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Rubio-García JJ, Mantilla Pinilla AJ, Gil Sánchez S, Villodre Tudela C, Alcázar López C, Melgar Requena P, Rodríguez Laiz G, Irurzun López J, Ramia-Ángel JM. Onyx®, A New Tool for Intraoperative Localization of Liver Lesions. Surg Innov 2024; 31:220-223. [PMID: 38387870 DOI: 10.1177/15533506241236732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Precise preoperative localization of liver tumors facilitates successful surgical procedures, Intraoperative ultrasonography is a sensitive imaging modality. However, the presence of small non-palpable isoechoic intraparenchymal lesions may be challenging intraoperatively. METHODOLOGY AND MATERIAL DESCRIPTION Onyx® is a non-adhesive liquid agent comprised of ethylene-vinyl alcohol usually used dissolved in dimethyl-sulfoxide and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy and ultrasonography and a macroscopic black shape. This embolization material has been increasingly used for the embolization of intracranial arteriovenous malformations. We present the novel application of Onyx® on liver surgery. CURRENT STATUS We present the case of a female, 55 years-old, whose medical history revealed an elective sigmoidectomy (pT3N1a). After 17 months of follow up, by PET-CT scan, the patient was diagnosed of a small intraparenchymal hypo-attenuated 13 mm tumor located at segment V consistent with metachronous colorectal liver metastasis. Open metastasectomy was performed, ultrasonography-guided Onyx® infusion was delivered the day after, intraoperative ultrasonography showed a palpable hyperechoic material with a posterior acoustic shadowing artifact around the lesion. Onyx® is a promising new tool, without any previous application on liver surgery, feasible with advantages in small not palpable intraparenchymal liver lesions.
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Affiliation(s)
- J J Rubio-García
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - A J Mantilla Pinilla
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Servicio de Radiodiagnóstico y Radiología Intervencionista, Hospital General Universitario de Alicante, Alicante, Spain
| | - S Gil Sánchez
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Servicio de Radiodiagnóstico y Radiología Intervencionista, Hospital General Universitario de Alicante, Alicante, Spain
| | - C Villodre Tudela
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - C Alcázar López
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - P Melgar Requena
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - G Rodríguez Laiz
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - J Irurzun López
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Servicio de Radiodiagnóstico y Radiología Intervencionista, Hospital General Universitario de Alicante, Alicante, Spain
| | - J M Ramia-Ángel
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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Chandra P, Sacks GD. Contemporary Surgical Management of Colorectal Liver Metastases. Cancers (Basel) 2024; 16:941. [PMID: 38473303 DOI: 10.3390/cancers16050941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Colorectal cancer is the third most common cancer in the United States and the second most common cause of cancer-related death. Approximately 20-30% of patients will develop hepatic metastasis in the form of synchronous or metachronous disease. The treatment of colorectal liver metastasis (CRLM) has evolved into a multidisciplinary approach, with chemotherapy and a variety of locoregional treatments, such as ablation and portal vein embolization, playing a crucial role. However, resection remains a core tenet of management, serving as the gold standard for a curative-intent therapy. As such, the input of a dedicated hepatobiliary surgeon is paramount for appropriate patient selection and choice of surgical approach, as significant advances in the field have made management decisions extremely nuanced and complex. We herein aim to review the contemporary surgical management of colorectal liver metastasis with respect to both perioperative and operative considerations.
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Affiliation(s)
- Pratik Chandra
- Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Greg D Sacks
- Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
- VA New York Harbor Healthcare System, New York, NY 10010, USA
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Ghazanfar MA, Abdelhamid A, Aldrighetti L, Sturesson C, Takemura N, Truant S, Fiorentini G, Teh C, Alikhanov R, Ahmed I, Hammond J, Ferrero A, Silva M, Pawlik T, Jones R, Bekheit M. The dilemma of the disappearing colorectal liver metastases: defining international trends in management. HPB (Oxford) 2023; 25:446-453. [PMID: 36775699 DOI: 10.1016/j.hpb.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/18/2022] [Accepted: 01/10/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE This survey sought to appraise the degree of consistency in the management of disappeared colorectal liver metastases (dCRLM) among liver surgeons in different countries. BACKGROUND Colorectal liver metastases (CRLM) account for half of the deaths secondary to colorectal cancer. Due to the high utilization of chemotherapy before surgery, some or all CRLM can disappear (dCRLM) but management of dCRLMs remains unclear. METHODS Seven simulated scenarios of dCRLM were presented to experienced liver surgeons using an online platform. Treatment decisions were submitted and analysed using the multi-rater kappa method. The effect of the experience, complexity of scenarios, and location and number of dCRLM on treatment decision were analysed. RESULTS Sixty-seven liver surgeons from 25 countries completed the survey. There was no agreement about the therapeutic strategies of dCRLM in all scenarios (kappa 0.12, IQR 0.20-0.32). In scenarios with lower difficulty scores, surgeons tended to offer surgical resection for dCRLM alongside the visible CRLM (vCRLM), however, with poor agreement (kappa 0.32, IQR 0.19-0.51). No agreement was seen for clinical scenario in which all CRLM lesions disappeared (kappa 0.20). CONCLUSION There are clear inconsistencies in the management decisions of dCRLM. Better evidence is required to define optimal management strategies.
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Affiliation(s)
- Mudassar A Ghazanfar
- Institute of Medical Sciences, University of Aberdeen, Scotland, UK; Department of HPB Surgery, NHS Grampian, Scotland, Aberdeen, UK
| | - Amir Abdelhamid
- Institute of Medical Sciences, University of Aberdeen, Scotland, UK; Department of HPB Surgery, NHS Grampian, Scotland, Aberdeen, UK
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Christian Sturesson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Nobuyuki Takemura
- Department of Surgery, National Center for Global Health and Medicine (NCGM), Tokyo, Japan
| | - Stephanie Truant
- Department of Surgery, Centre Hospitalier Régional Universitaire de Lille: Lille, Nord-Pas-de-Calais, Lille, France
| | - Guido Fiorentini
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, USA
| | - Catherine Teh
- Department of Surgery, Makati Medical Center, Makati Metro Manila, Philippines; Department of Surgery, National Kidney & Transplant Institute, Quezon, Philippines; Department of Surgery, St Luke's Medical Center, Quezon, Philippines
| | - Ruslan Alikhanov
- Moscow Clinical Scientific Center, Department of Liver and Pancreatic Surgery and Transplantation, Russia
| | - Irfan Ahmed
- Institute of Medical Sciences, University of Aberdeen, Scotland, UK; Department of HPB Surgery, NHS Grampian, Scotland, Aberdeen, UK
| | - John Hammond
- Department of HPB and Transplantation, Freeman Hospital, Newcastle Upon Tyne, Newcastle, UK
| | | | - Michael Silva
- Department of Surgery, Oxford University Hospital, Oxford, UK
| | - Timothy Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Ohio, USA
| | - Robert Jones
- Northwest Hepatobiliary Unit, Department of Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Mohamed Bekheit
- Institute of Medical Sciences, University of Aberdeen, Scotland, UK; Department of HPB Surgery, NHS Grampian, Scotland, Aberdeen, UK; HPB Integrated Center of Care, Elite Integrated Centers of Excellence, Alexandria, Egypt.
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Kuhlmann KF, Tufo A, Kok NF, Gordon-Weeks A, Poston GJ, Diaz Nieto R, Jones R, Fenwick SW, Malik HZ. Disappearing colorectal liver metastases in the era of state-of-the-art triple-modality diagnostic imaging. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1016-1022. [PMID: 36702715 DOI: 10.1016/j.ejso.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/19/2022] [Accepted: 01/11/2023] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Systemic therapy can result in disappearance of colorectal liver metastases in up to 40% of patients. This might be an overestimation caused by suboptimal imaging modalities. The aim of this study was to investigate the use of imaging modalities and the incidence, management and outcome of patients with disappearing liver metastases (DLMs). METHODS This was a retrospective study of consecutive patients treated for colorectal liver metastases at a high volume hepatobiliary centre between January 2013 and January 2015 after receiving induction or neoadjuvant systemic therapy. Main outcomes were use of imaging modalities, incidence, management and longterm outcome of patients with DLMs. RESULTS Of 158 patients included, 32 (20%) had 110 DLMs. Most patients (88%) had initial diagnostic imaging with contrast enhanced-CT, primovist-MR and FDG-PET and 94% of patients with DLMs were restaged using primovist-MR. Patients with DLMs had significantly smaller metastases and the median initial size of DLMs was 10 mm (range 5-61). In the per lesion analysis, recurrence after "watch & wait" for DLMs occurred in 36%, while in 19 of 20 resected DLMs no viable tumour cells were found. Median overall (51 vs. 28 months, p < 0.05) and progression free survival (10 vs. 3 months, p = 0.003) were significantly longer for patients with DLMs. CONCLUSION Even state-of-the-art imaging and restaging cannot solve problems associated with DLMs. Regrowth of these lesions occurs in approximately a third of the lesions. Patients with DLMs have better survival.
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Affiliation(s)
- K F Kuhlmann
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, the Netherlands; Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - A Tufo
- Department of General Surgery, Ospedale del Mare, Via Enrico Russo, 80147, Naples, Italy; Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - N F Kok
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, the Netherlands
| | - A Gordon-Weeks
- Nuffield Department of Surgical Sciences, University of Oxford, Old Road, OX3 7BN, United Kingdom
| | - G J Poston
- Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - R Diaz Nieto
- Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - R Jones
- Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - S W Fenwick
- Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - H Z Malik
- Liver Surgery Unit, Aintree University Hospital NHS Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom.
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Impact of Preoperative Chemotherapy Features on Patient Outcomes after Hepatectomy for Initially Unresectable Colorectal Cancer Liver Metastases: A LiverMetSurvey Analysis. Cancers (Basel) 2022; 14:cancers14174340. [PMID: 36077874 PMCID: PMC9454829 DOI: 10.3390/cancers14174340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Prognostic factors have been extensively reported after resection of colorectal liver metastases (CLM); however, specific analyses of the impact of preoperative systemic anticancer therapy (PO-SACT) features on outcomes is lacking. Methods: For this real-world evidence study, we used prospectively collected data within the international surgical LiverMetSurvey database from all patients with initially-irresectable CLM. The main outcome was Overall Survival (OS) after surgery. Disease-free (DFS) and hepatic-specific relapse-free survival (HS-RFS) were secondary outcomes. PO-SACT features included duration (cumulative number of cycles), choice of the cytotoxic backbone (oxaliplatin- or irinotecan-based), fluoropyrimidine (infusional or oral) and addition or not of targeted monoclonal antibodies (anti-EGFR or anti-VEGF). Results: A total of 2793 patients in the database had received PO-SACT for initially irresectable diseases. Short (<7 or <13 cycles in 1st or 2nd line) PO-SACT duration was independently associated with longer OS (HR: 0.85 p = 0.046), DFS (HR: 0.81; p = 0.016) and HS-RFS (HR: 0.80; p = 0.05). All other PO-SACT features yielded basically comparable results. Conclusions: In this international cohort, provided that PO-SACT allowed conversion to resectability in initially irresectable CLM, surgery performed as soon as technically feasible resulted in the best outcomes. When resection was achieved, our findings indicate that the choice of PO-SACT regimen had a marginal if any, impact on outcomes.
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Chávez-Villa M, Ruffolo LI, Tomiyama K, Hernandez-Alejandro R. Where Are We Now With Liver Transplant for Colorectal Metastasis? CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00373-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Colorectal cancer (CRC) is one of the most common cancers in the world. The most important determinant of survival and prognosis is the stage and presence of metastasis. The liver is the most common location for CRC metastasis. The only curative treatment for CRC liver metastasis (CRLM) is resection; however, many patients are ineligible for surgical resection of CRLM. Locoregional treatments such as ablation and intra-arterial therapy are also available for patients with CRLM. Assessment of response after chemotherapy is challenging due to anatomical and functional changes. Antiangiogenic agents such as bevacizumab that are used in the treatment of CRLM may show atypical patterns of response on imaging. It is vital to distinguish patterns of response in addition to toxicities to various treatments. Imaging plays a critical role in evaluating the characteristics of CRLM and the approach to treatment. CT is the modality of choice in the diagnosis and management of CRLM. MRI is best used for indeterminate lesions and to assess response to intra-arterial therapy. PET-CT is often utilized to detect extrahepatic metastasis. State-of-the-art imaging is critical to characterize patterns of response to various treatments. We herein review the imaging characteristics of CRLM with an emphasis on imaging changes following the most common CRLM treatments.
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Muaddi H, Silva S, Choi WJ, Coburn N, Hallet J, Law C, Cheung H, Karanicolas PJ. When is a Ghost Really Gone? A Systematic Review and Meta-analysis of the Accuracy of Imaging Modalities to Predict Complete Pathological Response of Colorectal Cancer Liver Metastases After Chemotherapy. Ann Surg Oncol 2021; 28:6805-6813. [PMID: 33772391 DOI: 10.1245/s10434-021-09824-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Administration of chemotherapy to patients with colorectal liver metastases may result in disappearing liver metastases (DLM). This poses a therapeutic dilemma due to the uncertainty of true complete (pathological) response. OBJECTIVE We aimed to examine the diagnostic performance of imaging modalities in detecting true complete response in patients with DLM after chemotherapy. METHODS We performed a systematic search for articles assessing the diagnostic performance of imaging modalities in evaluating DLM following chemotherapy. True complete response was defined as 1-year recurrence-free survival in non-resected patients or complete pathological response on histologic examination in resected patients. We calculated the negative predictive value (NPV) for detecting true complete response of each imaging modality using a random effects model. RESULTS Thirteen studies comprising 332 patients with at least one DLM were included. The number of DLMs after chemotherapy was 955 with computed tomography (CT), 104 with positron emission tomography (PET), 50 with intraoperative ultrasound (IOUS), 585 with magnetic resonance imaging (MRI), and 175 with contrast-enhanced IOUS (CEIOUS). Substantial variation in study design, patient characteristics, and imaging features was observed. Pooled NPV was 0.79 (95% confidence interval [CI] 0.53-0.96), 0.73 (95% CI 0.58-0.85), 0.54 (95% CI 0.37-0.7), 0.47 (95% CI 0.34-0.61), and 0.22 (95% CI 0.11-0.39) for CEIOUS, MRI, IOUS, CT, and PET, respectively. CONCLUSION After chemotherapy, MRI or CEIOUS are the most accurate imaging modalities for assessment of DLM and should be used routinely in this context. Given the high NPV of these two modalities, surgical resection of visible CRLM is warranted if technically possible, even if DLM remain.
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Affiliation(s)
- Hala Muaddi
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Stephanie Silva
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Woo Jin Choi
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie Coburn
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Calvin Law
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Helen Cheung
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul J Karanicolas
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Muaddi H, Karanicolas P. ASO Author Reflections: Disappearing Liver Metastases: Should We Be Afraid of the Dark? Ann Surg Oncol 2021; 28:6814-6815. [PMID: 33768395 DOI: 10.1245/s10434-021-09883-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Hala Muaddi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Paul Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada. .,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.
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