Preoperative and postoperative predictive models of early recurrence for colorectal liver metastases following chemotherapy and curative-intent one-stage hepatectomy

The Influence of Tumor Burden Score and Lymph Node Metastasis on the Survival Benefit of Adjuvant Chemotherapy in Intrahepatic Cholangiocarcinoma

INTRODUCTION

While postoperative adjuvant chemotherapy (AC) is generally recommended for intrahepatic cholangiocarcinoma (ICC), its benefit remains debated. This study aimed to identify patients that may benefit from AC following liver resection of ICC.

METHODS

Patients who underwent liver resection for ICC between 2000 and 2023 were identified from an international multi-institutional database. Individual multivariable Cox models were used to evaluate the interaction between each prognostic factor and the effect of AC on survival.

RESULTS

Among 1412 patients, 431 (30.5%) received AC. Both higher tumor burden score (TBS; hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.91-1.00; p = 0.033) and metastatic lymph node status (HR 0.58, 95% CI 0.38-0.89; p = 0.014) demonstrated interactions with the survival benefit from receipt of AC. Interaction plots highlighted how AC was associated with improved survival beyond a TBS of approximately 6. Notably, among 555 (39.3%) patients with TBS <6 and N0 or Nx status, 5-year overall survival (OS) was no different between patients who received AC versus individuals who did not (55.1% [95% CI 48.9-62.1] vs. 58.7% [95% CI 49.8-69.2]; p = 0.900). In contrast, among 857 (60.7%) patients with TBS ≥6 or N1 status, AC was associated with improved 5-year OS (30.7% [95% CI 26.2-36.0] vs. 33.0% [95% CI 26.9-40.5]; p = 0.018).

CONCLUSIONS

TBS and lymph node status may be useful in a multidisciplinary setting to inform decisions about AC planning for ICC patients following curative-intent resection.

Significance of serum APE1-AAbs, PTX-3, and miR-486-3p in patients with colorectal cancer undergoing radical surgery

BACKGROUND

Colorectal cancer (CRC) is a common malignant tumor of the digestive tract worldwide, characterized by high incidence and mortality rates.

AIM

To investigate the expression of serum apurinic/apyrimidinic endonuclease 1 autoantibodies (APE1-AAbs), peripheral pentraxin-3 (PTX-3), and miR-486-3p in patients with CRC undergoing radical surgery and their relationship with postoperative recurrence and metastasis.

METHODS

A retrospective analysis was conducted on the clinical data of 154 CRC patients who underwent laparoscopic radical surgery in our hospital from January 2022 to January 2024. Patients were followed for one year postoperatively and divided into an occurrence group (n = 28) and a non-occurrence group (n = 126) based on whether they experienced recurrence or metastasis. The clinical data and the expression levels of APE1-AAbs, PTX-3, and miR-486-3p were compared between the two groups. Multivariate logistic regression analysis was performed to identify risk factors for postoperative recurrence and metastasis in CRC patients. The relationship of APE1-AAbs, PTX-3, and miR-486-3p with postoperative recurrence and metastasis was analyzed using Spearman correlation analysis. Receiver operating characteristic curves were drawn to evaluate the predictive value of serum APE1-AAbs, PTX-3, and miR-486-3p levels alone and their combination for postoperative recurrence and metastasis in CRC.

RESULTS

The occurrence group had significantly higher proportions of patients with an age ≥ 60 years, lymph node metastasis, stage III disease, poor differentiation, tumor diameter > 5 cm, and higher platelet count, carcinoembryonic antigen, and carbohydrate antigen 19-9 levels than the non-occurrence group (P < 0.05). The expression levels of APE1-AAbs, PTX-3, and miR-486-3p in the occurrence group were significantly higher than those in the non-occurrence group (P < 0.05). Multivariate logistic regression analysis showed that lymph node metastasis, stage III disease, poor differentiation, and elevated levels of APE1-AAbs, PTX-3, and miR-486-3p were risk factors for postoperative recurrence and metastasis in CRC patients (odds ratio > 1, P < 0.05). Spearman correlation analysis revealed that the levels of APE1-AAbs, PTX-3, and miR-486-3p were positively correlated with postoperative recurrence and metastasis in CRC patients (r = 0.642, 0.653, and 0.631, respectively, P < 0.05). Receiver operating characteristic curve analysis showed that the area under the curve values for APE1-AAbs, PTX-3, and miR-486-3p levels alone and their combination in predicting postoperative recurrence and metastasis in CRC were 0.764, 0.783, 0.806, and 0.875, respectively, with the combination significantly outperforming individual markers (P < 0.05).

CONCLUSION

Serum APE1-AAbs, PTX-3, and miR-486-3p levels are higher in CRC patients with postoperative recurrence and metastasis. These three markers are risk factors for postoperative recurrence and metastasis in CRC and can be used as predictive biomarkers. The combined detection of these markers has higher predictive value compared to individual tests.

A Composite Endpoint of Liver Surgery (CELS): Development and Validation of a Clinically Relevant Endpoint Requiring a Smaller Sample Size

BACKGROUND

The feasibility of trials in liver surgery using a single-component clinical endpoint is low because single endpoints require large samples due to their low incidence. The current study sought to develop and validate a novel composite endpoint of liver surgery (CELS) to facilitate the generation of more feasible and robust high-level evidence in the field of liver surgery.

METHODS

Patients who underwent curative-intent hepatectomy for hepatocellular carcinoma, intrahepatic cholangiocarcinoma, or colorectal liver metastasis were identified using a multi-institutional database. Components of CELS were selected based on perioperative liver surgery-specific complications using univariable logistic regression models. The association of CELS with prolonged length of stay (LOS) and surgery-related death was evaluated and externally validated. Sample sizes were calculated for both individual outcomes and CELS.

RESULTS

Among 1958 patients, 377 (19.3%) met CELS criteria based on postoperative bile leak (n = 221, 11.3%), post-hepatectomy liver failure (n = 71, 3.6%), post-hepatectomy hemorrhage (n = 38, 1.9%), or intraoperative blood loss of 2000 ml or greater (n = 101, 5.2%). CELS demonstrated favorable discriminative accuracy of surgery-related death (analytic cohort: area under the curve [AUC], 0.79 vs external validation cohort: AUC, 0.85). In addition LOS was longer among the patients with a positive CELS (analytic cohort: 14 vs. 9 days [p < 0.001] vs. the validation cohort: 10 vs. 6 days [p < 0.001]). Relative to individual endpoints, CELS allowed a 45.8-91.6% reduction in sample size.

CONCLUSION

CELS effectively predicted surgery-related death and can be used as a standardized, clinically relevant endpoint in prospective trials, facilitating smaller sample sizes and enhancing feasibility compared with single quality outcome metrics.

"Biological R2" resection for intrahepatic cholangiocarcinoma: identification of patients at risk for poor oncologic outcomes after curative-intent resection

INTRODUCTION

We sought to define a cohort of patients with "biological R2" (bR2) resection, defined as recurrence within 12 weeks, following curative-intent resection for intrahepatic cholangiocarcinoma (ICC). In addition, we sought to identify factors associated with bR2 risk.

METHODS

Patients who underwent upfront curative-intent surgery for ICC were identified from an international, multi-institutional database. The weighted beta-coefficients of preoperative risk factors were used to construct an online tool to predict bR2.

RESULTS

Among 1138 patients, 106 (9.3 %) patients had a bR2 resection. Patients with bR2 were more likely to be younger (OR 0.97) and non-White (OR 2.19), as well as more often had cirrhosis (OR 2.11), a higher neutrophil-to-lymphocyte ratio (OR 1.07), a higher tumor burden score (OR 1.16), and metastatic nodal disease on preoperative imaging (OR 1.92). Patients categorized as low-risk had a 3.2 % risk of bR2, intermediate-risk patients had an 11.1 % risk of bR2, whereas patients in the high-risk category had a 27.6 % risk of bR2 (p < 0.001). An online tool was made available at https://junkawashima.shinyapps.io/bR2_ICC/, https://junkawashima.shinyapps.io/CRLMfollwingchemotherapy/.

CONCLUSIONS

Approximately one in ten patients with resectable ICC had a bR2 resection. An online calculator can may help clinicians identify patients with ICC at highest risk of a bR2 resection.

Textbook outcome in liver surgery after staged versus simultaneous resection for synchronous colorectal liver metastases

BACKGROUND

We sought to define the likelihood of textbook outcome in liver surgery (TOLS) among patients undergoing simultaneous versus staged resection for sCRLM.

METHODS

Patients with sCRLM who underwent curative-intent resection between 2000-2022 were identified from an international multi-institutional database. TOLS was defined by the absence of intraoperative grade ≥2 events, R1 resection margin, post-hepatectomy liver failure, bile leakage, major postoperative complications, in-hospital/90-day mortality, and 90-day readmission. Multivariable regression was utilized to study associations between surgical approach and TOLS.

RESULTS

Among 897 patients with median age of 62 (IQR 55-69) years, 376 (41.9 %) patients underwent synchronous resection whereas 521 (58.1 %) patients had staged resection of sCRLM. 62.8 % of patients had TOLS following sCRLM resection and patients who underwent staged resection were more likely to have TOLS (staged: 65.8 % vs. simultaneous: 58.5 %, p = 0.025). Staged resection was associated with 37 % higher odds of TOLS (OR 1.37, 95 % CI 1.04-1.80) than simultaneous resection. Incidence of TOLS decreased with extensive resection (low-risk colectomy and minor hepatectomy: 69.6 % vs. high-risk colectomy and major hepatectomy: 2.8 %; p < 0.001).

CONCLUSION

62.8 % of patients had TOLS following sCRLM resection. Staged versus simultaneous resection was associated with 37 % higher odds of TOLS. Extent of resection should be considered when determining the optimal operative approach.

Recurrence Timing and Risk Following Curative Resection of Colorectal Liver Metastases: Insights From a Hazard Function Analysis

INTRODUCTION

There is no consensus on the optimal surveillance interval for patients undergoing resection of colorectal liver metastases (CRLM). We sought to assess the timing and intensity of recurrence following curative-intent resection of CRLM utilizing a recurrence-free survival (RFS) hazard function analysis.

METHODS

Patients with CRLM who underwent curative-intent resection were identified from a multi-institutional database. The RFS hazard function was used to plot hazard rates and identify the peak of recurrence over time.

RESULTS

Among 1804 patients, the median RFS was 19.9 months. In the analytic cohort, the RFS hazard curve peaked at 5.9 months (peak hazard rate: 0.054) and gradually declined, indicative of early recurrence. In subgroup analyses, patients with high and medium tumor burden scores (TBS) had RFS hazard peaks at 4.9 months (peak hazard rate: 0.060) and 5.8 months (peak hazard rate: 0.054), respectively. In contrast, patients with low TBS had a later peak at 7.5 months, with the lowest peak hazard rate of 0.047.

CONCLUSIONS

The recurrence peak for CRLM patients occurred approximately 6 months postsurgery, highlighting the need for intensified early postoperative surveillance. Patients with high TBS experienced earlier recurrence, underscoring the importance of close monitoring, particularly during the first 6 months after surgery.

Adjuvant chemotherapy for isolated resectable colorectal lung metastasis: A retrospective study using inverse probability treatment weighting propensity analysis

BACKGROUND

The benefit of adjuvant chemotherapy (ACT) for patients with no evidence of disease after pulmonary metastasis resection (PM) from colorectal cancer (CRC) remains controversial.

AIM

To assess the efficacy of ACT in patients after PM resection for CRC.

METHODS

This study included 96 patients who underwent pulmonary metastasectomy for CRC at a single institution between April 2008 and July 2023. The primary endpoint was overall survival (OS); secondary endpoints included cancer-specific survival (CSS) and disease-free survival (DFS). An inverse probability of treatment-weighting (IPTW) analysis was conducted to address indication bias. Survival outcomes compared using Kaplan-Meier curves, log-rank test, Cox regression and confirmed by propensity score-matching (PSM).

RESULTS

With a median follow-up of 27.5 months (range, 18.3-50.4 months), the 5-year OS, CSS and DFS were 72.0%, 74.4% and 51.3%, respectively. ACT had no significant effect on OS after PM resection from CRC [original cohort: P = 0.08; IPTW: P = 0.15]. No differences were observed for CSS (P = 0.12) and DFS (P = 0.68) between the ACT and non-ACT groups. Multivariate analysis showed no association of ACT with better survival, while sublobar resection (HR = 0.45; 95%CI: 0.20-1.00, P = 0.049) and longer disease-free interval (HR = 0.45; 95%CI: 0.20-0.98, P = 0.044) were associated with improved survival.

CONCLUSION

ACT does not improve survival after PM resection for CRC. Further well-designed randomized controlled trials are needed to determine the optimal ACT regimen and duration.