Hepatic veno-occlusive disease after neoadjuvant treatment of colorectal liver metastases with oxaliplatin: a lesson of the month

Current status of minimally invasive liver surgery for cancers

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

Comparison Between Liver Stiffness Measurement by Fibroscan and Splenic Volume Index as NonInvasive Tools for the Early Detection of Oxaliplatin-induced Hepatotoxicity

Background

Oxaliplatin remains an essential component of many chemotherapy protocols for gastrointestinal cancers; however, neurotoxicity and hepatotoxicity may be dose-limiting. The gold standard for the diagnosis of oxaliplatin-induced hepatotoxicity is liver biopsy, which is invasive and costly. Splenomegaly has also been used as a surrogate for liver biopsy in detecting oxaliplatin-induced sinusoidal obstruction syndrome (SOS), but splenic measurement is not routine and can be inaccurate and complex. We investigated the correlation between increased liver elasticity assessed by Fibroscan and the increase in spleen volume on cross-sectional imaging after oxaliplatin as a noninvasive technique to assess liver stiffness associated with oxaliplatin-induced SOS.

Methods

Forty-six patients diagnosed with gastrointestinal cancers and planned to take oxaliplatin containing regimens were included in this prospective study at the American University of Beirut Medical Center (AUBMC). Measurement of spleen volume using cross-sectional imaging and of liver elasticity using Fibroscan was performed at baseline, 3 and 6 months after starting oxaliplatin. Mean liver elasticity measurements were compared between patients stratified by the development of splenomegaly using the Student t-test. Splenomegaly was defined as 50% increase in spleen size compared with baseline.

Results

Patients who developed splenomegaly after oxaliplatin use had significantly higher mean elasticity measurements as reported by Fibroscan at 3 (16.2 vs. 7.8 kPa, P = 0.036) and 6 (9.3 vs. 6.7 kPa, P = 0.03) months.

Conclusion

Measurement of elasticity using Fibroscan could be potentially used in the future as a noninvasive test for predicting oxaliplatin-induced hepatotoxicity.

Colorectal chemotherapy-associated liver injury

The increasing use of more effective chemotherapy in patients with colorectal cancer has raised awareness of the potential liver injuries induced by systemic drugs, such as fluorouracil, oxaliplatin and irinotecan. Chemotherapy-associated liver injuries can be revealed by histopathologic examination of nontumoral liver tissue. There are two broad categories of chemotherapy-induced liver injury: non-alcoholic fatty liver disease and sinusoidal injury. Many reports suggest that liver injuries may increase morbidity and mortality in patients who undergo hepatic resection for colorectal liver metastases, while some researchers have opposing views. This review describes the main types of chemotherapy-related liver injury and current controversy over this topic.

Oxaliplatin-mediated increase in spleen size as a biomarker for the development of hepatic sinusoidal injury

PURPOSE

Oxaliplatin-based chemotherapy can cause hepatic sinusoidal injury, with resultant sinusoidal damage and portal hypertension. We sought to explore the relationship between oxaliplatin induced hepatic sinusoidal injury, increases in spleen size, and the subsequent development of thrombocytopenia.

PATIENTS AND METHODS

We retrospectively assessed the relationship between chemotherapy exposure, changes in spleen size (determined by volumetric measurements), and platelet counts in 136 patients treated with adjuvant fluorouracil and oxaliplatin (FOLFOX) or fluoropyrimidine for stage II or III colorectal adenocarcinoma. Hepatic sinusoidal injury and changes in spleen size were graded in a separate population of 63 patients with metastatic colorectal cancer receiving fluoropyrimidine and oxaliplatin before liver resection.

RESULTS

Spleen size increased in 86% of patients treated with adjuvant FOLFOX (P < .001), with a > or = 50% increase in 24% of patients. Spleen size did not significantly increase in patients treated with adjuvant fluoropyrimidine. Increases in spleen size correlated with cumulative oxaliplatin dose (P = .003). Patients with splenic enlargement > or = 50% had higher rates of thrombocytopenia in the first year after completion of chemotherapy (27% v 5%; P = .003). In patients with hepatic metastases treated with preoperative fluoropyrimidine and oxaliplatin, increases in spleen size was a predictor of higher histologic grades of sinusoidal injury in both univariate (P = .03) and multivariate (P = .02) analyses.

CONCLUSION

Increases in spleen size correlate with increasing grade of hepatic sinusoidal injury and can serve as a simple method for identifying patients at risk for this toxicity. Oxaliplatin-induced increases in spleen size should be recognized as a potential etiology of persistent thrombocytopenia after oxaliplatin treatment.

Portal hypertension associated with oxaliplatin administration: clinical manifestations of hepatic sinusoidal injury

Oxaliplatin-based chemotherapy regimens are currently a standard of care for the treatment of colorectal cancer (CRC) in both the adjuvant treatment and metastatic disease settings. Significant improvements in outcomes have been achieved with oxaliplatin-based combinations in these settings when compared with administration of 5-fluorouracil alone. Pathologic evaluation of normal liver from patients undergoing neoadjuvant oxaliplatin treatment has identified histologic evidence of sinusoidal injury, although the effect of this finding on patient outcomes after hepatic resection appears to be minimal. This article describes the use of oxaliplatin-based chemotherapy in 6 patients with stage III or IV CRC who developed evidence of noncirrhotic portal hypertension. These patients developed complications of portal hypertension including esophageal or hemorrhoidal varices with bleeding, splenomegaly with associated thrombocytopenia, and ascites. In each case, oxaliplatin-induced hepatic sinusoidal injury was identified as the most likely factor contributing to the development of noncirrhotic portal hypertension. The literature on hepatic sinusoidal injury after oxaliplatin is reviewed and the proposed pathophysiology is discussed.