Management of disappearing colorectal liver metastases

Laparoscopic associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases: A single-center experience

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a procedure used for patients with initially unresectable colorectal liver metastases (CRLM). However, the procedure has been reported to be associated with high morbidity and mortality. Laparoscopic ALPPS has recently been reported as a minimally invasive technique that reduces perioperative risks.

AIM

To assess the safety and feasibility of full laparoscopic ALPPS in patients with CRLM.

METHODS

A retrospective analysis was conducted on all consecutive patients with CRLM who underwent full laparoscopic ALPPS at the Sixth Affiliated Hospital of Sun Yat-sen University between March 2021 and July 2024.

RESULTS

Fifteen patients were included, 13 with synchronous liver metastases. Nine patients had more than five liver tumors, with the highest count being 22. The median diameter of the largest lesion was 2.8 cm on preoperative imaging. No extrahepatic metastases were observed. RAS mutations were detected in nine patients, and 14 underwent preoperative chemotherapy. The median increase in future liver remnant volume during the interstage interval was 47.0%. All patients underwent R0 resection. Overall complication rates were 13.3% (stage 1) and 53.3% (stage 2), while major complication rates (Clavien-Dindo ≥ IIIa) were 13.3% (stage 1) and 33.3% (stage 2). No mortality occurred in either stage. The median hospital stay after stage 2 was 10 days.

CONCLUSION

Full laparoscopic ALPPS for CRLM is safe and feasible, with the potential for reduced morbidity and mortality, offering radical resection opportunities for patients with initially unresectable CRLM.

Ileal metastasis of colorectal cancer diagnosed by double-balloon endoscopy and resected via laparoscopy: A case report

INTRODUCTION

Small bowel metastasis of colorectal cancer (CRC) is rare, with a 3.8 % occurrence. Preoperative diagnosis was considered challenging; however, with the development of various endoscopes, diagnosis may now be possible. Most small bowel metastases of CRC are systemic metastatic events, such as direct invasion or disseminated metastasis. Therefore, R0 surgery is difficult to achieve, and local treatment is infrequent.

PRESENTATION OF CASE

A 70-year-old woman underwent laparoscopic left hemicolectomy for transverse colon cancer in 2022 and her final staging was pT4a, N1b, M0, pStage IIIb. One year after surgery, her carcinoembryonic antigen (CEA) level was elevated, and computed tomography (CT) showed no evidence of neoplastic lesions; however, positron emission tomography (PET) showed a 1 cm nodule with a high SUVmax:9.1 concentration near the uterus, suggesting the possibility of a small bowel tumor. Double-balloon endoscopy (DBE) revealed a submucosal tumor in the ileum. A biopsy could not be performed; however, the lesion was marked with ink dots and clips near the lesion. The lesion was diagnosed as solitary, and the patient underwent laparoscopic partial ileal resection. The tumor was located approximately 60 cm from the end of the ileum on the mesenteric side of the mouth, and it was impossible to determine whether it was an extramural or intraluminal lesion. The patient had a good postoperative course, and histopathologic examination revealed small bowel metastasis of transverse colon cancer, with tumor cells infiltrating from the subserosal layer to the intrinsic muscularis propria. The patient has been under observation for 1 year and 4 months after surgery without recurrence.

DISCUSSION

Small bowel metastases of CRC are very rare and have a poor prognosis; DBE can be used to identify neoplastic lesions in the ileum that could not be determined as extraintestinal or small bowel lesions by CT or PET alone. By marking the lesion with dots of ink and a clip, the lesion was determined to be solitary and amenable to R0 surgery. Laparoscopic surgery was chosen because of the ease of confirming the markings near the lesion and because it was minimally invasive. Furthermore, laparoscopic surgery allowed observation of the subdiaphragm, pelvic floor, and entire abdominal cavity. This report is the only case in which ink dots and clips were employed during DBE and subsequently utilized when laparoscopic surgery was performed.

CONCLUSION

We report a case involving a single site of small bowel metastasis after CRC surgery in which the patient underwent laparoscopic resection of the small intestine after locating the metastatic site with DBE and was successfully treated without recurrence. We conclude that if R0 surgery is possible for a single site of small bowel metastasis, it may contribute to an improved prognosis. Endoscopy is useful for detecting small intestinal tumors, and a single site of small bowel metastasis is a good indication for laparoscopic resection.

A long-term recurrence-free case of colorectal cancer with 13 simultaneous liver metastases: A case report

INTRODUCTION

Metastatic liver tumors result from distant metastasis of a primary tumor. While chemotherapy is the treatment of choice, liver resection is aggressively performed for metastatic liver cancer derived from colorectal cancer. However, during chemotherapy, some disappearing liver metastases (DLMs) can be undetectable on computed tomography (CT), and surgical treatment remains challenging.

PRESENTATION OF CASE

A 48-year-old woman with abdominal pain and constipation was diagnosed with multiple liver metastases of colorectal cancer (CRLM) origin after a thorough examination involving CT and ethoxybenzyl-magnetic resonance imaging. Thirteen simultaneous CRLM were observed (largest metastasis diameter, 37 mm). Resection of the primary tumor (laparoscopy-assisted left colon resection + D3 dissection) was performed. Following eight courses of chemotherapy with mFOLFOX6 + panitumumab, only two CRLM and 11 DLMs were detectable on CT. With no new lesions identified, the patient underwent anterior segment resection and segment 3 and segment 7 partial hepatectomies. Contrast-enhanced intraoperative ultrasonography was performed, and all detectable lesions were resected. However, pathology results showed three CRLM in the anterior segment and no tumor cells in the segment 3 and segment 7 specimens. Postoperatively, the patient received eight courses of adjuvant chemotherapy with capecitabine and oxaliplatin (with capecitabine as a single agent beginning mid-course). The patient is currently alive and recurrence-free 3.5 years post-hepatic resection.

DISCUSSION

The utility of EOB-MRI in the detection of DLMs has been demonstrated. The incidence of residual disease and subsequent early recurrence at sites diagnosed as DLMs on CT is reported to be approximately 80 %. Although aggressive resection of resectable DLMs is desirable to the extent that residual liver function can be preserved, recurrence is frequent and long-term careful follow-up is considered important.

CONCLUSION

Our patient, with multiple CRLM, responded to chemotherapy and underwent conversion surgery following resection of the primary tumor. Surgeons should consider possible surgical resection and DLM management when selecting the primary treatment.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

Ultrasound guidance in navigated liver surgery: toward deep-learning enhanced compensation of deformation and organ motion

PURPOSE

Accuracy of image-guided liver surgery is challenged by deformation of the liver during the procedure. This study aims at improving navigation accuracy by using intraoperative deep learning segmentation and nonrigid registration of hepatic vasculature from ultrasound (US) images to compensate for changes in liver position and deformation.

METHODS

This was a single-center prospective study of patients with liver metastases from any origin. Electromagnetic tracking was used to follow US and liver movement. A preoperative 3D model of the liver, including liver lesions, and hepatic and portal vasculature, was registered with the intraoperative organ position. Hepatic vasculature was segmented using a reduced 3D U-Net and registered to preoperative imaging after initial alignment followed by nonrigid registration. Accuracy was assessed as Euclidean distance between the tumor center imaged in the intraoperative US and the registered preoperative image.

RESULTS

Median target registration error (TRE) after initial alignment was 11.6 mm in 25 procedures and improved to 6.9 mm after nonrigid registration (p = 0.0076). The number of TREs above 10 mm halved from 16 to 8 after nonrigid registration. In 9 cases, registration was performed twice after failure of the first attempt. The first registration cycle was completed in median 11 min (8:00-18:45 min) and a second in 5 min (2:30-10:20 min).

CONCLUSION

This novel registration workflow using automatic vascular detection and nonrigid registration allows to accurately localize liver lesions. Further automation in the workflow is required in initial alignment and classification accuracy.

Preoperative percutaneous or transvascular marking for curative resection of small liver tumours with potential for missing during hepatectomy: a study protocol for an open-label, single-arm phase II study

INTRODUCTION

Small liver tumours are difficult to identify during hepatectomy, which prevents curative tumour excision. Preoperative marking is a standard practice for small, deep-seated tumours in other solid organs; however, its effectiveness for liver tumours has not been validated. The objective of this study is to evaluate the effectiveness of preoperative markings for curative resection of small liver tumours.

METHODS AND ANALYSIS

This is an open-label, single-arm, single-centre, phase II study. Patients with liver tumours of ≤15 mm requiring hepatectomy will be enrolled and will undergo preoperative marking by placing a microcoil near the tumour using either the percutaneous or transvascular approach. The tumours, including the indwelling markers, will be excised. The primary endpoint will be the successful resection rate of liver tumours, defined as achieving a surgical margin of ≥5 mm and ≤15 mm. Secondary endpoints will include the results of preoperative marking and hepatectomy.

ETHICS AND DISSEMINATION

Ethical approval for this trial was obtained from the Ethical Committee for Clinical Research of Hiroshima University, Japan. The results will be published at an academic conference or by submitting a paper to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

jRCTs062220088.

Changes in Oncological Surgical Principles Driven by Advances in Preoperative Treatments

From a surgical point of view, the development of preoperative oncological treatment has had a profound effect on the surgical treatment trends of cancer as well as on the outcomes of cancer patients. Consequently, these changes have challenged formerly entrenched oncological surgical principles. In our short report, we aimed to summarize the main shifts regarding the surgical principles of cancer treatment due to the development of preoperative oncological therapy in recent years. As a result of successful preoperative treatment, surgeons may perform less radical surgeries, the required free resection margin has been narrowed down to a few millimeters in dimension and preoperative treatment is justified in both definitely resectable tumors and in oligometastatic tumors as well. For prognosis assessment, the post-preoperative oncological treatment stage is now considered decisive, rather than the pretreatment stage as previously thought. Other changes include the introduction of the watch and wait strategy and the reverse order of treatment of the primary tumor and metastasis. Observing the continuously improving outcomes of cancer patients and the developments in oncological treatment modalities, a further expansion of the indication of preoperative treatments is to be expected.

The dilemma of the disappearing colorectal liver metastases: defining international trends in management

OBJECTIVE

This survey sought to appraise the degree of consistency in the management of disappeared colorectal liver metastases (dCRLM) among liver surgeons in different countries.

BACKGROUND

Colorectal liver metastases (CRLM) account for half of the deaths secondary to colorectal cancer. Due to the high utilization of chemotherapy before surgery, some or all CRLM can disappear (dCRLM) but management of dCRLMs remains unclear.

METHODS

Seven simulated scenarios of dCRLM were presented to experienced liver surgeons using an online platform. Treatment decisions were submitted and analysed using the multi-rater kappa method. The effect of the experience, complexity of scenarios, and location and number of dCRLM on treatment decision were analysed.

RESULTS

Sixty-seven liver surgeons from 25 countries completed the survey. There was no agreement about the therapeutic strategies of dCRLM in all scenarios (kappa 0.12, IQR 0.20-0.32). In scenarios with lower difficulty scores, surgeons tended to offer surgical resection for dCRLM alongside the visible CRLM (vCRLM), however, with poor agreement (kappa 0.32, IQR 0.19-0.51). No agreement was seen for clinical scenario in which all CRLM lesions disappeared (kappa 0.20).

CONCLUSION

There are clear inconsistencies in the management decisions of dCRLM. Better evidence is required to define optimal management strategies.

Disappearing colorectal liver metastases in the era of state-of-the-art triple-modality diagnostic imaging

INTRODUCTION

Systemic therapy can result in disappearance of colorectal liver metastases in up to 40% of patients. This might be an overestimation caused by suboptimal imaging modalities. The aim of this study was to investigate the use of imaging modalities and the incidence, management and outcome of patients with disappearing liver metastases (DLMs).

METHODS

This was a retrospective study of consecutive patients treated for colorectal liver metastases at a high volume hepatobiliary centre between January 2013 and January 2015 after receiving induction or neoadjuvant systemic therapy. Main outcomes were use of imaging modalities, incidence, management and longterm outcome of patients with DLMs.

RESULTS

Of 158 patients included, 32 (20%) had 110 DLMs. Most patients (88%) had initial diagnostic imaging with contrast enhanced-CT, primovist-MR and FDG-PET and 94% of patients with DLMs were restaged using primovist-MR. Patients with DLMs had significantly smaller metastases and the median initial size of DLMs was 10 mm (range 5-61). In the per lesion analysis, recurrence after "watch & wait" for DLMs occurred in 36%, while in 19 of 20 resected DLMs no viable tumour cells were found. Median overall (51 vs. 28 months, p < 0.05) and progression free survival (10 vs. 3 months, p = 0.003) were significantly longer for patients with DLMs.

CONCLUSION

Even state-of-the-art imaging and restaging cannot solve problems associated with DLMs. Regrowth of these lesions occurs in approximately a third of the lesions. Patients with DLMs have better survival.

Disappearing Colorectal Liver Metastases: Do We Really Need a Ghostbuster?

The development of new systemic treatment strategies has resulted in a significant increase in the response rates of colorectal liver metastases (CRLM) in the last few years. Although the radiological response is a favorable prognostic factor, complete shrinkage of CRLM, known as disappearing liver metastases (DLM), presents a therapeutic dilemma, and proper management is still debated in the literature. In fact, DLM is not necessarily equal to cure, and when resected, pathological examination reveals in more than 80% of patients a variable percentage of the tumor as residual disease or early recurrence in situ. Moreover, while a higher incidence of intrahepatic recurrence is documented in small series when surgery is avoided, its clinical significance for long-term OS is still under investigation. In light of this, a multidisciplinary approach and, in particular, radiologists’ role is needed to assist the surgeon in the management of DLM, thanks to emerging technology and strategy. Therefore, the aim of this review is to provide an overview of the DLM phenomenon and current management.

A radiological footprint equivalent to liquefactive necrosis observed in the course of disappearing liver metastases in rectal cancer: A case report and review of the literature

A 72-year-old female diagnosed with rectal cancer treated with a surgical procedure was reported. As 3 liver metastases (LMs) appeared in multidetector CT, adjuvant chemotherapy using Bevacizumab combined with modified FOLFOX-6 was completed. LMs were changed to cystic lesions during the follow-up period, consistent with liquefactive necrosis. These cystic lesions that appeared in the course of disappearing LMs (DLMs) were identified by CT as homogeneous low signal intensity in hepatocyte specific Gd-enhanced MRI. This might be pathognomonic radiological footprint equivalent to liquefactive necrosis observed in the process of DLM and must be carefully followed in the course of radiological complete response. The radiological changing findings of LMs to cystic changes, high sensitivity of detecting DLM, and limitations of Gd-MRI might be meaningful to clinicians.

The management of colorectal liver metastases amenable of surgical resection: How to shape treatment strategies according to clinical, radiological, pathological and molecular features

Metastatic colorectal cancer (mCRC) patients have poor chances of long term survival, being < 15% of them still alive after 5 years from diagnosis. Nonetheless, patients with colorectal liver metastases (CRLM) may be eligible for metastases resection thus being able to achieve long-term disease remission and survival. The likelihood for patients with CRLM of being or becoming eligible for liver metastasectomy is increasing, thanks to the evolution of surgical techniques, the availability of active systemic treatments and the widespread diffusion of experienced multidisciplinary boards to manage these patients. However, disease relapse after liver surgery is common and occurs in two-thirds of resected patients. Therefore, adequate radiological staging and risk stratification is crucial for the optimal selection of patients candidate to surgery in order to maximize the benefit-risk ratio of liver metastasectomy and to individualize the treatment strategy. Based on the multidimensional assessment, three possible approaches are available: upfront liver surgery followed by adjuvant chemotherapy, perioperative chemotherapy preceding and following liver surgery, and an upfront systemic treatment including chemotherapy plus a targeted agent, both chosen according to patients' and tumours' characteristics, then followed by liver surgery if indicated. In this review, we describe the most important factors impacting the therapeutic choices in patients with resectable and potentially resectable CRLM, and we discuss the most promising factors that may reshape the future decision-making process of these patients.

The Influence of Radiological “Disappearing Lesions” on the Efficacy and Prognosis of Patients with Colorectal Liver Metastases Undergoing Conversion Therapy

Purpose

The purpose of the current study was to analyze the influence of radiological “disappearing liver metastasis” (DLM) on the efficacy and prognosis of patients with colorectal liver metastases (CRLM) undergoing conversion therapy.

Methods

Patients with CRLM by the multidisciplinary team (MDT) of the First Affiliated Hospital of Chongqing Medical University were retrospectively enrolled from January 2014 to January 2021. The relationship between the occurrence and recurrence of DLM and different clinical factors was analyzed.

Results

Thirty-five of the 113 patients (31.0%) with initially unresectable CRLM developed DLM, and of the 361 lesions, 177 disappeared (49.0%). Within 6 months, 6-12 months, and 12-24 months groups, the recurrence rate was 3.4%, 16.8%, and 34.8%, but there is no recurrence in after 24 months group. There was a statistical difference between chemotherapy alone and chemotherapy combined with the targeted therapy group on the occurrence of DLM (58.3% vs. 37.1%, P < 0.001). There were significant differences between <5 mm group and >10 mm group on occurrence of DLM（76.7% vs. 30.4%, P < 0.001) and between 5-10 mm group and >10 mm group also (70.0% vs. 30.4%, P < 0.001). Through univariate and multivariate analyses, it was concluded that age (P = 0.026, 95%CI = 3.690) and treatment regimens (P = 0.033, 95%CI = 2.703) had a significant influence on the progression-free survival (PFS) time of DLM.

Conclusion

Younger patients, who use chemotherapy alone to achieve a therapeutic effect, might have better survival benefits when the lesions do not progress within 2 years after the appearance of DLMs.

Current Surgical Management Strategies for Colorectal Cancer Liver Metastases

Simple Summary

Colorectal cancer is one of the most common cancer diagnoses in the world. At least half of patients diagnosed with colorectal cancer will develop metastatic disease, with most being identified in the liver. Surgical resection of colorectal liver metastases (CRLM) is potentially curative. Surgical resection of CRLM, however, remains underutilized despite the continued expansion of operative strategies available. This is likely due to differing views on resectability. Resectability is a surgical assessment, and the classification of CRLM as unresectable should only be made by an experienced hepatobiliary surgeon. Obtaining a surgical evaluation at the time of liver metastasis discovery may help mitigate the challenge of assessing resectability and the determination of potential operative time windows within current multimodal management strategies. The aim of this review is to help facilitate discussions surrounding resectability as well as the timing and sequencing of both surgical and non-surgical therapies.

Abstract

Colorectal cancer is the third most common cancer diagnosis in the world, and the second most common cause of cancer-related deaths. Despite significant progress in management strategies for colorectal cancer over the last several decades, metastatic disease remains difficult to treat and is often considered incurable. However, for patients with colorectal liver metastases (CRLM), surgical resection offers the best opportunity for survival, can be curative, and remains the gold standard. Unfortunately, surgical treatment options are underutilized. Misperceptions regarding resectable and unresectable CRLM likely play a role in this. The assessment of factors that impact resectability status like medical fitness, technical considerations, and disease biology can be difficult, necessitating careful multidisciplinary input and discussion. The identification of ideal operative time windows that align with the multimodal management of these patients can also be perplexing. For all patients with CRLM it may therefore be advantageous to obtain surgical evaluation at the time of discovering liver metastases to mitigate these challenges and minimize the risk of undertreatment. In this review we summarize current surgical management strategies for CRLM and discuss factors to be considered when determining resectability.

Multi-institutional analysis of outcomes for thermosphere microwave ablation treatment of colorectal liver metastases: the SMAC study

OBJECTIVES

Oligometastatic colorectal cancer benefits of locoregional treatments but data concerning microwave ablation (MWA) are limited and interactions with systemic therapy are still debated. The aim of this study is to evaluate safety and effectiveness of Thermosphere™ MWA (T-MWA) of colorectal liver metastases (CLM) and factors affecting local tumor progression-free survival (LTPFS).

METHODS

In this multi-institutional retrospective study (January 2015-September 2019), patients who underwent T-MWA for CLM were enrolled. Complications according to SIR classification were collected, primary efficacy and LTP were calculated. Analyzed variables included CLM size at diagnosis and at ablation, CLM number, ablation margins, intra-segment progression, chemotherapy before ablation (CBA), variations in size (ΔS_DIA-ABL), and velocity of size variation (V_DIA-ABL) between CLM diagnosis and ablation. Uni/multivariate analyses were performed using mixed effects Cox model to account for the hierarchical structure of data, patient/lesions.

RESULTS

One hundred thirty-two patients with 213 CLM were evaluated. Complications were reported in 6/150 procedures (4%); no biliary complications occurred. Primary efficacy was achieved in 204/213 CLM (95.7%). LTP occurred in 58/204 CLM (28.4%). Six-, twelve-, and eighteen-month LTPFS were 88.2%, 75.8%, and 69.9%, respectively. At multivariate analysis, CLM size at ablation (p = 0.00045), CLM number (p = 0.046), ablation margin < 5 mm (p = 0.0035), and intra-segment progression (p < 0.0001) were statistically significant for LTPFS. ΔS_DIA-ABL (p = 0.63) and V_DIA-ABL (p = 0.38) did not affect LTPFS. Ablation margins in the chemo-naïve group were larger than those in the CBA group (p < 0.0001).

CONCLUSION

T-MWA is a safe and effective technology with adequate LTPFS rates. Intra-segment progression is significantly linked to LTPFS. CBA does not affect LTPFS. Anticipating ablation before chemotherapy may take the advantages of adequate tumor size with correct ablation margin planning.

KEY POINTS

• Thermosphere™-Microwave ablation is a safe and effective treatment for colorectal liver metastases with no registered biliary complications in more than 200 ablations. • Metastases size at time of ablation, intra-segment progression, and minimal ablation margin < 5 mm were found statistically significant for local tumor progression-free survival. • Chemotherapy before ablation modifies kinetics growth of the lesions but deteriorates ablation margins and does not significantly impact local tumor progression-free survival.

Imaging of Colorectal Liver Metastasis

Colorectal cancer (CRC) is one of the most common cancers in the world. The most important determinant of survival and prognosis is the stage and presence of metastasis. The liver is the most common location for CRC metastasis. The only curative treatment for CRC liver metastasis (CRLM) is resection; however, many patients are ineligible for surgical resection of CRLM. Locoregional treatments such as ablation and intra-arterial therapy are also available for patients with CRLM. Assessment of response after chemotherapy is challenging due to anatomical and functional changes. Antiangiogenic agents such as bevacizumab that are used in the treatment of CRLM may show atypical patterns of response on imaging. It is vital to distinguish patterns of response in addition to toxicities to various treatments. Imaging plays a critical role in evaluating the characteristics of CRLM and the approach to treatment. CT is the modality of choice in the diagnosis and management of CRLM. MRI is best used for indeterminate lesions and to assess response to intra-arterial therapy. PET-CT is often utilized to detect extrahepatic metastasis. State-of-the-art imaging is critical to characterize patterns of response to various treatments. We herein review the imaging characteristics of CRLM with an emphasis on imaging changes following the most common CRLM treatments.

Missing colorectal liver metastases: the surgical challenge

BACKGROUND

New chemotherapy schemes have allowed for a better radiological response of unresectable colorectal liver metastases, leading to an interesting scenario known as a complete radiological response. The aim of this study was to review the current management of missing liver metastases (MLM) from the liver surgeon's point of view.

METHODS

A systematic search was conducted on all publications of PubMed and Embase between 2003 and 2018. Meta-analysis was performed on MLM resected/unresected. Residual tumor or regrowth and relapse-free survival were used as evaluation indices.

RESULTS

After literature search, 18 original articles were included for analysis. The predictive factors for MLM are type and duration of chemotherapy and size and number of lesions. Magnetic resonance is the most sensitive preoperative technique. Regarding clinical management, liver surgery is deemed the fundamental pillar in the therapeutic strategy of these patients. Meta-analysis due to data heterogeneity was inconclusive.

CONCLUSIONS

Depending on the clinical context, MLM monitoring appears to be a valid therapeutic alternative. Nevertheless, prospective randomized clinical studies are needed.

MicroRNAs differential expression profile in metastatic colorectal cancer: A pilot study with literature review

BACKGROUND AND OBJECTIVES

Colorectal cancer is still one of the leading causes of cancer-related deaths worldwide and specific tools to improve disease assessment and treatment response are advocated. The aim of this study was to analyze miRNAs expression in metastatic and non-metastatic colorectal cancer, in order to identify reliable biomarkers suitable for prognosis, treatment and patient's monitoring.

MATERIAL AND METHODS

Among 25 patients (mean age 71 ± 12 years; Female/Male: 12/13) submitted to laparoscopic colorectal resection between August 2017 and February 2019, miRNAs were extracted from fresh frozen tissues of solid tumors. Gene expression's analysis arising from microarray technology was performed.

RESULTS

Pathological evaluation identified 15 metastatic patients (8 presenting with stage III and 7 with stage IV cancers) and 10 non-metastatic patients (4 presenting with stage I and 6 stage II cancers). Bioinformatic analysis of solid biopsies revealed 16 miRNAs (11 upregulated and 5 downregulated) differently expressed between metastatic and non-metastatic groups, with three miRNAs (miR-7515, miR-7109-5p and miR-6831-5p) never linked to colorectal cancer before.

CONCLUSIONS

Our study showed an association between miRNAs and metastatic colorectal cancer, suggesting their potential role as biomarkers for tumor management, if confirmed by further studies.

When is a Ghost Really Gone? A Systematic Review and Meta-analysis of the Accuracy of Imaging Modalities to Predict Complete Pathological Response of Colorectal Cancer Liver Metastases After Chemotherapy

BACKGROUND

Administration of chemotherapy to patients with colorectal liver metastases may result in disappearing liver metastases (DLM). This poses a therapeutic dilemma due to the uncertainty of true complete (pathological) response.

OBJECTIVE

We aimed to examine the diagnostic performance of imaging modalities in detecting true complete response in patients with DLM after chemotherapy.

METHODS

We performed a systematic search for articles assessing the diagnostic performance of imaging modalities in evaluating DLM following chemotherapy. True complete response was defined as 1-year recurrence-free survival in non-resected patients or complete pathological response on histologic examination in resected patients. We calculated the negative predictive value (NPV) for detecting true complete response of each imaging modality using a random effects model.

RESULTS

Thirteen studies comprising 332 patients with at least one DLM were included. The number of DLMs after chemotherapy was 955 with computed tomography (CT), 104 with positron emission tomography (PET), 50 with intraoperative ultrasound (IOUS), 585 with magnetic resonance imaging (MRI), and 175 with contrast-enhanced IOUS (CEIOUS). Substantial variation in study design, patient characteristics, and imaging features was observed. Pooled NPV was 0.79 (95% confidence interval [CI] 0.53-0.96), 0.73 (95% CI 0.58-0.85), 0.54 (95% CI 0.37-0.7), 0.47 (95% CI 0.34-0.61), and 0.22 (95% CI 0.11-0.39) for CEIOUS, MRI, IOUS, CT, and PET, respectively.

CONCLUSION

After chemotherapy, MRI or CEIOUS are the most accurate imaging modalities for assessment of DLM and should be used routinely in this context. Given the high NPV of these two modalities, surgical resection of visible CRLM is warranted if technically possible, even if DLM remain.

Hepatic Steatosis Predicts Higher Incidence of Recurrence in Colorectal Cancer Liver Metastasis Patients

Purpose: Colorectal liver metastasis (CRLM) is the major cause of death due to colorectal cancer. Although great efforts have been made in treatment of CRLM, about 60–70% of patients will develop hepatic recurrence. Hepatic steatosis was reported to provide fertile soil for metastasis. However, whether hepatic steatosis predicts higher incidence of CRLM recurrence is not clear. Therefore, we aimed to determine the role of hepatic steatosis in CRLM recurrence in the present study.

Methods: Consecutive CRLM patients undergoing curative treatment were retrospectively enrolled and CT liver-spleen attenuation ratio was used to detect the presence of hepatic steatosis. In patients with hepatic steatosis, we also detected the presence of fibrosis. Besides, a systematic literature search was performed to do meta-analysis to further analyze the association between hepatic steatosis and CRLM recurrence.

Results: A total of 195 eligible patients were included in our center. Patients with hepatic steatosis had a significantly worse overall (P = 0.0049) and hepatic recurrence-free survival (RFS) (P = 0.0012). Univariate and multivariate analysis confirmed its essential role in prediction of RFS. Besides, hepatic fibrosis is associated with worse overall RFS (P = 0.039) and hepatic RFS (P = 0.048). In meta-analysis, we included other four studies, with a total of 1,370 patients in the case group, and 3,735 patients in the control group. The odds ratio was 1.98 (95% CI: 1.25–3.14, P = 0.004), indicating that patients with steatosis had a significantly higher incidence of CRLM recurrence.

Conclusion: In summary, patients with hepatic steatosis had a significantly worse overall and hepatic RFS and it's associated with higher incidence of CRLM recurrence.

Surgical treatment of colorectal liver metastasis

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

What is the optimal number of neoadjuvant chemotherapy cycles for resectable colorectal liver oligometastases?

BACKGROUND

The optimal number of neoadjuvant chemotherapy (NAC) cycles for resectable colorectal liver oligometastases (CLOM) remains unclear. The aim of this study was to investigate the optimal number of NAC cycles.

METHODS

One hundred twenty-nine consecutive patients were included in this study. X-tile analysis was implemented to investigate the optimal cut-off point for NAC cycles. Propensity score matching was performed to reduce selection bias. Kaplan-Meier curves and Cox risk regression models were used to analyse progression-free survival (PFS) and overall survival (OS).

RESULTS

The optimal cut-off point for NAC cycles was 5. There were no significant differences in R0 resection, pathological response or postoperative complications between the groups with a low number of NAC cycles group (≤5 cycles, n=80) and high number of NAC cycles (>5 cycles, n=49). Patients with a high number of NAC cycles were more likely to have NAC toxicity than those with a low number of cycles (87.8% vs. 65.0%, P=0.004). Multivariate analysis revealed that >5 NAC cycles was an independent predictor of reduced PFS (HR =1.808, 95% CI: 1.205-2.712, P=0.004) and reduced OS (HR =1.723, 95% CI: 1.041-2.851, P=0.034). In the oxaliplatin-based regimen group, patients with a low number of NAC cycles had a better PFS (P<0.001, mPFS: 14.7 vs. 5.4 months) and better OS (P=0.018, mOS: 57.7 months vs. 41.0 months) than those with a high number of cycles. After 1:1 propensity matching (34 cases vs. 34 cases), multivariate analysis revealed that >5 NAC cycles was an independent predictor of reduced PFS (HR =2.265, 95% CI: 1.281-4.007, P=0.005) and reduced OS (HR =2.813, 95% CI: 1.359-5.822, P=0.005). In the oxaliplatin-based regimen group, patients with a low number of NAC cycles had better PFS (P<0.001, mPFS: 17.5 vs. 5.6 months) and better OS (P=0.008, mOS: 59.0 vs. 31.8 months) than those with a high number of cycles.

CONCLUSIONS

Fewer than 5 NAC cycles was optimal for biologically resectable CLOM patients. Giving more than 5 NAC cycles was unnecessary because a higher number of NAC cycles has more unfavourable survival and higher NAC toxicities, while leading to similar R0 resection rates and pathological responses.

Imaging in disappearing colorectal liver metastases and their accuracy: a systematic review

Background

Approximately 30% of patients with colorectal cancer develop colorectal liver metastases (CRLM). CRLM that become undetectable by imaging after chemotherapy are called disappearing liver metastases (DLM). But a DLM is not necessarily equal to cure. An increasing incidence of patients with DLM provides surgeons with a difficult dilemma: to resect or to not resect the original sites of DLM? The aim of this review was to investigate to what extent a DLM equates a complete response (CR) and to compare outcomes.

Methods

This review was conducted in accordance with the PRISMA guidelines and registered in Prospero (registration number CRD42017070441). Literature search was made in the PubMed and Embase databases. During the process of writing, PubMed was repeatedly searched and reference lists of included studies were screened for additional studies of interest for this review. Results were independently screened by two authors with the Covidence platform. Studies eligible for inclusion were those reporting outcomes of DLM in adult patients undergoing surgery following chemotherapy.

Results

Fifteen studies were included with a total of 2955 patients with CRLM. They had 4742 CRLM altogether. Post-chemotherapy, patients presented with 1561 DLM. Patients with one or more DLM ranged from 7 to 48% (median 19%). Median DLM per patient was 3.4 (range 0.4–5.6). Patients were predominantly evaluated by contrast-enhanced computed tomography (CE-CT) before and after chemotherapy, with some exceptions and with addition of magnetic resonance imaging (MRI) in some studies. Intraoperative ultrasound (IOUS) was universally performed in all but two studies. If a DLM remained undetectable by IOUS, this DLM represented a CR in 24–96% (median 77.5%). Further, if a DLM on preoperative CE-CT remained undetectable by additional workup with MRI and CE-IOUS, this DLM was equal to a CR in 75–94% (median 89%). Patients with resected DLM had a longer disease-free survival compared to patients with DLM left in situ but statistically significant differences in overall survival could not be found.

Conclusion

Combination of CE-CT, MRI, and IOUS showed promising results in accurately identifying DLM with CR. This suggests that leaving DLM in situ could be an alternative to surgical resection when a DLM remains undetectable by MRI and IOUS.

Immune-Modulating Effects of Conventional Therapies in Colorectal Cancer

Biological heterogeneity and low inherent immunogenicity are two features that greatly impact therapeutic management and outcome in colorectal cancer. Despite high local control rates, systemic tumor dissemination remains the main cause of treatment failure and stresses the need for new developments in combined-modality approaches. While the role of adaptive immune responses in a small subgroup of colorectal tumors with inherent immunogenicity is indisputable, the challenge remains in identifying the optimal synergy between conventional treatment modalities and immune therapy for the majority of the less immunogenic cases. In this context, cytotoxic agents such as radiation and certain chemotherapeutics can be utilized to enhance the immunogenicity of an otherwise immunologically silent disease and enable responsiveness to immune therapy. In this review, we explore the immunological characteristics of colorectal cancer, the effects that standard-of-care treatments have on the immune system, and the opportunities arising from combining immune checkpoint-blocking therapy with immune-modulating conventional treatments.

[Computed tomography and/or magnetic resonance imaging of the liver : How, why, what for?]

CLINICAL PROBLEM

Colorectal metastases are the most common malignant liver lesions. Imaging of the liver in patients with colorectal carcinoma is performed for early detection of liver metastases (CRLM) at the time of initial tumor diagnosis, for monitoring and follow-up in order to exclude or diagnose metachronous metastases.

STANDARD RADIOLOGICAL METHODS

Radiological imaging includes primarily multislice computed tomography (CT) and magnetic resonance imaging (MRI), which play an important role regarding therapeutic management and assessment of prognosis.

PERFORMANCE, ACHIEVEMENTS

Contrast-enhanced CT is broadly available and allows for rapid image acquisition including the possibility for complete tumor staging. MRI, on the other hand, is characterized by very good soft tissue contrast and has-especially with the use of diffusion-weighted imaging and administration of liver-specific contrast agents-the highest sensitivity for detection of metastases smaller than 1 cm.

PRACTICAL RECOMMENDATIONS

The choice of imaging in daily routine is often dependent on availability and clinical question. Frequently, e.g. for assessment of resectability (extent of metastases, anatomic relation of lesions to critical structures), both modalities may be implemented in combination.

Initial systemic chemotherapeutic and targeted therapy strategies for the treatment of colorectal cancer patients with liver metastases

Introduction: The liver is the most common metastatic site in colorectal cancer with more than half the patients developing a liver metastasis either at the time of their diagnosis (synchronous) or later (metachronous). Surgical resection remains the principal curative approach that offers significant survival improvements. However, upfront surgery is only possible in about 10-20% of patients at the time of diagnosis, making the consideration of other treatment modalities essential. Areas covered: In this review, the authors provide an overview of the standard approaches for the initial management of patients with colorectal cancer with liver metastases. They then provide an up-to-date discussion of first-line systemic chemotherapy/targeted therapy options in the contexts of initially resectable and unresectable disease and review toxicities and complications following these options. Expert opinion: Advances in chemotherapeutic agents and biological targeted therapies have improved the prognosis of colorectal cancer with liver metastases. However, there is still no 'single best approach', making further trials necessary to provide more evidence.

Disappearing liver metastases: A systematic review of the current evidence

Advances in systemic chemotherapy have resulted in a significant increase in the reported response rates of colorectal liver metastases (CRLM) over time. Although radiologic response is usually prognostic of favorable outcomes, complete shrinkage of CRLM after chemotherapy, namely "disappearing liver metastases" (DLMs) poses significant therapeutic dilemmas. A systematic review of the literature was conducted to evaluate the existing evidence on the imaging and management of patients with DLMs using the PubMed (Medline), Embase and Cochrane library through December 21st, 2018. The following algorithm was used: "(disappearing OR vanishing OR missing OR (residual tiny)) AND ((liver OR hepatic) AND (metastasis OR metastases OR metastatic OR secondary))." From the 225 records retrieved, 15 studies were finally deemed eligible. A total of 479 patients with DLMs with a median age of 59.5 years (range, 30-83) were identified. Median number of DLM per patient ranged from 1 to 8.8. Median size of LMs prior to chemotherapy was 1.07 cm (range 0.3-3.5). The systemic treatment used to achieve DLMs included systemic chemotherapy alone (only 2 studies) or in combination with targeted agents (11 studies). The median number of chemotherapy cycles in the included studies was 7.8 (range 6-12). Identified factors predisposing to the development of DLM were small size (<2 cm), increased number of treatment cycles, oxaliplatin-based therapy, increased number of CRLM (≥3) and synchronous CRLM. Baseline and preoperative MRI with iv contrast showed the highest sensitivity for DLM detection. Fiducial placement facilitated pre- and intra-operative identification of DLM. Although resection of DLM decreased the local recurrence risk, there was no clearly demonstrated survival benefit after resecting all sites of disappearing lesions. Future randomized clinical trials are highly encouraged to provide strict, evidence-based recommendations for the treatment of patients with DLM.

Colorectal liver metastases: An update on multidisciplinary approach

Liver metastasis is the commonest form of distant metastasis in colorectal cancer. Selection criteria for surgery and liver-directed therapies have recently been extended. However, resectability remains poorly defined. Tumour biology is increasingly recognized as an important prognostic factor; hence molecular profiling has a growing role in risk stratification and management planning. Surgical resection is the only treatment modality for curative intent. The most appropriate surgical approach is yet to be established. The primary cancer and the hepatic metastasis can be removed simultaneously or in a two-step approach; these two strategies have comparable long-term outcomes. For patients with a limited future liver remnant, portal vein embolization, combined ablation and resection, and associating liver partition and portal vein ligation for staged hepatectomy have been advocated, and each has their pros and cons. The role of neoadjuvant and adjuvant chemotherapy is still debated. Targeted biological agents and loco-regional therapies (thermal ablation, intra-arterial chemo- or radio-embolization, and stereotactic radiotherapy) further improve the already favourable results. The recent debate about offering liver transplantation to highly selected patients needs validation from large clinical trials. Evidence-based protocols are missing, and therefore optimal management of hepatic metastasis should be personalized and determined by a multi-disciplinary team.

Evaluation of a strategy using pretherapeutic fiducial marker placement to avoid missing liver metastases

Background

Hepatic surgery is appropriate for selected patients with colorectal liver metastases (CRLM). Advances in chemotherapy have led to modification of management, particularly when metastases disappear. Treatment should address all initial CRLM sites based on pretherapeutic cross-sectional imaging. This study aimed to evaluate pretherapeutic fiducial marker placement to optimize CRLM treatment.

Methods

This pilot investigation included patients with CRLM who were considered for potentially curative treatment between 2009 and 2016. According to a multidisciplinary team decision, lesions smaller than 25 mm in diameter that were more than 10 mm deep in the hepatic parenchyma and located outside the field of a planned resection were marked. Complication rates and clinicopathological data were analysed.

Results

Some 76 metastases were marked in 43 patients among 217 patients with CRLM treated with curative intent. Of these, 23 marked CRLM (30 per cent), with a mean(s.d.) size of 11·0(3·4) mm, disappeared with preoperative chemotherapy. There were four complications associated with marking: two intrahepatic haematomas, one fiducial migration and one misplacement. After a median follow-up of 47·7 (range 18·1-144·9) months, no needle-track seeding was noted. Of four disappearing CRLM that were marked and resected, two presented with persistent active disease. Other missing lesions were treated with thermoablation.

Conclusion

Pretherapeutic fiducial marker placement appears useful for the curative management of CRLM.

Oligometastatic Disease in Colorectal Cancer - How to Proceed?

BACKGROUND

Oligometastatic disease in colorectal cancer may affect the liver, lung, and peritoneum. This review mainly focuses on colorectal liver metastases (CRLM) and highlights recommendations and therapeutic strategies drawn from the current literature and consensus conferences. The following data address a paradigm shift in surgical approaches to CRLM, pushing the limits of multimodal treatment concepts.

METHODS

A systematic review of the relevant literature on multimodal treatment strategies for synchronous and metachronous CRLM is presented.

RESULTS

The choice of treatment strategy depends on the clinical scenario; however, perioperative chemotherapy and the liver-first concept in synchronous CRLM are favored with subsequent partial extended liver resection with or without various augmentation techniques for liver surgery.

CONCLUSION

Surgical strategies should be strongly defined with regard to an adequate liver remnant. All patients with synchronous CRLM should be evaluated by a multidisciplinary team.