjs.5730] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Background
Resection offers the only realistic chance of cure for hepatic colorectal metastases. The aim of this study was to examine the potential of laparoscopy and laparoscopic intraoperative ultrasonography (IOUS) for detecting incurable disease, and to determine whether the Clinical Risk Score (CRS) is useful in selecting patients for laparoscopy before hepatic resection.
Methods
All patients with potentially curable colorectal liver metastases who underwent staging laparoscopy and laparoscopic IOUS before planned hepatic resection between January 2000 and December 2004 were included. A preoperative CRS was determined for each patient and correlated with curability.
Results
Two hundred patients were identified, of whom 133 were found to have resectable disease at laparotomy. Laparoscopy detected 39 (58 per cent) of 67 patients with incurable disease, changing the management in 19·5 per cent of the 200 patients. The CRS correlated with the likelihood of detecting incurable disease; incurable disease was present in two of 31 patients with a CRS of 0–1, 35 of 129 with a score of 2–3 and 30 of 40 with a score of 4–5. The potential benefit of laparoscopy increased progressively with increasing CRS, changing management in none of 31 patients with a CRS of 0–1, 18 of 129 with a score of 2–3 and 21 of 40 with a score of 4–5.
Conclusion
Staging laparoscopy and IOUS detected more than half of the incurable disease in this cohort. Laparoscopy had a low diagnostic yield in patients with a CRS of 0–1 and its routine use in this group of patients is therefore not recommended.
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Affiliation(s)
- C D Mann
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester, Gwendolen Road, Leicester LE5 4PW, UK.
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Julianov A, Karashmalakov A. Simultaneous pulmonary metastasectomy and hepatic radiofrequency ablation to treat recurrent metastases from rectal cancer. Eur J Cancer Care (Engl) 2007; 15:369-70. [PMID: 16968319 DOI: 10.1111/j.1365-2354.2006.00669.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Julianov
- Department of General Surgery, Thracian University Hospital, Stara Zagora, Bulgaria.
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Lyratzopoulos G, Tyrrell C, Smith P, Yelloly J. Recent trends in liver resection surgery activity and population utilization rates in English regions. HPB (Oxford) 2007; 9:277-80. [PMID: 18345304 PMCID: PMC2215396 DOI: 10.1080/13651820701504165] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We conducted a study to examine recent trends in population-based utilization rates for liver resection surgery in England, to help identify potentially unmet healthcare need and to help inform future service planning. MATERIALS AND METHODS Hospital Episodes Statistics data were analysed for the 5-year period 2000-1 to 2004-5 to identify episodes of care relating to liver resection surgery (defined as OPSC IV codes J21 to J24, J31, J38 and J39). RESULTS In England, the liver excision surgery population access rate was 1.82 and 2.95/100,000 general population in 2000-1 and 2004-5, respectively--a 62% increase during the 5-year study period, or a mean 12% annual increase. About two-thirds of all liver resection surgery (69%) related to metastatic liver disease. Between English regions, utilization rates ranged from 0.5 to 4.5/100,000 general population in 2000-1; and from 0.8 to 4.6/100 000 general population in 2004-5. DISCUSSION In recent years, a rapid increase in liver resection surgery activity has been observed. Most of the activity was related to metastatic disease. There was substantial regional variation in population utilization rates within the same country. This variation is unlikely to represent regional differences in disease burden and healthcare need.
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Affiliation(s)
| | | | - Paul Smith
- Eastern Region Public Health ObservatoryCambridgeUK
| | - Julia Yelloly
- East of England Specialised Services GroupCambridgeUK
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Lambert PC, Dickman PW, Österlund P, Andersson T, Sankila R, Glimelius B. Temporal trends in the proportion cured for cancer of the colon and rectum: A population-based study using data from the Finnish Cancer Registry. Int J Cancer 2007; 121:2052-2059. [PMID: 17640061 DOI: 10.1002/ijc.22948] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Colorectal cancer is the third most common cancer worldwide and the second most common cancer in Europe. Cumulative relative survival curves for both cancer of the colon and cancer of the rectum generally plateau after approximately 6-8 years. When this occurs, "population" or "statistical" cure is reached. We analyzed data from the Finnish Cancer Registry over a 50-year period using methods that simultaneously estimate the proportion of patients cured of disease (the cure fraction) and the survival time distribution of the "uncured" group. Our primary aim was to investigate temporal trends in the cure fraction and median survival of the uncured by age group for both cancer of the colon and rectum. For both cancers, the cure fraction has increased dramatically over time for all age groups. However, the difference in the cure fraction between age groups has reduced over time, particularly for cancer of the colon. Median survival in the uncured has also increased over time in all age groups but there still remains an inverse relationship between age and median survival, with shorter median survival with increasing age. The reasons for these impressive increases in patient survival are complex, but are highly likely to be strongly related to many improvements in cancer care over this same time period.
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Affiliation(s)
- Paul C Lambert
- Department of Health Sciences, Centre for Biostatistics and Genetic Epidemiology, University of Leicester, Leicester, United Kingdom
| | - Paul W Dickman
- Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Österlund
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Therese Andersson
- Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Bengt Glimelius
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department Oncology, Radiology and Clinical Immunology, University of Uppsala, Sweden
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Abstract
It is time to challenge the current orthodoxy that frowns upon surgical and nonsurgical methods of tumor reduction for patients with metastatic colon cancer. Although the studies conducted with radiofrequency ablation, chemoembolization, and radiation therapy in patients with metastatic colon cancer have tended to be small and may have been subject to selection bias, they have produced survival data that require careful consideration. At the very least, it is clear that locoregional approaches to debulking tumors are feasible and that their combination with systemic chemotherapy should be investigated.
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Affiliation(s)
- David P Ryan
- Tucker Gosnell Gastrointestinal Cancer Center, Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02114, USA.
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Faries MB, Morton DL. The promise of metastasectomy in melanoma. Ann Surg Oncol 2006; 13:607-9. [PMID: 16538408 DOI: 10.1245/aso.2006.01.901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Accepted: 01/05/2006] [Indexed: 11/18/2022]
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Yoshimura K, Jain A, Allen HE, Laird LS, Chia CY, Ravi S, Brockstedt DG, Giedlin MA, Bahjat KS, Leong ML, Slansky JE, Cook DN, Dubensky TW, Pardoll DM, Schulick RD. Selective targeting of antitumor immune responses with engineered live-attenuated Listeria monocytogenes. Cancer Res 2006; 66:1096-104. [PMID: 16424046 DOI: 10.1158/0008-5472.can-05-2307] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Improved immunization and ex vivo T-cell culture strategies can generate larger numbers and more potent tumor-specific effector cells than previously possible. Nonetheless, the capacity of these cells to eliminate established tumors is limited by their ability to efficiently enter tumor-bearing organs and mediate their effector function. In the current study, we show that the administration of an engineered organ-homing microbe selectively targets tumor-specific immune responses to metastases within that organ. Specifically, an attenuated Listeria monocytogenes strain, which preferentially infects the liver following systemic administration, dramatically enhances the activity of a cancer vaccine against liver metastases but not metastases in the lung. This enhanced activity results from both local recruitment of innate immune effectors as well as concentration and increased activation of vaccine-induced antitumor T cells within the liver. These findings show a general approach to focus systemic cancer immunotherapies to specific organs bearing tumor metastases by taking advantage of differential tropisms and the proinflammatory nature of microbes.
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Affiliation(s)
- Kiyoshi Yoshimura
- Immunology and Hematopoiesis Division, Department of Medical Oncology, Sidney Kimmel Cancer Center, Johns Hopkins Medical Institutions, 1650 Orleans Street, Baltimore, MD 21231, USA
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