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Hirokawa F, Hayashi M, Asakuma M, Shimizu T, Komeda K, Inoue Y, Uchiyama K. Early Recurrence After Initial Hepatectomy for Colorectal Liver Metastases. Int Surg 2019; 104:375-82. [DOI: 10.9738/intsurg-d-17-00018.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
This study investigated the frequency of early recurrence in patients who had undergone hepatectomy for colorectal cancer liver metastasis (CRLM) and assessed the indications for adjuvant chemotherapy in these patients.
Methods
This retrospective analysis included 133 consecutive patients who underwent initial hepatectomy for CRLM between April 2000 and May 2010 and have been followed more than 5 years.
Results
Of the 133 patients, 83 (62%) experienced tumor recurrence, with 14 of the 83 recurrences within 6 months after initial hepatectomy. Overall survival was significantly poorer in patients with recurrences within 6 months than those without any recurrence (P = 0.015). The frequency of adjuvant chemotherapy was significantly lower in patients with recurrences within 6 months than those without recurrences within 6 months. Multivariate analysis showed that H-2 classification was the only independent risk factor for recurrence within 6 months after hepatectomy (P = 0.002). Adjuvant chemotherapy improved prognosis in patients classified as H2.
Conclusions
Patients who experienced tumor recurrence within 6 months after initial hepatectomy for CRLM had a poorer prognosis than patients who experienced recurrence after 6 months. Patients with H2-classification of CRLM should receive preoperative adjuvant chemotherapy.
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de Oliveira CVC, Fonseca GM, Kruger JAP, de Mello ES, Coelho FF, Herman P. Histopathological prognostic factors for colorectal liver metastases: A systematic review and meta-analysis of observational studies. Histol Histopathol 2020; 36:159-181. [PMID: 33165892 DOI: 10.14670/hh-18-274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Resection is the mainstay of treatment for colorectal liver metastases (CRLMs). Many different histopathological factors related to the primary colorectal tumour have been well studied; however, histopathological prognostic factors related to CRLMs are still under evaluation. OBJECTIVE To identify histopathological factors related to overall survival (OS) and disease-free survival (DFS) in patients with resected CRLMs. METHODS A systematic review was performed with the following databases up to August 2020: PubMed, EMBASE, Web of Science, SciELO, and LILACS. The GRADE approach was used to rate the overall certainty of evidence by outcome. RESULTS Thirty-three studies including 4,641 patients were eligible. We found very low certainty evidence that the following histopathological prognostic factors are associated with a statistically significant decrease in OS: presence of portal vein invasion (HR, 0,50 [95% CI, 0,37 to 0,68]; I²=0%), presence of perineural invasion (HR, 0,55 [95% CI, 0,36 to 0,83]; I²=0%), absence of pseudocapsule (HR, 0,41 [CI 95%, 0,29 to 0,57], p<0,00001; I²=0%), presence of satellite nodules (OR, 0,45 [95% CI, 0,26 to 0,80]; I²=0%), and the absence of peritumoural inflammatory infiltrate (OR, 0,20 [95% CI, 0,08 to 0,54]; I²=0%). Outcome data on DFS were scarce, except for tumour borders, which did not present a significant impact, precluding the meta-analysis. CONCLUSION Of the histopathological prognostic factors studied, low- to moderate-certainty evidence shows that vascular invasion, perineural invasion, absence of pseudocapsule, presence of satellite nodules, and absence of peritumoral inflammatory infiltrate are associated with shorter overall survival in CRLMs.
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Affiliation(s)
- Cássio Virgílio Cavalcante de Oliveira
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School (USP), São Paulo, Brazil.,Surgery Department, Paraíba Federal University, João Pessoa, Paraíba, Brazil. .,Nova Esperança Medicine Faculty, João Pessoa, Paraíba, Brazil
| | - Gilton Marques Fonseca
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School (USP), São Paulo, Brazil
| | - Jaime Arthur Pirola Kruger
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School (USP), São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Cancer Institute of the State of São Paulo "Octavio Frias de Oliveira" (ICESP), Department of Pathology, University of São Paulo Medical School (USP), São Paulo, Brazil
| | - Fabricio Ferreira Coelho
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School (USP), São Paulo, Brazil
| | - Paulo Herman
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School (USP), São Paulo, Brazil
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Noro T, Nishikawa M, Hoshikawa M, Einama T, Aosasa S, Kajiwara Y, Yaguchi Y, Okamoto K, Shinto E, Tsujimoto H, Hase K, Ueno H, Yamamoto J. Prognostic Impact of Budding Grade in Patients With Residual Liver Recurrence of Colorectal Cancer After Initial Hepatectomy. Ann Surg Oncol 2020; 27:5200-5207. [PMID: 32488517 DOI: 10.1245/s10434-020-08684-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many patients undergoing hepatectomy for colorectal liver metastases (CRLM) experience recurrence. However, no criteria for screening candidates to undergo repeat hepatectomy (RH) for CRLM have been established. Budding, one form by which colorectal carcinoma malignancies are expressed, is a new pathologic index. This study aimed to analyze prognostic factors, including budding, and to provide criteria for screening candidates to undergo RH for recurrent CRLM. METHODS Data of 186 consecutive patients who underwent hepatectomy for CRLM between April 2008 and December 2015 were collected. Survival was calculated using the Kaplan-Meier method. Uni- and multivariate analyses were performed to determine factors significantly affecting mortality. RESULTS Of 186 patients, 131 experienced recurrence after hepatectomy, with 83 of the 131 patients showing recurrence in the liver, and 52 of these 83 patients undergoing primary surgery at the authors' institution and having information on budding grade. In the univariate analysis, preoperative chemotherapy, budding grade, extrahepatic metastases, and number of liver metastases at the time of recurrence were associated with overall survival (OS) for the 52 patients. In the multivariate analysis, budding grade and number of liver metastases at the time of recurrence were associated with OS. CONCLUSION The study examined simple prognostic factors that could help to screen patients better for RH. Repeat hepatectomy improved the prognosis for patients with recurrent CRLM. The independent prognostic factors for OS were number of liver metastases at recurrence as a conventional factor and budding grade as a new pathologic factor. With budding used as an index, patients who could benefit from hepatectomy can be screened more precisely.
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Affiliation(s)
- Takuji Noro
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya-Shi, Saitama, Japan.
| | - Makoto Nishikawa
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Mayumi Hoshikawa
- Department of Surgery, New Tokyo Hospital, Matsudo-Shi, Chiba, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Suefumi Aosasa
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Yoshiki Kajiwara
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Yoshihisa Yaguchi
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Koichi Okamoto
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Kazuo Hase
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Tokorozawa-Shi, Saitama, Japan
| | - Junji Yamamoto
- Department of Surgery, New Tokyo Hospital, Matsudo-Shi, Chiba, Japan
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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: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Lionti S, Reggiani Bonetti L, Bettelli S, Spallanzani A, Gelsomino F, Barresi V. Histopathological variables in liver metastases of patients with stage IV colorectal cancer: potential prognostic relevance of poorly differentiated clusters. Hum Pathol 2018; 78:115-124. [PMID: 29715463 DOI: 10.1016/j.humpath.2018.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/08/2018] [Accepted: 04/12/2018] [Indexed: 02/07/2023]
Abstract
The prognosis of patients with colorectal liver metastases (LMs) is mostly established on clinical variables or on the anatomic extent of colorectal cancer (CRC). Histopathological factors of LMs which may actually reflect the biological aggressiveness of the tumor are not routinely considered to define the risk of worse clinical outcome in those patients. The number of poorly differentiated clusters (PDCs) of neoplastic cells in primary CRC is associated with metastatic risk and bad prognosis, but PDC presence in LMs has been barely analyzed thus far. We assessed PDC presence in the histological slides of surgically resected and synchronous LMs in 63 patients with CRC who had been not submitted to any neoadjuvant treatments. Then, we analyzed its association with patients' cancer-specific survival (CSS) or progression-free survival. The presence of PDCs (P = .016) and PDC localization at tumor edge of LMs (P = .0004) were significantly associated with shorter CSS. PDC presence at the periphery of LMs and positive resection margin were independent prognostic variables for CSS. PDC localization at the tumor edge of LMs was a significant (P = .0079) and independent prognosticator of shorter progression-free survival. Our data suggest that PDC presence and peripheral localization in LMs may be relevant to predict outcome and useful for clinical decision making in patients with colorectal synchronous LMs.
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Affiliation(s)
- Simona Lionti
- Department of Pathology in Evolutive Age and Adulthood "Gaetano Barresi," University of Messina, 98125, Messina, Italy
| | - Luca Reggiani Bonetti
- Department of Laboratory Integrated Activities, Anatomic Pathology and Legal Medicine, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Stefania Bettelli
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124, Modena, Italy
| | - Andrea Spallanzani
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124, Modena, Italy
| | - Fabio Gelsomino
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124, Modena, Italy
| | - Valeria Barresi
- Department of Pathology in Evolutive Age and Adulthood "Gaetano Barresi," University of Messina, 98125, Messina, Italy.
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Acciuffi S, Meyer F, Bauschke A, Settmacher U, Lippert H, Croner R, Altendorf-Hofmann A. Analysis of prognostic factors after resection of solitary liver metastasis in colorectal cancer: a 22-year bicentre study. J Cancer Res Clin Oncol. 2018;144:593-599. [PMID: 29340767 DOI: 10.1007/s00432-018-2583-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/11/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE The investigation of the predictors of outcome after hepatic resection for solitary colorectal liver metastasis. METHODS We recruited 350 patients with solitary colorectal liver metastasis at the University Hospitals of Jena and Magdeburg, who underwent curative liver resection between 1993 and 2014. All patients had follow-up until death or till summer 2016. RESULTS The follow-up data concern 96.6% of observed patients. The 5- and 10-year overall survival rates were 47 and 28%, respectively. The 5- and 10-year disease-free survival rates were 30 and 20%, respectively. The analysis of the prognostic factors revealed that the pT category of primary tumour, size and grade of the metastasis and extension of the liver resection had no statistically significant impact on survival and recurrence rates. In multivariate analysis, age, status of lymph node metastasis at the primary tumour, location of primary tumour, time of appearance of the metastasis, the use of preoperative chemotherapy and the presence of extrahepatic tumour proved to be independent statistically significant predictors for the prognosis. Moreover, patients with rectal cancer had a lower intrahepatic recurrence rate, but a higher extrahepatic recurrence rate. CONCLUSION The long-term follow-up of patients with R0-resected liver metastasis is multifactorially influenced. Age and comorbidity have a role only in the overall survival. More than three lymph node metastasis reduced both the overall and disease-free survival. Extrahepatic tumour had a negative influence on the extrahepatic recurrence and on the overall survival. Neither overall survival nor recurrence rates was improved using neoadjuvant chemotherapy.
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Fonseca GM, Herman P, Faraj SF, Kruger JAP, Coelho FF, Jeismann VB, Cecconello I, Alves VAF, Pawlik TM, de Mello ES. Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol. Histopathology 2017; 72:377-390. [PMID: 28858385 DOI: 10.1111/his.13378] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Colorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.
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Affiliation(s)
- Gilton M Fonseca
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Paulo Herman
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Sheila F Faraj
- Department of Pathology, São Paulo State Cancer Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Jaime A P Kruger
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabricio F Coelho
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vagner B Jeismann
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Digestive Surgery Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
| | - Venancio A F Alves
- Department of Pathology, São Paulo State Cancer Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Evandro S de Mello
- Department of Pathology, São Paulo State Cancer Institute, University of São Paulo Medical School, São Paulo, Brazil
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Abstract
BACKGROUND Metastases to the liver is the leading cause of death in patients with colorectal cancer. METHODS The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered. RESULTS Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%. CONCLUSIONS By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.
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Affiliation(s)
- James M McLoughlin
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612-9497, USA
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Gray SA, Raber MH, Provoost E, Toes GJ, Klaase JM. Colorectal Liver Metastasis, Primary Gallbladder Carcinoma and Myelofibrosis Present Simultaneously in a Liver Resection Specimen. Case Rep Gastroenterol 2015; 9:335-40. [PMID: 26600770 PMCID: PMC4649708 DOI: 10.1159/000441383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Myelofibrosis and gallbladder carcinoma are both very rare diseases. This case report describes a patient with a history of myelofibrosis and colorectal carcinoma who was diagnosed with colorectal liver metastases. Surgery was performed to remove the metastases, and on site, the gallbladder was removed because of involvement in one of the liver lesions. After pathological examination, a primary gallbladder carcinoma and myelofibrosis were found in addition to the liver metastases. The combination of diseases was not likely to be interconnected but rather an unlucky course of events for the patient.
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Affiliation(s)
- Sophie A Gray
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Menno H Raber
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Esther Provoost
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Gert-Jan Toes
- Department of Pathology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
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Luo LX, Yu ZY, Huang JW, Wu H. Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis. Eur J Surg Oncol 2014; 40:1036-48. [PMID: 24915859 DOI: 10.1016/j.ejso.2014.03.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/02/2014] [Accepted: 03/07/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy. METHODS Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score. RESULTS A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001). CONCLUSIONS Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.
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Affiliation(s)
- L X Luo
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China.
| | - Z Y Yu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - J W Huang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - H Wu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
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Vogl TJ, Dommermuth A, Heinle B, Nour-Eldin NE, Lehnert T, Eichler K, Zangos S, Bechstein WO, Naguib NN. Colorectal cancer liver metastases: long-term survival and progression-free survival after thermal ablation using magnetic resonance-guided laser-induced interstitial thermotherapy in 594 patients: analysis of prognostic factors. Invest Radiol. 2014;49:48-56. [PMID: 24056114 DOI: 10.1097/rli.0b013e3182a6094e] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was the evaluation of prognostic factors for long-term survival and progression-free survival (PFS) after treatment of colorectal cancer (CRC) liver metastases with magnetic resonance-guided laser-induced interstital thermotherapy (LITT). PATIENTS AND METHODS We included 594 patients (mean age, 61.2 years) with CRC liver metastases who were treated with LITT. The statistical analysis of the long-term survival and PFS were based on the Kaplan-Meier method. The Cox regression model tested different parameters that could be of prognostic value. The tested prognostic factors were the following: sex, age, the location of primary tumor, the number of metastases, the maximal diameter and total volume of metastases and necroses, the quotient of total volumes of metastases and necroses, the time of appearance of liver metastases and location in the liver, the TNM classification of CRC, extrahepatic metastases, and neoadjuvant treatments. RESULTS The median survival was 25 months starting from the date of the first LITT. The 1-, 2-, 3-, 4-, and 5-year survival rates were 78%, 50.1%, 28%, 16.4%, and 7.8%, respectively. The median PFS was 13 months. The 1-, 2-, 3-, 4-, and 5-year PFS rates were 51.3%, 35.4%, 30.7%, 25.4%, and 22.3%, respectively. The number of metastases and their maximal diameter were the most important prognostic factors for both long-term survival and PFS. Long-term survival was also highly influenced by the initial involvement of the lymph nodes. CONCLUSIONS For patients treated with LITT for CRC liver metastases, the number and size of metastases, together with the initial lymph node status, are significant prognostic factors for long-term survival.
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Jiao SF, Sun K, Chen XJ, Zhao X, Cai N, Liu YJ, Xu LM, Kong XM, Wei LX. Inhibition of tumor necrosis factor alpha reduces the outgrowth of hepatic micrometastasis of colorectal tumors in a mouse model of liver ischemia-reperfusion injury. J Biomed Sci 2014; 21:1. [PMID: 24397824 PMCID: PMC3902418 DOI: 10.1186/1423-0127-21-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/04/2014] [Indexed: 12/13/2022] Open
Abstract
Background Patients with colorectal cancer (CRC) often develop liver metastases, in which case surgery is considered the only potentially curative treatment option. However, liver surgery is associated with a risk of ischemia-reperfusion (IR) injury, which is thought to promote the growth of colorectal liver metastases. The influence of IR-induced tumor necrosis factor alpha (TNF-α) elevation in the process still is unknown. To investigate the role of TNF-α in the growth of pre-existing micrometastases in the liver following IR, we used a mouse model of colorectal liver metastases. In this model, mice received IR treatment seven days after intrasplenic injections of colorectal CT26 cells. Prior to IR treatment, either TNF-α blocker Enbrel or low-dose TNF-α, which could inhibit IR-induced TNF-α elevation, was administered by intraperitoneal injection. Results Hepatic IR treatment significantly promoted CT26 tumor growth in the liver, but either Enbrel or low-dose TNF-α pretreatment reversed this trend. Further studies showed that the CT26 + IR group prominently increased the levels of ALT and AST, liver necrosis, inflammatory infiltration and the expressions of hepatic IL-6, MMP9 and E-selectin compared to those of CT26 group. Inhibition of TNF-α elevation remarkably attenuated the increases of these liver inflammatory damage indicators and tumor-promoting factors. Conclusion These findings suggested that inhibition of TNF-α elevation delayed the IR-enhanced outgrowth of colorectal liver metastases by reducing IR-induced inflammatory damage and the formation of tumor-promoting microenvironments. Both Enbrel and low-dose TNF-α represented the potential therapeutic approaches for the protection of colorectal liver metastatic patients against IR injury-induced growth of liver micrometastases foci.
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Affiliation(s)
| | | | | | | | | | | | | | - Xian-Ming Kong
- Medical Sciences Research Center, Renji hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Road, Shanghai 200127, China.
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Tan MCB, Butte JM, Gonen M, Kemeny N, Fong Y, Allen PJ, Kingham TP, DeMatteo RP, Jarnagin WR, D'Angelica MI. Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis. HPB (Oxford) 2013; 15:803-13. [PMID: 23782400 PMCID: PMC3791120 DOI: 10.1111/hpb.12136] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/29/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model. METHODS Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution. RESULTS In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0-2) or high (3-5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance. DISCUSSION After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.
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Affiliation(s)
- Marcus CB Tan
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Nancy Kemeny
- Department of Medicine, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
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Snoeren N, van Hooff SR, Adam R, van Hillegersberg R, Voest EE, Guettier C, van Diest PJ, Nijkamp MW, Brok MO, van Leenen D, Groot Koerkamp MJA, Holstege FCP, Borel Rinkes IHM. Exploring gene expression signatures for predicting disease free survival after resection of colorectal cancer liver metastases. PLoS One 2012. [PMID: 23185333 PMCID: PMC3504021 DOI: 10.1371/journal.pone.0049442] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study was designed to identify and validate gene signatures that can predict disease free survival (DFS) in patients undergoing a radical resection for their colorectal liver metastases (CRLM). METHODS Tumor gene expression profiles were collected from 119 patients undergoing surgery for their CRLM in the Paul Brousse Hospital (France) and the University Medical Center Utrecht (The Netherlands). Patients were divided into high and low risk groups. A randomly selected training set was used to find predictive gene signatures. The ability of these gene signatures to predict DFS was tested in an independent validation set comprising the remaining patients. Furthermore, 5 known clinical risk scores were tested in our complete patient cohort. RESULT No gene signature was found that significantly predicted DFS in the validation set. In contrast, three out of five clinical risk scores were able to predict DFS in our patient cohort. CONCLUSIONS No gene signature was found that could predict DFS in patients undergoing CRLM resection. Three out of five clinical risk scores were able to predict DFS in our patient cohort. These results emphasize the need for validating risk scores in independent patient groups and suggest improved designs for future studies.
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Affiliation(s)
- Nikol Snoeren
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Sander R. van Hooff
- Department of Molecular Cancer Research, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Rene Adam
- Department of Surgery, Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 12 Avenue Paul Vaillant Couturier, Villejuif, France
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Emile E. Voest
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Catherine Guettier
- Department of Pathology, Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 12 Avenue Paul Vaillant Couturier, Villejuif, France
| | - Paul J. van Diest
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Mariel O. Brok
- Department of Molecular Cancer Research, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Dik van Leenen
- Department of Molecular Cancer Research, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Marian J. A. Groot Koerkamp
- Department of Molecular Cancer Research, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Frank C. P. Holstege
- Department of Molecular Cancer Research, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Inne H. M. Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
- * E-mail:
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15
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Kanas GP, Taylor A, Primrose JN, Langeberg WJ, Kelsh MA, Mowat FS, Alexander DD, Choti MA, Poston G. Survival after liver resection in metastatic colorectal cancer: review and meta-analysis of prognostic factors. Clin Epidemiol 2012; 4:283-301. [PMID: 23152705 PMCID: PMC3496330 DOI: 10.2147/clep.s34285] [Citation(s) in RCA: 258] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Hepatic metastases develop in approximately 50% of colorectal cancer (CRC) cases. We performed a review and meta-analysis to evaluate survival after resection of CRC liver metastases (CLMs) and estimated the summary effect for seven prognostic factors. Methods Studies published between 1999 and 2010, indexed on Medline, that reported survival after resection of CLMs, were reviewed. Meta-relative risks for survival by prognostic factor were calculated, stratified by study size and annual clinic volume. Cumulative meta-analysis results by annual clinic volume were plotted. Results Five- and 10-year survival ranged from 16% to 74% (median 38%) and 9% to 69% (median 26%), respectively, based on 60 studies. The overall summary median survival time was 3.6 (range: 1.7–7.3) years. Meta-relative risks (95% confidence intervals) by prognostic factor were: node positive primary, 1.6 (1.5–1.7); carcinoembryonic antigen level, 1.9 (1.1–3.2); extrahepatic disease, 1.9 (1.5–2.4); poor tumor grade, 1.9 (1.3–2.7); positive margin, 2.0 (1.7–2.5); >1 liver metastases, 1.6 (1.4–1.8); and >3 cm tumor diameter, 1.5 (1.3–1.8). Cumulative meta-analyses by annual clinic volume suggested improved survival with increasing volume. Conclusion The overall median survival following CLM liver resection was 3.6 years. All seven investigated prognostic factors showed a modest but significant predictive relationship with survival, and certain prognostic factors may prove useful in determining optimal therapeutic options. Due to the increasing complexity of surgical interventions for CLM and the inclusion of patients with higher disease burdens, future studies should consider the potential for selection and referral bias on survival.
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16
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Li GZ, Turley RS, Lidsky ME, Barbas AS, Reddy SK, Clary BM. Impact of simultaneous diaphragm resection during hepatectomy for treatment of metastatic colorectal cancer. J Gastrointest Surg 2012; 16:1508-15. [PMID: 22739844 DOI: 10.1007/s11605-012-1896-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/17/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION For colorectal cancer patients with liver metastases involving the hepatic dome or invading the diaphragm, a concomitant diaphragm resection is often required to achieve negative surgical margins. The purpose of this study is to determine whether diaphragm resection during partial hepatectomy for metastatic colorectal cancer influences short-term perioperative outcomes and overall survival. METHODS Demographics, treatments, and outcomes of 442 patients who underwent hepatic resection for metastatic colorectal cancer from 1996 to 2010 at a high-volume center were reviewed. Recurrence and survival were measured from the date of metastectomy. Actuarial curves were generated using the Kaplan-Meier method and compared using log-ranks testing. Multivariate predictors of worse survival were compared using a Cox-proportional hazards model. RESULTS A total of 442 patients underwent hepatectomy for metastatic colorectal cancer. Of these, 34 required simultaneous diaphragm resection (DR) and 408 did not (LR). No significant differences existed in patient demographics or comorbidities. The DR group had longer median operative times (336 vs. 267 min, p = 0.0008) but had comparable rates of perioperative morbidity and mortality. Median overall survival was shorter in the DR group compared to the LR group (18.8 vs. 36 months, p = 0.0017). When controlling for potential cofounders, liver metastases size > 5 cm (HR 1.45 95 % CI (1.08-1.99), p = 0.015) and diaphragm resection (HR = 1.72 95 % CI (1.03-2.86), p = 0.038) predicted worse survival. CONCLUSIONS Simultaneous diaphragm resection during partial hepatectomy does not significantly influence perioperative morbidity or mortality despite longer operative times. However, patients who require diaphragm resection have less favorable survival rates as compared to those who do not.
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Affiliation(s)
- George Z Li
- School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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17
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Nygård IE, Lassen K, Kjæve J, Revhaug A. Mortality and survival rates after elective hepatic surgery in a low-volume centre are comparable to those of high-volume centres. ISRN Surg 2012; 2012:783932. [PMID: 22900204 PMCID: PMC3415082 DOI: 10.5402/2012/783932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 06/26/2012] [Indexed: 12/16/2022]
Abstract
Background. Over the last decades, liver resection has become a frequently performed procedure in western countries because of its acceptance as the most effective treatment for patients with selected cases of metastatic tumours. The purpose of this study was to evaluate the results after hepatic resections performed electively in our centre since 1979 and compare the results to those of larger high-volume centres. Methods. Medical records of all patients who underwent liver resection from January 1979 to December 2011 were reviewed. Disease-free survival and overall survival were determined by Kaplan-Meier analysis. Risk factors for complications were tested with the log-rank test and the Cox proportional hazard model. Complications were classified according to the modified Clavien classification system. Results. 290 elective liver resections were performed between January 1979 and December 2011. There were 171 males (59.0%) and 119 females (41.0%). Median age was 63 years, range 1–87. Overall survival ranged from 0 to 383 months, with a median of 31 months. Five-year survival rate for patients who underwent liver resection for colorectal metastases was 35.8% (34/95). Discussion. Hepatic resections are safely performed at a low-volume centre, with regard to perioperative- and in-house mortality and 5-year survival rates.
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Affiliation(s)
- I E Nygård
- Department of Digestive Surgery, University Hospital of Northern Norway, University of Tromsø, 9038 Tromsø, Norway
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18
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Ramacciato G, D'Angelo F, Baldini R, Petrucciani N, Antolino L, Aurello P, Nigri G, Bellagamba R, Pezzoli F, Balesh A, Cucchetti A, Cescon M, Gaudio MD, Ravaioli M, Pinna AD. Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections. Am Surg 2012. [DOI: 10.1177/000313481207800438] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.
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Affiliation(s)
- Giovanni Ramacciato
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Francesco D'Angelo
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Rossella Baldini
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - NiccolÒ Petrucciani
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Laura Antolino
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Paolo Aurello
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Giuseppe Nigri
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Riccardo Bellagamba
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Francesca Pezzoli
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Albert Balesh
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Alessandro Cucchetti
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Matteo Cescon
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Massimo Del Gaudio
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Matteo Ravaioli
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Antonio Daniele Pinna
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
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Vogl TJ, Jost A, Nour-Eldin NA, Mack MG, Zangos S, Naguib NN. Repeated transarterial chemoembolisation using different chemotherapeutic drug combinations followed by MR-guided laser-induced thermotherapy in patients with liver metastases of colorectal carcinoma. Br J Cancer 2012; 106:1274-9. [PMID: 22382689 DOI: 10.1038/bjc.2012.69] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To evaluate a treatment protocol with repeated transarterial-chemoembolisation (TACE) downsizing before MR-guided laser-induced interstitial thermotherapy (LITT) using different chemotherapeutic combinations in patients with unresectable colorectal cancer (CRC) liver metastases. METHODS Two hundred and twenty-four patients were included in the current study. Transarterial-chemoembolisation (mean 3.4 sessions per patient) was performed as a downsizing treatment to meet the LITT requirements (number5, diameter <5 cm). The intra-arterial protocol consisted of either Irinotecan and Mitomycin (n=77), Gemcitabine and Mitomycin (n=49) or Mitomycin alone (n=98) in addition to Lipiodol and Embocept in all patients. Post TACE, all patients underwent LITT (mean 2.2 sessions per patient). RESULTS Overall, TACE resulted in a mean reduction in diameter of the target lesions of 21.4%. The median time to progression was 8 months, calculated from the start of therapy and the median local tumour control rate was 7.5 months, calculated as of therapy completion. Median survival of patients calculated from the beginning of TACE was 23 months (range 4-110 months), in patients treated with Irinotecan and Mitomycin the median was 22.5 months, Gemcitabine and Mitomycin 23 months and Mitomycin only 24 months with a statistically significant difference between the groups (P<0.01). CONCLUSION Repeated TACE offers adequate downsizing of CRC liver metastases to allow further treatment with LITT. The combined treatment illustrates substantial survival rates and high local tumour control with statistically significant differences between the three protocols used. Further randomised trials addressing the current study results are required.
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Kaibori M, Iwamoto Y, Ishizaki M, Matsui K, Yoshioka K, Asano H, Kwon AH. Predictors and outcome of early recurrence after resection of hepatic metastases from colorectal cancer. Langenbecks Arch Surg 2011; 397:373-81. [DOI: 10.1007/s00423-011-0861-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 10/10/2011] [Indexed: 11/29/2022]
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21
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Lambregts DM, Maas M, Cappendijk VC, Prompers LM, Mottaghy FM, Beets GL, Beets-tan RG. Whole-body diffusion-weighted magnetic resonance imaging: Current evidence in oncology and potential role in colorectal cancer staging. Eur J Cancer 2011; 47:2107-16. [DOI: 10.1016/j.ejca.2011.05.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/11/2011] [Accepted: 05/10/2011] [Indexed: 01/11/2023]
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22
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Grat M, Grzegorczyk K, Lewandowski Z, Sujecki D, Szwedowski D, Boltuc A, Smoter P, Kornasiewicz O, Krawczyk M. Intraoperative injuries during liver resection: analysis of 1,005 procedures. Hepatol Int 2012; 6:498-504. [PMID: 21670969 DOI: 10.1007/s12072-011-9281-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 05/30/2011] [Indexed: 12/27/2022]
Abstract
PURPOSE Risk of liver resection has been well investigated in many studies. However, the problem of intraoperative injuries is rarely mentioned. The aim of this study was to assess the incidence, the type, and management of intraoperative injuries during liver resection. METHODS A total of 1,005 liver resections between 2004 and 2009 were included in this retrospective investigation. We analyzed the incidence of intraoperative injuries, risk factors, and an impact on patients' clinical outcome. RESULTS The overall incidence of intraoperative injuries was 4.4% (44 of 1,005). Injuries of the diaphragm (1.6%, 16 of 1,005) and hepatocaval junction (1%, 10 of 1,005) were the most frequent. In multivariate analysis, tumor recurrence (p = 0.0199) and tumor size (p = 0.0317) were the only independent risk factors for diaphragm injuries, whereas the extent of resection (p = 0.0007) was the only independent risk factor for caval or hepatic vein injuries. Injuries of the inferior vena cava or hepatic veins significantly increased perioperative mortality (p = 0.0005). CONCLUSIONS Minor injuries causing no significant complications were the most frequent. However, prevention and proper management of the rare injuries of hepatocaval junction are essential to avoid increased mortality in major liver resections.
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23
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D'Angelica M, Kornprat P, Gonen M, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Effect on outcome of recurrence patterns after hepatectomy for colorectal metastases. Ann Surg Oncol 2010; 18:1096-103. [PMID: 21042942 DOI: 10.1245/s10434-010-1409-1] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite improvements in surgery and chemotherapy, most patients develop recurrence after hepatectomy for metastatic colorectal cancer. Data are lacking on the effect of these patterns on outcome. METHODS A retrospective review of a prospectively maintained hepatobiliary database was performed. Pattern and timing of recurrence and outcome after recurrence were analyzed. Univariate and multivariate analyses of factors associated with outcome after recurrence were carried out. RESULTS From January 1997 through May 2003, a total of 733 patients underwent hepatectomy for colorectal metastases. Of these, 637 patients (87%) were included in the analysis, and in 393 patients (62%), recurrence was documented at the time of last follow-up. Initial recurrence patterns included the following: liver only in 120 patients (31%), lung only in 107 (27%), other single sites in 49 (12%), and multiple sites in 117 (30%). Recurrence occurred within 2 years of hepatectomy in 75% of patients and after 3 years in 11%. Margins at hepatectomy, recurrence pattern, resected recurrence, and disease-free interval from time of colectomy to hepatic metastasis and from time of hepatectomy to recurrence were independently associated with survival as measured from the time of recurrence. Recurrence in the lung, resected recurrence, and time to recurrence after hepatectomy were associated with prolonged survival as measured from the time of hepatectomy and the time of recurrence. CONCLUSIONS The timing and pattern of recurrence after hepatic resection for metastatic colorectal cancer are important predictors of long-term survival.
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Affiliation(s)
- Michael D'Angelica
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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24
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Gurusamy KS, Imber C, Davidson BR. Management of the hepatic lymph nodes during resection of liver metastases from colorectal cancer: a systematic review. HPB Surg 2008; 2008:684150. [PMID: 18475315 DOI: 10.1155/2008/684150] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2007] [Accepted: 06/22/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatic lymph node involvement is generally considered a contraindication for liver resection performed for colorectal liver metastases. However, some advocate hepatic lymphadenectomy in the presence of macroscopic involvement and others routine lymphadenectomy. The aim of this review is to assess the role of lymphadenectomy in resection of liver metastases from colorectal cancer. METHODS Medline, Embase and Central databases were searched using a formal search strategy. Trials with survival data with a minimum follow-up of 1 year were considered for inclusion. Meta-analysis was performed using Revman. RESULTS A total of 4230 references were identified. Ten reports of nine studies including 926 patients qualified for the review. The prevalence of nodal metastases after routine lymphadenectomy was 16.3%. The overall 3-year and 5-year survival rates in node-positive patients were 9/151 (11.3%) and 2/137 (1.5%), respectively, compared to 3-year and 5-year survival rates of 424/787 (53.9%) and 246/767 (32.1%) in node-negative patients. The odds ratios for 3-year and 5-year survivals in node positive disease compared to node-negative disease were 0.12 (95% CI 0.06 to 0.24) and 0.08 (95% CI 0.03 to 0.22). There was no randomized controlled trial which assessed the survival benefit of routine or "selective" lymphadenectomy. CONCLUSION Currently, there is no evidence of survival benefit for routine or selective lymphadenectomy. Survival rates are low in patients with positive lymph nodes draining the liver irrespective of whether they are detected by routine lymphadenectomy or by macroscopic involvement. Further trials in this patient group are required.
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25
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Gurusamy KS, Ramamoorthy R, Imber C, Davidson BR. Surgical resection versus non-surgical treatment for hepatic node positive patients with colorectal liver metastases. Cochrane Database Syst Rev 2010; 2010:CD006797. [PMID: 20091607 PMCID: PMC7389879 DOI: 10.1002/14651858.cd006797.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Involvement of hepatic lymph node in patients with colorectal liver metastases is associated with poor prognosis. OBJECTIVES To determine the benefits and harms of curative liver resection with lymphadenectomy versus other treatments for colorectal liver metastases with hepatic node involvement. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until September 2009 for identifying the randomised trials. SELECTION CRITERIA We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing liver resection (alone or in combination with radiofrequency ablation or cryoablation) versus other treatments (neo-adjuvant chemotherapy, chemotherapy, or radiofrequency ablation) in patients with colorectal liver metastases with hepatic node involvement. DATA COLLECTION AND ANALYSIS Two authors independently identified trials for inclusion. MAIN RESULTS We were unable to identify any randomised clinical trial fulfilling the inclusion criteria of this review. We were also unable to identify any quasi-randomised or cohort studies, which could meaningfully answer this important issue. AUTHORS' CONCLUSIONS There is no evidence in the literature to assess the role of surgery versus other treatments for patients with colorectal liver metastases with hepatic node involvement. High quality randomised clinical trials are feasible and are necessary to determine the optimal management of patients with colorectal liver metastases with hepatic node involvement.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Hospital and University College School of MedicineUniversity Department of Surgery9th Floor, Royal Free HospitalPond StreetLondonUKNW3 2QG
| | - Rajarajan Ramamoorthy
- Royal Free Hospital and University College School of MedicineUniversity Department of Surgery9th Floor, Royal Free HospitalPond StreetLondonUKNW3 2QG
| | - Charles Imber
- University College London HospitalGeneral Surgery235 Euston RoadLondonUKNW1 2BU
| | - Brian R Davidson
- Royal Free Hospital and University College School of MedicineUniversity Department of Surgery9th Floor, Royal Free HospitalPond StreetLondonUKNW3 2QG
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Abstract
The global incidence of liver cancer is greater than a million cases a year. Surgical resection where applicable is still the standard of care for these patients. Various liver-directed regional therapies have been developed in an effort to treat the vast majority of unresectable liver tumors. This article reviews the principles behind various ablation therapies currently available for malignant liver tumors and their outcomes.
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Affiliation(s)
- Srikanth Padma
- Section of Hepato-Pancreatico-Biliary Surgery, Division of GI & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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Vogl TJ, Wissniowski TT, Naguib NNN, Hammerstingl RM, Mack MG, Münch S, Ocker M, Strobel D, Hahn EG, Hänsler J. Activation of tumor-specific T lymphocytes after laser-induced thermotherapy in patients with colorectal liver metastases. Cancer Immunol Immunother 2009; 58:1557-63. [PMID: 19184001 PMCID: PMC11030790 DOI: 10.1007/s00262-009-0663-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE To asses if laser-induced thermotherapy (LITT) induces a specific cytotoxic T cell response in patients treated with LITT for colorectal cancer liver metastases. METHODS Eleven patients with liver metastases of colorectal cancer underwent LITT. Blood was sampled before and after LITT. Peripheral T cell activation was assessed by an interferon gamma (IFNg) secretion assay and flow cytometry. Test antigens were autologous liver and tumor lysate obtained from each patient by biopsy. T cells were stained for CD3/CD4/CD8 and IFNg to detect activated T cells. The ratio of IFNg positive to IFNg negative T cells was determined as the stimulation index (SI). To assess cytolytic activity, T cells were co-incubated with human colorectal cancer cells (CaCo) and cytosolic adenylate kinase release was measured by a luciferase assay. RESULTS IFNg secretion assay: before LITT SI was 12.73 (+/-4.83) for CD3+, 4.36 (+/-3.32) for CD4+ and 3.64 (+/-1.77) for CD8+ T cells against autologous tumor tissue. Four weeks after LITT SI had increased to 92.09 (+/-12.04) for CD3+ (P < 0.001), 42.92 (+/-16.68) for CD4+ (P < 0.001) and 47.54 (+/-15.68) for CD8+ T cells (P < 0.001) against autologous tumor tissue. No increased SI was observed with normal liver tissue at any time point. Cytotoxicity assay: before LITT activity against the respective cancer cells was low, with RLU = 1,493 (+/-1,954.68), whereas after LITT cytolytic activity had increased to RLU = 7,260 [+/-3,929.76 (P < 0.001)]. CONCLUSION Patients with liver metastases of colorectal cancer show a tumor-specific cytotoxic T cell stimulation and a significantly increased cytolytic activity of CD3+, CD4+ and CD8+ T cells after LITT against an allogenic tumor (CaCo cell line).
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Affiliation(s)
- Thomas Josef Vogl
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Abstract
Abstract
Background
Resection of colorectal liver metastases (CLMs) is potentially curative but the effect of tumour number on prognosis is uncertain. This study compared the prognosis after resection and/or ablation of between one and three, or four or more CLMs.
Methods
A systematic literature review from January 2000 to June 2008 was performed. Study selection and data extraction were standardized, and analysis included assessment of methodological quality, heterogeneity and bias. Main outcomes were 3- and 5-year survival. A meta-analysis comparing radical treatment in the two groups was performed using the hazard ratio for overall survival.
Results
Of 1307 studies screened, 46 (9934 patients) were included in the analysis. Methodological quality was variable, and there was significant heterogeneity and reporting bias. The overall 5-year survival rate after radical treatment ranged from 7 to 58 per cent. Pooled hazard ratio for overall survival was 1·67 (95 per cent confidence interval 1·43 to 1·95; P < 0·001). Median reported 5-year survival for patients with four or more CLMs was 17·1 per cent.
Conclusion
Radical treatment of more than three CLMs results in poorer overall survival. Nevertheless, 5-year survival is achievable and the number of lesions should not, of itself, be used to exclude patients from surgery.
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Affiliation(s)
- M D Smith
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - J L McCall
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
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Nuzzo G, Giuliante F, Ardito F, Vellone M, Giovannini I, Federico B, Vecchio FM. Influence of surgical margin on type of recurrence after liver resection for colorectal metastases: a single-center experience. Surgery 2007; 143:384-93. [PMID: 18291260 DOI: 10.1016/j.surg.2007.09.038] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 08/08/2007] [Accepted: 09/28/2007] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hepatectomy for colorectal liver metastases (CRLM) may offer good long-term survival. The impact of the tumor-free surgical margin on long-term results remains controversial, and we have assessed this component in 185 patients. METHODS Between 1992 and 2005, 185 patients underwent primary hepatectomy with curative intent for CRLM (which originated from colon/rectum 133/52, synchronous/metachronous 66/119, and single/multiple 100/85). In this study, 105 major and 80 minor hepatectomies were evaluated; 133 hepatectomies had pedicle clamping. RESULTS Operative mortality was 1.1%, morbidity was 25.7%, and blood transfusion requirement was 27.6%. Stratification of tumor-free margin in the patients with R0 liver resection was greater than or equal to 10 mm (63.0% of patients), 6-9 mm (11.4% of patients), 3-5 mm (16.5% of patients), and less than or equal to 2 mm (9.1% of patients), with infiltrated margin in the remainder (R1 liver resection 4.9% of the total number of patients). The 3-year, 5-year, and 10-year survival rates were 54.9%, 37.9%, and 22.9%, respectively. Global and surgical margin recurrence rates increased as the tumor-free margin decreased (P = .01 and P < .001, respectively). At univariate analysis, the width of surgical margin (P < .001), transfusion requirement, major hepatectomy, R1 resection, number of metastases, high preoperative CEA, and increasing tumor size (P value from .001 to .03) were associated with lesser rates of long-term survival. A similar association was found with disease-free survival. At multivariate analysis, width of surgical margin was the only independent predictor of both overall (P = .003) and disease-free (P < .001) survival. Although smaller margins were associated with synchronicity, increasing number of, and with bilobar distribution of, metastases which contributed to explain recurrences away from the margin), the width of surgical margin maintained the prominent impact on outcome. CONCLUSIONS In our patients, the width of the surgical margin was a powerful prognostic factor after hepatectomy for CRLM. A resection margin less than or equal to 5 mm was associated with a greater risk of recurrence on the surgical margin, with a lesser rate of overall and disease-free survival.
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Affiliation(s)
- Gennaro Nuzzo
- Department of Surgery, Hepatobiliary Surgery Unit, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy.
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Abstract
In Europe, colorectal cancer is the second most prevalent form of cancer diagnosed. Globally each year, almost one million cases of colorectal cancer are registered and almost half a million deaths are attributed to this disease. This high mortality is associated with the development of liver metastases. For oncological advances to occur, accurate in vivo models are required to study colorectal cancer metastasis development. These models, by increasing our understanding of the early stages of colorectal liver establishment, will facilitate the development of novel therapeutic interventions and allow the clinical effects of these interventions to be studied. By analysis of current in vivo models for early development of colorectal liver metastasis, this review examines available methods of the tumour cell preparation, introduction and monitoring in vivo. An insight into the technical problems which can occur will be discussed. The implications of these different techniques on the resulting metastasis picture will be analysed. Existing in vivo models are assessed regarding the accuracy of the metastatic picture they portray.
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Affiliation(s)
- John H P Robertson
- GI & Hepatobiliary Research Group, Academic Division of Surgery and Interventional Sciences, University College London, London, UK
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Mulier S, Ni Y, Jamart J, Michel L, Marchal G, Ruers T. Radiofrequency ablation versus resection for resectable colorectal liver metastases: time for a randomized trial? Ann Surg Oncol 2007; 15:144-57. [PMID: 17906898 DOI: 10.1245/s10434-007-9478-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Accepted: 05/07/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surgical resection is the gold standard in the treatment of resectable colorectal liver metastases (CRLM). In several centers, resection is being replaced by radiofrequency ablation (RFA), even though there is no evidence yet from randomized trials to support this. The aim of this study was to critically review the oncological evidence for and against the use of RFA for resectable CRLM. METHODS An exhaustive review of RFA of colorectal metastases was carried out. RESULTS Five-year survival data after RFA for resectable CRLM are not available. Percutaneous RFA is associated with worse local control, worse staging, and a small risk of electrode track seeding when compared with resection (level V evidence). For tumors </=3 cm, local control after surgical RFA is equivalent to resection, especially if applied by experienced physicians to nonperivascular tumors (level V evidence). There is indirect evidence for profoundly different biological effects of RFA and resection. CONCLUSIONS A subgroup of patients has been identified for whom local control after RFA might be equivalent to resection. Whether this is true, and whether this translates into equivalent survival, remains to be proven. The time has come for a randomized trial.
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Affiliation(s)
- Stefaan Mulier
- Department of Surgery, Leopold Park Clinic, Froissartstraat 34, B-1040, Brussels, Belgium
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Dicato M, Cherrier S, Van Custsem E, Berchem G. Postsurgical surveillance: How intensive should it be? Curr colorectal cancer rep 2007. [DOI: 10.1007/s11888-007-0014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Thelen A, Jonas S, Benckert C, Schumacher G, Lopez-Hänninen E, Rudolph B, Neumann U, Neuhaus P. Repeat liver resection for recurrent liver metastases from colorectal cancer. Eur J Surg Oncol 2007; 33:324-8. [PMID: 17112697 DOI: 10.1016/j.ejso.2006.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Accepted: 10/09/2006] [Indexed: 12/18/2022] Open
Abstract
AIMS Numerous patients suffer from recurrence after resection of liver metastases from colorectal cancer. Recurrence is frequently restricted to the liver and repeat liver resection may offer a curative option in these patients. This study was conducted to clarify safety and effectiveness of this treatment and to identify prognostic factors of a favourable outcome after repeat hepatectomy. METHODS Between January 1988 and March 2006 in our institution 811 patients underwent 841 liver resections for metastases from colorectal cancer. Among these, 94 patients underwent a repeat hepatectomy. Patients were identified from a prospective database and retrospectively reviewed. Results of different time periods were assessed and prognostic factors for a favourable outcome were determined. RESULTS The perioperative morbidity and mortality was 24% (23 of 94) and 3% (3 of 94), respectively. The one-, three-, five- and ten-year survival for all patients in this series was 89%, 55%, 38% and 23%, respectively. In the univariate analysis, pT-stage of the primary, diameter of the largest metastases, surgical radicality, period of resection and distribution of metastases showed statistically significant influence on survival. The multivariate analysis revealed only pT-stage of the primary tumour, surgical radicality and period of resection as independent prognostic factors. CONCLUSIONS Repeat hepatectomy is a safe and effective treatment for recurrent liver metastases from colorectal cancer. Perioperative risk and long-term survival were similar when compared to the results obtained during the initial resection. Achieving a curative resection is the most relevant prognostic factor for a favourable prognosis after repeat liver resection.
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Affiliation(s)
- A Thelen
- Departmant of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum, Charité Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Abstract
Background The burden of cancer metastases within an individual is commonly used to clinically characterize a tumor's biological behavior. Assessments like these implicitly assume that spurious effects can be discounted. Here the influence of chance on the burden of metastasis is studied to determine whether or not this assumption is valid. Methods Monte Carlo simulations were performed to estimate tumor burdens sustained by individuals with cancer, based upon empirically derived and validated models for the number and size distributions of metastases. Factors related to the intrinsic metastatic potential of tumors and their host microenvironments were kept constant, to more clearly demonstrate the contribution from chance. Results Under otherwise identical conditions, both the simulated numbers and the sizes of metastases were highly variable. Comparable individuals could sustain anywhere from no metastases to scores of metastases, and the sizes of the metastases ranged from microscopic to macroscopic. Despite the marked variability in the number and sizes of the metastases, their respective growth times were rather more narrowly distributed. In such situations multiple occult metastases could develop into fully overt lesions within a comparatively short time period. Conclusion Chance can have a major effect on the burden of metastases. Random variability can be so great as to make individual assessments of tumor biology unreliable, yet constrained enough to lead to the apparently simultaneous appearance of multiple overt metastases.
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Affiliation(s)
- Wayne S Kendal
- Division of Radiation Oncology, The Ottawa Hospital Regional Cancer Centre, 503 Smyth, Ottawa, Ontario, K1H 1C4 Canada.
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