Survival after liver resection for metastatic colorectal carcinoma in a large population

Radiomics and Machine Learning for prediction of two-year disease-specific mortality and KRAS mutation status in metastatic colorectal cancer

PURPOSE

Colorectal cancer is usually accompanied by liver metastases. The prediction of patient evolution is essential for the choice of the appropriate therapy. The aim of this study is to develop and evaluate machine learning models to predict KRAS gene mutations and 2-year disease-specific mortality from medical images.

METHODS

Clinical and follow-up information was collected from patients with metastatic colorectal cancer who had undergone computed tomography prior to liver resection. The dominant liver lesion was segmented in each scan and radiomic features were extracted from the volumes of interest. The 65% of the cases were employed to perform feature selection and to train machine learning algorithms through cross-validation. The best performing models were assembled and evaluated in the remaining cases of the cohort.

RESULTS

For the mortality model development, 101 cases were used as training set (64 alive, 37 deceased) and 35 as test set (22 alive, 13 deceased); while for KRAS mutation models, 55 cases were used for training (31 wild-type, 24 mutated) and 30 for testing (17 wild-type, 13 mutated). The ensemble of top performing models resulted in an area under the receiver operating characteristic curve of 0.878 for mortality and 0.905 for KRAS prediction.

CONCLUSIONS

Predicting the prognosis of patients with metastatic colorectal cancer is useful for making timely decisions about the best treatment options. This study presents a noninvasive method based on quantitative analysis of baseline images to identify factors influencing patient outcomes, with the aim of incorporating these tools as support systems.

The Role of Stereotactic Body Radiation Therapy in the Management of Liver Metastases

The liver is a common site for metastatic spread for various primary tumor histologies. Stereotactic body radiation therapy (SBRT) is a non-invasive treatment technique with broad patient candidacy for the ablation of tumors in the liver and other organs. SBRT involves focused, high-dose radiation therapy delivered in one to several treatments, resulting in high rates of local control. Use of SBRT for ablation of oligometastatic disease has increased in recent years and emerging prospective data have demonstrated improvements in progression free and overall survival in some settings. When delivering SBRT to liver metastases, clinicians must balance the priorities of delivering ablative tumor dosing while respecting dose constraints to surrounding organs at risk (OARs). Motion management techniques are crucial for meeting dose constraints, ensuring low rates of toxicity, maintaining quality of life, and can allow for dose escalation. Advanced radiotherapy delivery approaches including proton therapy, robotic radiotherapy, and real-time MR-guided radiotherapy may further improve the accuracy of liver SBRT. In this article, we review the rationale for oligometastases ablation, the clinical outcomes with liver SBRT, tumor dose and OAR considerations, and evolving strategies to improve liver SBRT delivery.

Survival Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-2)

Introduction: Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-CRLM) was a propensity score matched (PSM) study that reported short-term outcomes of patients with CRLM who met the Milan criteria and underwent either open (OLR), laparoscopic (LLR) or robotic liver resection (RLR). This study, designated as SIMMILR-2, reports the long-term outcomes from that initial study, now referred to as SIMMILR-1. Methods: Data regarding neoadjuvant chemotherapeutic (NC) and neoadjuvant biological (NB) treatments received were collected, and Kaplan−Meier curves reporting the 5-year overall (OS) and recurrence-free survival (RFS) for OLR, LLR and RLR were created for patients who presented with synchronous lesions only, as there was insufficient follow-up for patients with metachronous lesions. Results: A total of 73% of patients received NC and 38% received NB in the OLR group compared to 70% and 28% in the LLR group, respectively (p = 0.5 and p = 0.08). A total of 82% of patients received NC and 40% received NB in the OLR group compared to 86% and 32% in the RLR group, respectively (p > 0.05). A total of 71% of patients received NC and 53% received NB in the LLR group compared to 71% and 47% in the RLR group, respectively (p > 0.05). OS at 5 years was 34.8% after OLR compared to 37.1% after LLR (p = 0.4), 34.3% after OLR compared to 46.9% after RLR (p = 0.4) and 30.3% after LLR compared to 46.9% after RLR (p = 0.9). RFS at 5 years was 12.1% after OLR compared to 20.7% after LLR (p = 0.6), 33.3% after OLR compared to 26.3% after RLR (p = 0.6) and 22.7% after LLR compared to 34.6% after RLR (p = 0.6). Conclusions: When comparing OLR, LLR and RLR, the OS and RFS were all similar after utilization of the Milan criteria and PSM. Biological agents tended to be utilized more in the OLR group when compared to the LLR group, suggesting that highly aggressive tumors are still managed through an open approach.

Surgical Resection of Colorectal Liver Metastases: Attitudes and Practice Patterns in the Deep South

BACKGROUND

Metastatic disease is the leading cause of mortality in colorectal cancer. Resection of colorectal liver metastases, when possible, is associated with improved long-term survival and the possibility of cure. However, nationwide studies suggest that liver resection is under-utilized in the treatment of colorectal liver metastases. This study was undertaken to understand attitudes and practice patterns among medical oncologists in the Deep South.

METHODS

A survey of medical oncologists in the states of Alabama, Mississippi, and the Florida panhandle was performed. Respondents were queried regarding perceptions of resectability and attitudes towards surgical referral.

RESULTS

We received 63 responses (32% response rate). Fifty percent of respondents reported no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic metastatic disease (72%), presence of > 4 metastases (72%), bilobar metastases (61%), and metastases > 5 cm (46%). Bilobar metastatic disease was perceived as a contraindication more frequently by non-academic medical oncologists (70% vs. 33%, p = 0.03).

CONCLUSIONS

Wide variations exist in perceptions of resectability and referral patterns for colorectal liver metastases among surveyed medical oncologists. There is a need for wider dissemination of resectability criteria and more liver surgeon involvement in the management of patients with colorectal liver metastases.

Early Versus Late Recurrence in Rectal Cancer: Does Timing Matter?

BACKGROUND

The definition of early recurrence (ER) in rectal cancer is unclear, and the association of ER with post-recurrence survival (PRS) is poorly described. We therefore sought to identify if time to recurrence (TTR) is associated with PRS.

METHODS

We reviewed all curative-intent resections of nonmetastatic rectal cancer from 2003 to 2018 in our institutional registry within an NCI-Designated Comprehensive Cancer Center. Clinicopathologic data at diagnosis and first recurrence were collected and analyzed. ER was pre-specified at < 24 months and late recurrence (LR) at ≥ 24 months. PRS was evaluated by the Kaplan-Meier method and Cox proportional hazards modeling.

RESULTS

At a median follow-up of 53 months, 61 out of 548 (11.1%) patients undergoing resection experienced recurrence. Median TTR was 14 months (IQR 10-18) with 45 of 61 patients (74%) classified as ER. There were no significant baseline differences between patients with ER and LR. Most recurrences were isolated to the liver (26%) or lung (31%), and 16% were locoregional. ER was not associated with worse PRS compared to LR (P > 0.99). On multivariable analysis, detection of recurrence via workup for symptoms, CEA > 10 ng/mL at recurrence, and site of recurrence were independently associated with PRS.

CONCLUSION

ER is not associated with PRS in patients with resected rectal cancer. Symptomatic recurrences and those accompanied by CEA elevations are associated with worse PRS, while metastatic disease confined to the liver or lung is associated with improved PRS. Attention should be directed away from TTR and instead toward determining therapy for patients with treatable oligometastatic disease.

Repeated hepatectomy after ALPPS for recurrence of colorectal liver metastasis: the edge of limits?

BACKGROUND

Repeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described.

METHODS

Patients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival.

RESULTS

Thirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy.

CONCLUSION

Repeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.

The role of liver transplantation for colorectal liver metastases: A systematic review and pooled analysis

BACKGROUND

Liver transplantation (LT) has gained interest in the treatment of unresectable colorectal liver metastases (CRLM) over the last two decades. Despite the initial poor outcomes, recent reports from countries with graft abundance have provided further insights in the potential of LT as a treatment for unresectable CRLM.

METHODS

A systematic literature search was conducted in the MEDLINE (PubMed), Embase, Scopus, Cochrane Library, Google Scholar, Virtual Health Library, Clinicaltrials.gov, and Web of Science databases (end-of-search date: January 27th, 2020) to identify relevant studies. Pooled overall and recurrence-free survival analysis at 6 months, 1, 2, 3, and 5 years was conducted with the Kaplan-Meier (Product Limit) method.

RESULTS

Eighteen studies comprising 110 patients were included. The population consisted of 59.8% males with a mean age of 52.3 ± 9.3 years. CRLM diagnosis was synchronous in 83%, while 99% received chemotherapy, and 39% received liver resection prior to LT. The mean time from primary tumor resection to LT was 39.5 ± 32.5 months, the mean post-LT follow-up was 32.1 ± 22.2 months, and the mean time to recurrence was 15.0 ± 11.3 months. The pooled 6-month, 1-, 2-, 3-, and 5-year overall survival rates were 95.7% (95%CI: 89.1%-98.4%), 88.1% (95%CI: 79.6%-93.2%), 74.6% (95%CI: 64.2%-82.3%), 58.4% (95%CI: 47.2%-62.0%), and 50.5% (95%CI: 39.0%-61.0%), respectively. The pooled 6-months, 1-, 2-, 3-, and 5-year recurrence-free survival rates were 77.2% (95%CI: 67.2%-84.5%), 59.9% (95%CI: 49.0%-69.2%), 42.4% (95%CI: 31.8%-52.6%), 30.7% (95%CI: 20.9%-41.1%), and 25.6% (95%CI: 16.2%-36.0%), respectively.

CONCLUSION

LT should be considered in patients with unresectable liver-only CRLM under strict selection criteria and only under well-designed research protocols. Ongoing studies are expected to further elucidate the indications and prognosis of patients undergoing LT for unresectable CRLM.

Use of perioperative chemotherapy in colorectal cancer metastatic to the liver

A curative-intent approach may improve survival in carefully selected patients with oligometastatic colorectal cancer. Aggressive treatments are most frequently administered to patients with isolated liver metastasis, though they may be judiciously considered for other sites of metastasis. To be considered for curative intent with surgery, patients must have disease that can be definitively treated while leaving a sufficient functional liver remnant. Neoadjuvant chemotherapy may be used for upfront resectable disease as a test of tumor biology and/or for upfront unresectable disease to increase the likelihood of resectability (so-called 'conversion' chemotherapy). While conversion chemotherapy in this setting aims to improve survival, the choice of a regimen remains a complex and highly individualized decision. In this review, we discuss the role of RAS status, primary site, sidedness, and other clinical features that affect chemotherapy treatment selection as well as key factors of patients that guide individualized patient-treatment recommendations for colorectal-cancer patients being considered for definitive treatment with metastasectomy.

How to increase the resectability of initially unresectable colorectal liver metastases: A surgical perspective

Although surgical resection is the only treatment of choice that can offer prolonged survival and a chance of cure in patients with colorectal liver metastases (CRLM), nearly 80% of patients are deemed to be unresectable at the time of diagnosis. Considerable efforts have been made to overcome this initial unresectability, including expanding the indication of surgery, the advent of conversion chemotherapy, and development and modification of specific surgical techniques, regulated under multidisciplinary approaches. In terms of specific surgical techniques, portal vein ligation/embolization can increase the volume of future liver remnant and thereby reduce the risk of hepatic insufficiency and death after major hepatectomy. For multiple bilobar CRLM that were traditionally considered unresectable even with preoperative chemotherapy and portal vein embolization, two-stage hepatectomy was introduced and has been adopted worldwide with acceptable short- and long-term outcomes. Recently, ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was reported as a novel variant of two-stage hepatectomy. Although issues regarding safety remain unresolved, rapid future liver remnant hypertrophy and subsequent shorter intervals between the two stages lead to a higher feasibility rate, reaching 98%. In addition, adding radiofrequency ablation and vascular resection and reconstruction techniques can allow expansion of the pool of patients with CRLM who are candidates for liver resection and thus a cure. In this review, we discuss specific techniques that may expand the criteria for resectability in patients with initially unresectable CRLM.

Dosimetric comparison of flattened and flattening filter-free beams for liver stereotactic body irradiation in deep inspiration breath hold, and free breathing conditions

Aim

The aim of this study is to evaluate the influence of flattened and flattening filter-free (FFF) beam 6 MV photon beam for liver stereotactic body radiation therapy by using volumetric modulated arc therapy (VMAT) technique in deep inspiration breath hold (DIBH) and free breathing condition.

Materials and methods

Eight liver metastasis patients (one to three metastasis lesions) were simulated in breath hold and free breathing condition. VMAT-based treatment plans were created for a prescription dose of 50 Gy in 10 fractions, using a 230° coplaner arc and 60° non-coplanar arc for both DIBH and free breathing study set. Treatment plans were evaluated for planning target volume (PTV) dose coverage, conformity and hot spots. Parallel and serial organs at risk were compared for average and maximum dose, respectively. Dose spillages were evaluated for different isodose volumes from 5 to 80%.

Result

Mean D98% (dose received by 98% target volume) for FFF in DIBH, flattened beam in DIBH, FFF in free breathing and flatten beam in free breathing dataset were 48·9, 47·81, 48·5 and 48·3 Gy, respectively. D98% was not statistically different between FFF and flatten beam (p = 0·34 and 0·69 for DIBH and free breathing condition). PTV V105% (volume receiving 105% dose) for the same set were 3·76, 0·25, 1·2 and 0·4%, respectively. Mean heterogeneity index for all study sets and beam models varies between 1·05 and 1·07. Paddik conformity index using unflattened and flattened beam in DIBH at 98% prescription dose were 0·91 and 0·79, respectively. Maximum variation of isodose volume was observed for I-5%, which was ranging between 2288·8 and 2427·2 cm3. Increase in isodose value shows a diminishing difference in isodose volumes between different techniques. DIBH yields a significant reduction in the chest wall dose compared with free breathing condition. Average monitor units for FFF beam in DIBH, flattened beam in DIBH, FFF beam in free breathing CT dataset and flattened beam in free breathing CT dataset were 1318·6 ± 265·1, 1940·3 ± 287·6, 1343·3 ± 238·1 and 2192·5 ± 252·6 MU.

Conclusion

DIBH and FFF is a good combination to reduce the treatment time and to achieve better tumour conformity. No other dosimetric gain was observed for FFF in either DIBH or free breathing condition.

Rapid screening of engineered microbial therapies in a 3D multicellular model

Synthetic biology is transforming therapeutic paradigms by engineering living cells and microbes to intelligently sense and respond to diseases including inflammation, infections, metabolic disorders, and cancer. However, the ability to rapidly engineer new therapies far outpaces the throughput of animal-based testing regimes, creating a major bottleneck for clinical translation. In vitro approaches to address this challenge have been limited in scalability and broad applicability. Here, we present a bacteria-in-spheroid coculture (BSCC) platform that simultaneously tests host species, therapeutic payloads, and synthetic gene circuits of engineered bacteria within multicellular spheroids over a timescale of weeks. Long-term monitoring of bacterial dynamics and disease progression enables quantitative comparison of critical therapeutic parameters such as efficacy and biocontainment. Specifically, we screen Salmonella typhimurium strains expressing and delivering a library of antitumor therapeutic molecules via several synthetic gene circuits. We identify candidates exhibiting significant tumor reduction and demonstrate high similarity in their efficacies, using a syngeneic mouse model. Last, we show that our platform can be expanded to dynamically profile diverse microbial species including Listeria monocytogenes, Proteus mirabilis, and Escherichia coli in various host cell types. This high-throughput framework may serve to accelerate synthetic biology for clinical applications and for understanding the host-microbe interactions in disease sites.

Developing and validating a center-specific preoperative prediction calculator for risk of outcomes following major hepatectomy procedures

BACKGROUND

The American College of Surgeons NSQIP^® Surgical Risk Calculator (SRC) was developed to estimate postoperative outcomes. Our goal was to develop and validate an institution-specific risk calculator for patients undergoing major hepatectomy at Carolinas Medical Center (CMC).

METHODS

Outcomes generated by the SRC were recorded for 139 major hepatectomies performed at CMC (2008-2016). Novel predictive models for seven postoperative outcomes were constructed and probabilities calculated. Brier score and area under the curve (AUC) were employed to assess accuracy. Internal validation was performed using bootstrap logistic regression. Logistic regression models were constructed using bivariate and multivariate analyses.

RESULTS

Brier scores showed no significant difference in the predictive ability of the SRC and CMC model. Significant differences in the discriminative ability of the models were identified at the individual level. Both models closely predicted 30-day mortality (SRC AUC: 0.867; CMC AUC: 0.815). The CMC model was a stronger predictor of individual postoperative risk for six of seven outcomes (SRC AUC: 0.531-0.867; CMC AUC: 0.753-0.970).

CONCLUSION

Institution-specific models provide superior outcome predictions of perioperative risk for patients undergoing major hepatectomy. If properly developed and validated, institution-specific models can be used to deliver more accurate, patient-specific care.

Liver resection for colorectal cancer metastases: a comparison of outcomes over time in South Australia

BACKGROUND

The aim of the current study was to assess outcomes following liver resection in metastatic CRC (mCRC) in South Australia across two study periods (pre-2006 versus post-2006).

METHODS

The South Australian (SA) Clinical Registry for mCRC maintains data prospectively on all patients in SA with mCRC diagnosed from 01 February 2006. This data was linked with a prospectively collated database on liver resections for mCRC from 01/01/1992 to 01/02/2006. The primary end point was overall survival.

RESULTS

757 patients underwent liver resection for mCRC. Liver resection was performed on 286 patients pre-2006 and 471 patients post-2006. The median age of the study population was 62 years, and this was similar across both eras. Overall survival was significantly better in the post-2006 era (hazard ratio HR = 0.45, p = 0.001). Complications (59% pre-2006 versus 23% post-2006) and transfusion rates (34% pre-2006 versus 2% post-2006) were significantly higher in the pre-2006 era. Repeat liver resection rates were significantly higher in the post-2006 era (1% pre-2006 versus 10% post-2006).

CONCLUSIONS

Outcomes following liver resection for mCRC have improved over time, with significantly better overall survival in the post-2006 era compared to pre-2006.

Post-pulmonary metastasectomy prognosis after curative resection for colorectal cancer

Purpose

We aimed to compare disease-free survival after pulmonary metastasectomy to that after hepatic metastasectomy, and to identify prognostic factors after pulmonary metastasectomy.

Results

Between 2005 and 2015, 129 patients underwent resection of isolated metachronous lung metastases from colorectal cancer. Three-year DFS after pulmonary metastasectomy was similar to that after hepatic metastasectomy (50.7% vs. 45.5%, respectively; p=0.58). Rectal cancer (hazard ratio [HR]: 2.04, 95% confidence interval [CI]: 1.09–3.79; p=0.03) and ≥2 metastases (HR: 2.17, 95% CI: 1.28–3.68; p=0.004) were independent adverse risk factors associated with disease-free survival after pulmonary metastasectomy on multivariate analysis. Three-year DFS for colon vs. rectal cancer patients was 72.5% vs. 42.6%, respectively (p=0.04). The number of lung metastases was an independent risk factor for DFS after pulmonary metastasectomy in rectal cancer patients.

Patients and Methods

Patients who underwent lung metastasectomy after curative resection of colorectal cancers were investigated. Disease-free survival (DFS) after pulmonary metastasectomy was compared to that after hepatic metastasectomy, which has a relatively well-known prognosis. Multivariate Cox proportional hazards analysis was performed to identify clinical variables predictive of survival after pulmonary metastasectomy.

Conclusions

Disease-free survival rates after resection of lung vs. liver metastases arising from colorectal cancers are similar. However, lung metastases specifically from rectal cancers produce poorer DFS rates. Primary tumor location must be considered for pulmonary metastasis treatment and follow-up in colorectal cancer patients.

Perfusion imaging of colorectal liver metastases treated with bevacizumab and stereotactic body radiotherapy

Stereotactic body radiotherapy (SBRT) and bevacizumab are used in the treatment of colorectal liver metastases. This study prospectively evaluated changes in perfusion of liver metastases in seven patients treated with both bevacizumab and SBRT. Functional imaging using dynamic contrast-enhanced CT perfusion and contrast-enhanced ultrasound were performed at baseline, after bevacizumab, and after SBRT. After bevacizumab, a significant decrease was found in permeability (−28%, p < .05) and blood volume (−47%, p < .05), while SBRT led to a significant reduction in permeability (−22%, p < .05) and blood flow (−37%, p < .05). This study demonstrates that changes in perfusion can be detected after bevacizumab and SBRT.

Prospective comparison of gadoxetic acid-enhanced liver MRI and contrast-enhanced CT with histopathological correlation for preoperative detection of colorectal liver metastases following chemotherapy and potential impact on surgical plan

OBJECTIVE

To prospectively compare the diagnostic performance of gadoxetic acid-enhanced MRI (EOB-MRI) and contrast-enhanced CT (CECT) for preoperative detection of colorectal liver metastases (CRLM) following chemotherapy and to evaluate the potential change in the hepatic resection plan.

METHODS

51 patients with CRLM treated with preoperative chemotherapy underwent liver imaging by EOB-MRI and CECT prospectively. Two independent blinded readers characterized hepatic lesions on each imaging modality using a 5-point scoring system. 41 patients underwent hepatic resection and histopathological evaluation.

RESULTS

151 CRLM were confirmed by histology. EOB-MRI, compared to CECT, had significantly higher sensitivity in detection of CRLM ≤1.0 cm (86% vs. 45.5%; p < 0.001), significantly lower indeterminate lesions diagnosis (7% vs. 33%; p < 0.001) and significantly higher interobserver concordance rate in characterizing the lesions ≤1.0 cm (72% vs. 51%; p = 0.041). The higher yield of EOB-MRI could have changed the surgical plan in 45% of patients.

CONCLUSION

Following preoperative chemotherapy, EOB-MRI is superior to CECT in detection of small CRLM (≤1 cm) with significantly higher sensitivity and diagnostic confidence and interobserver concordance in lesion characterization. This improved diagnostic performance can alter the surgical plan in almost half of patients scheduled for liver resection.

Hepatic Metastasis from Colorectal Cancer

The liver is the most common site of metastasis in patients with colorectal cancer due to its anatomical situation regarding its portal circulation. About 14 to 18% of patients with colorectal cancer present metastasis at the first medical consultation, and 10 to 25% at the time of the resection of the primary colorectal cancer. The incidence is higher (35%) when a computed tomography (CT) scan is used.

In the last decades, a significant increase in the life expectancy of patients with colorectal cancer has been achieved with different diagnostic and treatment programs. Despite these improvements, the presence of metastasis, disease recurrence, and advanced local tumors continue to remain poor prognostic factors.

Median survival without treatment is <8 months from the moment of its presentation, and a survival rate at 5 years of 11% is the best prognosis for those who present with local metastasis. Even in patients with limited metastatic disease, 5-year survival is exceptional. Patients with hepatic metastasis of colorectal cancer have a median survival of 5 to 20 months with no treatment. Approximately 20 to 30% of patients with colorectal metastasis have disease confined to the liver, and this can be managed with surgery. Modern surgical strategies at the main hepatobiliary centers have proved that hepatectomy of 70% of the liver can be performed, with a mortality rate of <5%.

It is very important to have knowledge of predisposing factors, diagnostic methods, and treatment of hepatic metastasis. However, the establishment of newer, efficient, preventive screening programs for early diagnosis and adequate treatment is vital.

How to cite this article: Valderrama-Treviño AI, Barrera-Mera B, Ceballos-Villalva JC, Montalvo-Javé EE. Hepatic Metastasis from Colorectal Cancer. Euroasian J Hepato-Gastroenterol 2017;7(2):166-175.

Surgical management of lung metastases

Management of pulmonary metastases has evolved considerably over the last few decades but is still controversial. The surgical management of lung metastases is outlined, discussing the preoperative management, indications for surgery, the surgical approach and outcomes according to the primary histology.

Normal Tissue Constraints for Abdominal and Thoracic Stereotactic Body Radiotherapy

Although stereotactic body radiotherapy (SBRT) or stereotactic ablative radiotherapy has become an established standard of care for the treatment of a variety of malignancies, our understanding of normal tissue dose tolerance with extreme hypofractionation remains immature. Since Timmerman initially proposed normal tissue dose constraints for SBRT in the 2008 issue of Seminars of Radiation Oncology, experience with SBRT has grown, and more long-term clinical outcome data have been reported. This article reviews the modern toxicity literature and provides updated clinically practical and useful recommendations of SBRT dose constraints for extracranial sites. We focus on the major organs of the thoracic and upper abdomen, specifically the liver and the lung.

Surgical resection of synchronous and metachronous lung and liver metastases of colorectal cancers

PURPOSE

Surgical resection of isolated hepatic or pulmonary metastases of colorectal cancer is an established procedure, with a 5-year survival rate of about 50%. However, the role of surgical resections in patients with both hepatic and pulmonary metastases is not well established. We aimed to analyze overall survival of these patients and associated factors.

METHODS

Data retrospectively collected from 66 patients who underwent both hepatic and pulmonary metastasectomy after colorectal cancer surgery from August 2002 through August 2013 were analyzed. In univariate analysis, the log-rank test compared patient survival between groups. P < 0.1 was considered indicative of significance. Multivariate analysis of the significance data using a Cox proportional hazard model identified factors associated with overall survival. The synchronous group (n = 57) was defined as patients who had metastasectomy within 3 months from primary colorectal cancer surgery. The remaining nine patients constituted the metachronous group.

RESULTS

Median follow-up was 126 months from the primary colorectal cancer surgery. The 5-year survival was 73.4%. There was no difference in overall survival between the synchronous and metachronous groups, consistent with previous studies. Distribution (involving one hemiliver or both, P = 0.010 in multivariate analysis) of liver metastases and multiplicity of the pulmonary metastasis (P = 0.039) were predictors of poor prognosis.

CONCLUSION

Sequential or simultaneous resection of both hepatic and pulmonary metastasis of colorectal cancer resulted in good long-term survival in selected patients. Thus, an aggressive surgical approach and multidisciplinary decision making with surgeons seems to be justified.

Elective hepatic resection is feasible and safe in a regional centre

BACKGROUND

Hepatic resectional surgery remains a highly specialized area of general surgery usually reserved for completion at tertiary metropolitan referral centres. Port Macquarie, on the Mid North Coast of New South Wales, is the only regionally based hospital offering surgery of this nature in mainland Australia. The purpose of this study is to review the data for patients undergoing hepatic resectional surgery in this non-metropolitan centre in order to illustrate that these operations can be carried out safely in a regional setting with comparable results to tertiary-level centres.

METHODS

A retrospective review of consecutive patients undergoing elective hepatic resections at Port Macquarie from February 2008 to 31 October 2015 was completed. Pre-morbid patient clinical and demographic factors, histopathological details, post-operative complications, survival and mortality data were all noted.

RESULTS

A total of 66 consecutive elective liver resections were performed during the study period. Metastatic colorectal cancer was the most commonly observed pathology (n = 33, 50.0%). The 90-day mortality was 4.5% (n = 3) whilst 17 patients (n = 17, 25.8%) experienced major complications (Clavien-Dindo grade 3 or 4). The median overall survival following hepatectomy for colorectal metastases was 48 months (95% confidence interval 37-59 months).

CONCLUSION

Our study shows excellent morbidity, mortality and survival for hepatic resectional surgery performed in a regional centre and is comparable data to major metropolitan centres. Our study confirms that major hepatic resectional surgery in this setting is safe and effective.

Patterns of hepatic resections in North America: use of concurrent partial resections and ablations

BACKGROUND

National registries have not adequately captured concurrent partial hepatic resections or ablations. Therefore, the aim of this analysis was to describe the patterns of concurrent partial resections and ablations in North America.

METHODS

Patients undergoing a hepatic resection were identified using the American College of Surgeons-National Surgical Quality Improvement Program Targeted Hepatectomy database. Perioperative outcomes were compared for patients undergoing concurrent "wedge" resections and/or ablations and other subsets.

RESULTS

A total of 2714 patients were identified who met inclusion criteria. Major hepatectomy was performed in 1037 patients (38.2%) while partial lobectomy was performed in 1677 (61.8%) patients. Concurrent "wedge" hepatic resections and ablations were undertaken in 56.0% and 14.2% of patients, respectively, and were more frequently performed among patients undergoing a partial lobectomy and among patients undergoing surgery for colorectal liver metastasis (both p < 0.001). While associated with a decreased incidence of postoperative complications (p = 0.027) and liver failure (p = 0.031) among patients undergoing a major hepatectomy, concurrent therapies were associated with comparable 30-day outcomes for patients undergoing partial lobectomy.

CONCLUSION

Concurrent "wedge" hepatic resections and ablations are performed in 56.0% and 14.2%, respectively of patients undergoing hepatectomy. Concurrent procedures were not associated with worse clinical outcomes.

Image guided SBRT for multiple liver metastases with ExacTrac® Adaptive Gating

AIM

To report the outcome and toxicity of sequential stereotactic body radiotherapy (SBRT) for multiple liver metastases in patients treated with ExacTrac Adaptive Gating.

BACKGROUND

In selected patients with a limited number of liver metastases, SBRT has been evaluated as a safe and effective treatment, with minimal toxicity and high rates of local control.

MATERIALS AND METHODS

From April 2008 to October 2013, 21 patients with multiple (3-14) liver metastases (n = 101) were treated sequentially with SBRT at our institution. Maximum tumor diameter was 7.5 cm. Prior to treatment, internal markers were placed inside or near the tumor. CT or PET-CT simulation was used for the definition of gross tumor volume (GTV). Median planning target volume was 32.3 cc (3.6-139.3 cc). Treatment consisted of 3 fractions (12-20 Gy/fraction) or 5 fractions (10 Gy/fraction), prescribed to the 90-95% of the PTV volume. Daily intra-fraction image guidance was performed with ExacTrac Adaptive Gating. Regular follow-up included CT or PET-CT imaging.

RESULTS

After a median of 23.2 months, the estimated local control rate was 94.4%, 80.6%, 65% and 65% after 1, 2, 3 and 4 years; the median overall survival was 62 months (95% CI 49.12-74.87) and the actuarial survival reached at 60 months was 57.6%. The univariate data analysis revealed that only primary histology other than colorectal adenocarcinoma was shown as an independent significant prognostic factor for local control (p = 0.022). Number of treated metastases did not modify significantly the overall survival (p = 0.51). No toxicity higher than G3 (1 patient with chest wall pain) and no radiation-induced liver disease were observed.

CONCLUSIONS

Sequential SBRT with ExacTrac Adaptive Gating for multiple liver metastases can be considered an effective, safe therapeutic option, with a low treatment-related toxicity. Excellent rates of local control and survival were obtained.

Is Survival for Patients with Resectable Lung Metastatic Colorectal Cancer Comparable to Those with Resectable Liver Disease? Results from the South Australian Metastatic Colorectal Registry

BACKGROUND

Hepatic resection for colorectal (CRC) metastasis is considered a standard of care. Resection of metastasis isolated to lung also is considered potentially curable, although there is still some variation in recommendations. We explore outcomes for patients undergoing lung resection for mCRC, with the liver resection group as the comparator.

METHODS

South Australian (SA) metastatic CRC registry data were analysed to assess patient characteristics and survival outcomes for patients suitable for lung or liver resection.

RESULTS

A total of 3241 patients are registered on the database to December 2014. One hundred two (3.1 %) patients were able to undergo a lung resection compared with 420 (12.9 %) who had a liver resection. Of the lung resection patients, 62 (61 %) presented with lung disease only, 21 % initially presented with liver disease only, 11 % had both lung and liver, and 7 % had brain or pelvic disease resection. Of these patients, 79 % went straight to surgery without any neoadjuvant treatment and 34 % had lung resection as the only intervention. Chemotherapy for metastatic disease was given more often to liver resection patients: 76.9 versus 53.9 %, p = 0.17. Median overall survival is 5.6 years for liver resection and has not been reached for lung resection (hazard ratio 0.82, 95 % confidence interval 0.54-1.24, p = 0.33).

CONCLUSIONS

Lung resection was undertaken in 3.1 % of patients with mCRC in our registry. These data provide further support for long-term survival after lung resection in mCRC, survival that is at least comparable to those who undergo resection for liver metastasis in mCRC.

Programmable probiotics for detection of cancer in urine

Rapid advances in the forward engineering of genetic circuitry in living cells has positioned synthetic biology as a potential means to solve numerous biomedical problems, including disease diagnosis and therapy. One challenge in exploiting synthetic biology for translational applications is to engineer microbes that are well tolerated by patients and seamlessly integrate with existing clinical methods. We use the safe and widely used probiotic Escherichia coli Nissle 1917 to develop an orally administered diagnostic that can noninvasively indicate the presence of liver metastasis by producing easily detectable signals in urine. Our microbial diagnostic generated a high-contrast urine signal through selective expansion in liver metastases (10(6)-fold enrichment) and high expression of a lacZ reporter maintained by engineering a stable plasmid system. The lacZ reporter cleaves a substrate to produce a small molecule that can be detected in urine. E. coli Nissle 1917 robustly colonized tumor tissue in rodent models of liver metastasis after oral delivery but did not colonize healthy organs or fibrotic liver tissue. We saw no deleterious health effects on the mice for more than 12 months after oral delivery. Our results demonstrate that probiotics can be programmed to safely and selectively deliver synthetic gene circuits to diseased tissue microenvironments in vivo.

Failure to Achieve a 2-Stage Hepatectomy for Colorectal Liver Metastases: How to Prevent It?

OBJECTIVES

The aim of the study was to identify predictive factors of failure of 2-stage hepatectomy (TSH) for the selection of patients with extensive bilobar colorectal liver metastases (CRLM), who are candidates for TSH.

BACKGROUND

The main weakness of TSH is the risk of failure to complete both the sequential procedures.

METHODS

Between 2000 and 2012, from a total cohort of 845 patients resected for CRLM, 125 patients (14.8%) with extensive CRLM were planned for TSH. All factors related to the failure of TSH were analyzed, and a predictive model was built utilizing the independent predictive factors of failure.

RESULTS

Forty-four patients (35.2%) could not proceed to the second stage, and their overall survival (OS) was significantly worse than that of those who completed the TSH (5-year OS: 0% vs 44.2%; P < 0.0001). Multivariate analysis revealed that carcinoembryonic antigen >30 ng/mL [relative risk (RR) 2.73, P = 0.03], tumor size >40 mm (RR 2.89, P = 0.04), chemotherapy cycles >12 (RR 3.46, P = 0.01), and tumor progression during first-line chemotherapy (RR 6.56, P = 0.01) were independent predictive factors of failure. For patients not presenting any factors, the probability of failure was 10.5%, with a 5-year OS rate of 41.9%. The addition of each subsequent factor increased the risk to 43.5%, 72.7%, 88.5%, and 95.5%, and decreased the 5-year OS to 38.8%, 29.2%, 0%, and 0%, respectively, for 1, 2, 3, and 4 factors.

CONCLUSIONS

TSH should not be recommended in patients with more than 2 risk factors. Avoidance of these factors significantly reduces the risk of failure and is crucial for long-term survival.

Diffusion-weighted and hepatobiliary phase gadoxetic acid-enhanced quantitative MR imaging for identification of complete pathologic response in colorectal liver metastases after preoperative chemotherapy

PURPOSE

To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) to differentiate colorectal liver metastasis (CRLM) with complete pathologic response from those with incomplete response in patients treated with preoperative chemotherapy.

METHODS

Gadoxetic acid-enhanced liver MRI and DWI were performed after completion of preoperative chemotherapy in patients with CRLM scheduled for liver resection. Metastases were classified as those with complete pathologic response (CR-CRLM) or incomplete response (IR-CRLM) according to postsurgical histopathology. Quantitative analysis was performed on non-contrast-enhanced images and hepatobiliary phase images following gadoxetic acid administration. Apparent diffusion coefficient values (ADC), normalized relative enhancement (NRE), and relative signal intensity difference (RSID) along with their diagnostic measures for detection of CR-CRLM were calculated for all lesions.

RESULTS

In 23 patients, 10 CR-CRLM and 35 IR-CRLM (mean diameter, 21.2 mm) were evaluated. In CR-CRLM, ADC was significantly higher after exclusion of the outliers (p = 0.030); and RSID was significantly lower (p = 0.008). Combined indices range of ADC = 1.25-1.9 × 10(-3) mm(2)/s, NRE = 0-35% and RSID <120 had 60% sensitivity and 100% specificity for detection of CR-CRLM.

CONCLUSION

DWI and gadoxetic acid-enhanced MRI appear promising for the detection of CRLM with complete response to preoperative chemotherapy. This could have significant implications for liver resection planning after preoperative chemotherapy.

Surgical resection and peri-operative chemotherapy for colorectal cancer liver metastases: A population-based study

BACKGROUND

Most literature describing surgery for colorectal cancer (CRC) liver metastases (LM) comes from high volume centres. Here, we report management and outcomes achieved in routine clinical practice.

METHODS

All cases of CRC in Ontario who underwent resection of LM in 1994-2009 were identified using the population-based Ontario Cancer Registry. Electronic treatment records identified chemotherapy delivery. Temporal trends are described for 3 periods: 1994-1999, 2000-2004, 2005-2009. We describe volume of resected CRCLM as a ratio of incident cases per CRCLM resection. Overall (OS) and cancer-specific survival (CSS) are measured from time of LM resection.

RESULTS

2717 patients underwent resection of CRCLM. Between 1994 and 2009 there was a 78% increase in case volume; from one resection for every 48 incident cases to one resection for every 27 incident cases, p < 0.001. Use of peri-operative chemotherapy increased over study periods from 44% (306/700), to 52% (429/830), to 65% (777/1187, p < 0.001). Chemotherapy utilization rates varied across geographic regions (range 43%-69%, p < 0.001). Post-operative mortality rates at 30 and 90 days were 2.5% and 4.3% respectively. Five year OS during the study periods was 36% (95% CI 32-39%), 40% (95% CI 36-43%), and 46% (95% CI 43-49%) (p < 0.001); CSS was 38% (95% CI 35-42%), 42% (95% CI 38-45%), 49% (95% CI 44-53%) (p < 0.001). The temporal improvement in OS/CSS persisted on adjusted analyses.

CONCLUSIONS

Outcomes of patients with resected CRCLM in routine practice is comparable to those reported from high volume centres. Survival improved over the study period despite a greater proportion of patients with CRC undergoing liver resection.

CT texture analysis in colorectal liver metastases: A better way than size and volume measurements to assess response to chemotherapy?

BACKGROUND

Response Evaluation Criteria In Solid Tumors (RECIST) are known to have limitations in assessing the response of colorectal liver metastases (CRLMs) to chemotherapy.

OBJECTIVE

The objective of this article is to compare CT texture analysis to RECIST-based size measurements and tumor volumetry for response assessment of CRLMs to chemotherapy.

METHODS

Twenty-one patients with CRLMs underwent CT pre- and post-chemotherapy. Texture parameters mean intensity (M), entropy (E) and uniformity (U) were assessed for the largest metastatic lesion using different filter values (0.0 = no/0.5 = fine/1.5 = medium/2.5 = coarse filtration). Total volume (cm(3)) of all metastatic lesions and the largest size of one to two lesions (according to RECIST 1.1) were determined. Potential predictive parameters to differentiate good responders (n = 9; histological TRG 1-2) from poor responders (n = 12; TRG 3-5) were identified by univariable logistic regression analysis and subsequently tested in multivariable logistic regression analysis. Diagnostic odds ratios were recorded.

RESULTS

The best predictive texture parameters were Δuniformity and Δentropy (without filtration). Odds ratios for Δuniformity and Δentropy in the multivariable analyses were 0.95 and 1.34, respectively. Pre- and post-treatment texture parameters, as well as the various size and volume measures, were not significant predictors. Odds ratios for Δsize and Δvolume in the univariable logistic regression were 1.08 and 1.05, respectively.

CONCLUSIONS

Relative differences in CT texture occurring after treatment hold promise to assess the pathologic response to chemotherapy in patients with CRLMs and may be better predictors of response than changes in lesion size or volume.

A systematic review and meta-analysis to reappraise the role of adjuvant hepatic arterial infusion for colorectal cancer liver metastases

OBJECTIVE

The potential benefit of adjuvant hepatic arterial infusion remains unknown for patients with colorectal liver metastases after radical hepatic resection. The principle aim of this study was to investigate the long-term outcome of adjuvant hepatic arterial infusion.

METHODS

Eligible trials were identified from Embase, PubMed, the Web of Science, and the Cochrane library since their inception to June 1, 2014. Patients with colorectal liver metastases, who underwent radical hepatic resection and received adjuvant hepatic arterial infusion, were enrolled. The study outcomes included 5-year disease-free and overall survival rate, respectively. Hazard ratio with a 95 % confidence interval was used to measure the pooled effect according to a random effects model or fixed effects model, depending on the heterogeneity between the included studies. The statistical heterogeneity between trials was detected by I (2) test. Sensitivity analyses were also carried out.

RESULTS

A total of nine studies containing 1057 patients were included. The comparison indicated that the overall pooled hazard ratio for 5-year overall survival was 0.75 (95 % CI: 0.56-0.99, p = 0.048). The hazard ratio for 5-year disease-free survival rate was 0.61 (95 % CI: 0.48-0.79, p = 0.001). When compared with systemic chemotherapy alone, adjuvant hepatic arterial infusion plus systemic chemotherapy also improved the long-term survival.

CONCLUSIONS

Adjuvant hepatic arterial infusion improved the 5-year disease-free and overall survival rate, respectively. It should be recommended for patients with a high risk of recurrence, but these findings require prospective confirmation.

SABR for aggressive local therapy of metastatic cancer: A new paradigm for metastatic non-small cell lung cancer

Metastectomy has been performed for many years in situations where the functional consequences allow it, for example in the liver, lung, adrenal glands, and ovaries. This history suggests that selected patients may benefit from aggressive treatment of metastases. Technological developments now allow for ablative treatment of other tumor sites and perhaps for larger volume and/or increasing multiplicity of disease using Stereotactic Ablative Radiation Therapy (SABR) with relatively lower risk of morbidity to patients. Here we further explore the concept of aggressive local treatment of metastatic disease in adult patients and review the rationale for use of SABR to treat metastases and highlight new data supporting this approach in metastatic Non-Small Cell Lung Cancer.

Complications following liver resection for colorectal metastases do not impact on longterm outcome

BACKGROUND

It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases.

OBJECTIVES

This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases.

METHODS

A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999-2008 was conducted.

RESULTS

The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of > 300 ml, multiple metastases, large (≥ 35 mm) metastases and resection margins of < 1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor.

CONCLUSIONS

Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors.

Phase II study on hepatic arterial infusion chemotherapy using percutaneous catheter placement techniques for liver metastases from colorectal cancer (JFMC28 study)

AIM

This prospective multicenter study aimed to evaluate the efficacy and adverse events of hepatic arterial infusion chemotherapy (HAIC) using percutaneous catheter placement techniques for liver metastases from colorectal cancer (CRC).

METHODS

We administered 5-fluorouracil at 1000 mg/m2 over 5 h via hepatic arterial infusion on a weekly schedule. The primary endpoint was the overall response rate (RR). The secondary endpoints were the overall survival (OS), progression-free survival (PFS) and toxicities.

RESULTS

Between February 2000 and March 2002, seventy-seven eligible patients were enrolled in this study. After a median of 26 treatment cycles, 4 patients achieved a complete response, 29 achieved a partial response, 28 had stable disease, 15 had progressive disease and the status of one patient was unknown. The overall RR was 42.9% and the disease control rate (DCR) was 79.2%. The median PFS and OS times were 203 and 560 days, respectively. The most common grade 3 or 4 hematological and non-hematological toxicities were total bilirubin level elevation (10.4%) and gamma-glutamyl transferase level elevation (10.4%). With regard to the relationship between the background factors and treatment outcomes, the DCR, RR, PFS and OS were different between patients with and without extrahepatic lesions (DCR: 86.5% vs 64%, RR: 46.2% vs 36.0%, PFS: 233 days vs 99 days, OS: 587 days vs 558 days).

CONCLUSION

The primary endpoint of this study was not met. HAIC using percutaneous catheter placement techniques did not improve the RR for liver metastasis from CRC.

Impact of surgical margins on overall and recurrence-free survival in parenchymal-sparing laparoscopic liver resections of colorectal metastases

BACKGROUND

The relationship between the width of surgical margins and local and distant recurrence of colorectal liver metastases (CRLM) remain controversial. We analyzed the impact of surgical margins in laparoscopic liver resections (LLR) for CRLM, using the parenchymal-sparing approach on overall (OS) and recurrence-free survival (RFS).

METHODS

From January 2005 to October 2012, 114 first LLR for CRLM were performed and retrospectively analyzed. The ultrasonic aspirator was used for parenchyma division. R1 margins were defined when the tissue width was <1 mm.

RESULTS

After a mean follow-up of 30.9 ± 1.71 months, OS was 97.1-73.9-58.9% and the RFS 64.2-35.2-31% at 1-3-5 years, respectively. The major resection rate was 7%. The median margin width was 3 (0-40) mm, and R1 resection was recorded in 14 (12.3%) cases. Twenty-two patients (33.3%) with hepatic recurrence underwent a repeat hepatectomy. R1 margins were significantly related to lower RFS survival (p = 0.038) but did not affect OS. Multivariate analysis showed that lesions located in postero-superior segments (HR = 2.4, 95% CI 1.24-4.61, p = 0.009) as well as blood loss (HR = 3.2, 95% CI 1.23-7.99, p = 0.012) were independent risk factors for tumor recurrence. The carcinoembryonic antigen level >10 mcg/L affected OS (HR = 4.2 95% CI 2.02-16.9, p = 0.001), and the resection of more than two tumors was significantly associated with R1 margins (HR = 9.32, 95% CI 1.14-32.5, p = 0.037).

DISCUSSION

Laparoscopic parenchymal-sparing surgery of CRLM does not compromise the oncological outcome, allowing a higher percentage of repeat hepatectomy. R1 margins are a risk factor for tumor recurrence but not for overall survival. The presence of multiple lesions is the only independent risk factor of R1 margins and also the major disadvantage of this technique.

Optimal management of colorectal liver metastases in older patients: a decision analysis

BACKGROUND

Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.

METHODS

A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.

RESULTS

In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.

CONCLUSIONS

HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.

Systematic review of outcomes of patients undergoing resection for colorectal liver metastases in the setting of extra hepatic disease

BACKGROUND

Surgical resection for patients with colorectal liver metastases (CRLM) can offer patients a significant survival benefit. We hypothesised that patients with CRLM and extra hepatic disease (EHD) undergoing metastasectomy had comparable survival and describe outcomes based on the distribution of metastatic disease.

METHODS

A systematic search using a predefined registered protocol was undertaken between January 2003 and June 2012. Primary exposure was hepatic resection for CRLM and primary outcome measure was overall survival. Meta-regression techniques were used to analyse differences between patients with and without extra hepatic disease.

FINDINGS

From a pool of 4996 articles, 50 were retained for data extraction (3481 CRLM patients with EHD). The median survival (MS) was 30.5 (range, 9-98) months which was achieved with an operative mortality rate of 0-4.2%. The 3-year and 5-year overall survival (OS) were 42.4% (range, 20.6-77%) and 28% (range, 0-61%) respectively. Patients with EHD of the lungs had a MS of 45 (range, 39-98) months versus lymph nodes (portal and para-aortic) 26 (range, 21-48) months versus peritoneum 29 (range, 18-32) months. The MS also varied by the amount of liver disease - 42.2months (<two lesions) versus 39.6months (two lesions) versus 28months (⩾three lesions).

INTERPRETATION

In the evolving landscape of multimodality therapy, selective hepatic resection for CRLM patients with EHD is feasible with potential impact on survival. Patients with minimal liver disease and EHD in the lung achieve the best outcome.

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

OBJECTIVE

A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).

METHODS

A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.

RESULTS

Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.

CONCLUSION

A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.

Rationale for ablation of oligometastatic disease and the role of stereotactic body radiation therapy for hepatic metastases

Management paradigms for metastatic solid tumors are evolving. Once regarded as uniformly incurable, today there is recognition of an intermediate oligometastatic state, where ablation of metastatic foci may improve disease control and prolong survival. In the setting of limited colorectal liver metastases, hepatic resection has resulted in favorable long-term outcomes, but is technically unsuitable for most patients. Stereotactic body radiation therapy represents an effective, noninvasive means of tumor ablation, supported by a large body of prospective evidence specific to hepatic metastases. This review examines the current rationale for ablation of oligometastatic disease, including various objectives beyond indefinite disease-free survival. The role of stereotactic body radiation therapy for ablation of hepatic metastases is then comprehensively reviewed.

Splenic volume may be a useful indicator of the protective effect of bevacizumab against oxaliplatin-induced hepatic sinusoidal obstruction syndrome

AIMS

The aim of this study was to investigate the relationship between the use of bevacizumab (Bmab) in addition to oxaliplatin (OX), the development of sinusoidal obstruction syndrome (SOS) and the changes in splenic volume as an indicator of the protective effect of Bmab against OX-induced SOS.

METHODS

Seventy-nine patients who received OX-based chemotherapy with (OX + Bmab group: n = 48) or without Bmab (OX group: n = 31) for colorectal liver metastases were included in this study. The changes in splenic volume after chemotherapy were evaluated in the two groups. Furthermore, the relationship between the changes in splenic volume and SOS were analyzed in the 55 patients who underwent hepatectomy.

RESULTS

A significant increase in the splenic volume was observed in the OX group, but not in the OX + Bmab group. The increase in the splenic volume relative to baseline was significantly higher in the OX group than in the OX + Bmab group (39.1% vs. 2.3%, p < 0.0001). The incidence of moderate or severe SOS was significantly higher in the OX group than in the OX + Bmab group (50.0% vs. 16.0%, p = 0.0068), and the increase in the splenic volume was significantly higher in the patients with SOS than in those without SOS (42.9% vs. 9.9%, p = 0.0001). A multivariate analysis identified the increase in the splenic volume as an independent predictor of the development of SOS.

CONCLUSIONS

This study demonstrated that the inhibition of splenic volume enlargement might be a useful indicator of the protective effect of Bmab against OX-induced SOS.

Impact of hepatectomy margin on survival following resection of colorectal metastasis: the role of adjuvant therapy and its effects

INTRODUCTION

The optimal width of microscopic margin and the use of adjuvant therapy after a positive margin for hepatic resection for colorectal liver metastasis (CRCLM) has not been conclusively determined. The aim of the current study is to evaluate the influence of width of surgical margin and adjunctive therapy upon disease free and overall survival.

METHODS

All patients undergoing hepatectomy for CRCLM from 1997 to 2012 were identified from a prospectively maintained, IRB approved database. Patients were divided into four subgroups based on the parenchymal margin: positive, <0.1 cm, 0.1 cm-1 cm, and >1 cm.

RESULTS

A total of 373 patients were included for analysis with a median follow up of 26 months (range 9-103 months) and a median overall survival of 53 months. The resection margin was positive (26 patients median OS 24 months), <0.1 cm (48 patients median OS 36 mon), 0.1 cm-1 cm (82 patients median OS 44 months), and >1 cm (217 patients median OS 64 months). The most common adjunctive therapy was chemotherapy, hepatic arterial therapy, or local. Patients with positive margins also had the shortest disease free survival (DFS), 16 months. The DFS was similar amongst the other margin groups (<0.1 cm: 21 months, 0.1-1 cm: 22 months, >1 cm 25 months). Hepatectomy margin independently influenced survival (p = 0.017) and disease free survival (p = 0.034). Patients with negative margins has similar overall recurrence rates (p = 0.36) and survival rates (p = 0.89).

CONCLUSIONS

A positive surgical margin indicates a worse overall biology of disease for patients undergoing hepatectomy for CRCLM, and appropriate multi-disciplinary therapy should be considered in this high risk patient population. Marginal width if a complete resection has been achieved does not adversely effect overall surgical in patients with CRCLM.

Computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT) ablation of metastases adjacent to the liver hilum

PURPOSE

To evaluate technical feasibility and clinical outcome of computed tomography-guided high-dose-rate-brachytherapy (CT-HDRBT) ablation of metastases adjacent to the liver hilum.

MATERIALS AND METHODS

Between November 2007 and May 2012, 32 consecutive patients with 34 metastases adjacent to the liver hilum (common bile duct or hepatic bifurcation ≤5 mm distance) were treated with CT-HDRBT. Treatment was performed by CT-guided applicator placement and high-dose-rate brachytherapy with an iridium-192 source. MRI follow-up was performed 6 weeks and every 3 months post intervention. The primary endpoint was local tumor control (LTC); secondary endpoints included time to progression (TTP) and overall survival (OS).

RESULTS

Patients were available for MRI evaluation for a mean follow-up time of 18.75 months (range: 3-56 months). Mean tumor diameter was 4.3 cm (range: 1.3-10.7 cm). One major complication was observed. Four (11.8%) local recurrences were observed after a local tumor control of 5, 8, 9 and 10 months, respectively. Twenty-two patients (68.75%) experienced a systemic tumor progression during the follow up period. Mean TTP was 12.9 months (range: 2-56 months). Nine patients died during the follow-up period. Median OS was 20.24 months.

CONCLUSION

Minimally invasive CT-HDRBT is a safe and effective option also for unresectable liver metastases adjacent to the liver hilum that would have been untreatable by thermal ablation.

Liver resection for colorectal cancer metastases

QUESTIONS

Should surgery be considered for colorectal cancer (crc) patients who have liver metastases plus (a) pulmonary metastases, (b) portal nodal disease, or (c) other extrahepatic metastases (ehms)?What is the role of chemotherapy in the surgical management of crc with liver metastases in (a) patients with resectable disease in the liver, or (b) patients with initially unresectable disease in the liver that is downsized with chemotherapy ("conversion")?What is the role of liver resection when one or more crc liver metastases have radiographic complete response (rcr) after chemotherapy?

PERSPECTIVES

Advances in chemotherapy have improved survival in crc patients with liver metastases. The 5-year survival with chemotherapy alone is typically less than 1%, although two recent studies with folfox or folfoxiri (or both) reported rates of 5%-10%. However, liver resection is the treatment that is most effective in achieving long-term survival and offering the possibility of a cure in stage iv crc patients with liver metastases. This guideline deals with the role of chemotherapy with surgery, and the role of surgery when there are liver metastases plus ehms. Because only a proportion of patients with crc metastatic disease are considered for liver resection, and because management of this patient population is complex, multidisciplinary management is required.

METHODOLOGY

Recommendations in the present guideline were formulated based on a prepublication version of a recent systematic review on this topic. The draft methodology experts, and external review by clinical practitioners. Feedback was incorporated into the final version of the guideline.

PRACTICE GUIDELINE

These recommendations apply to patients with liver metastases from crc who have had or will have a complete (R0) resection of the primary cancer and who are being considered for resection of the liver, or liver plus specific and limited ehms, with curative intent. 1(a). Patients with liver and lung metastases should be seen in consultation with a thoracic surgeon. Combined or staged metastasectomy is recommended when, taking into account anatomic and physiologic considerations, the assessment is that all pulmonary metastases can also be completely removed. Furthermore, liver resection may be indicated in patients who have had a prior lung resection, and vice versa.1(b). Routine liver resection is not recommended in patients with portal nodal disease. This group includes patients with radiologically suspicious portal nodes or malignant portal nodes found preoperatively or intraoperatively. Liver plus nodal resection, together with perioperative systemic therapy, may be an option-after a full discussion with the patient-in cases with limited nodal involvement and with metastases that can be completely resected.1(c). Routine liver resection is not recommended in patients with nonpulmonary ehms. Liver plus extrahepatic resection, together with perioperative systemic therapy, may be an option-after a full discussion with the patient-for metastases that can be completely resected.2(a). Perioperative chemotherapy, either before and after resection, or after resection, is recommended in patients with resectable liver metastatic disease. This recommendation extends to patients with ehms that can be completely resected (R0). Risks and potential benefits of perioperative chemotherapy should be discussed for patients with resectable liver metastases. The data on whether patients with previous oxaliplatin-based chemotherapy or a short interval from completion of adjuvant therapy for primary crc might benefit from perioperative chemotherapy are limited.2(b). Liver resection is recommended in patients with initially unresectable metastatic liver disease who have a sufficient downstaging response to conversion chemotherapy. If complete resection has been achieved, postoperative chemotherapy should be considered.3. Surgical resection of all lesions, including lesions with rcr, is recommended when technically feasible and when adequate functional liver can be left as a remnant. When a lesion with rcr is present in a portion of the liver that cannot be resected, surgery may still be a reasonable therapeutic strategy if all other visible disease can be resected. Postoperative chemotherapy might be considered in those patients. Close follow-up of the lesion with rcr is warranted to allow localized treatment or further resection for an in situ recurrence.