Hepatic colorectal metastases: methods of improving resectability

Impact of Surgical Management for Relapse After Conversion Hepatectomy for Initially Unresectable Colorectal Liver Metastasis: A Retrospective Cohort Study

BACKGROUND

For patients with initially unresectable colorectal liver metastasis (IU-CRLM) receiving conversion therapy, disease relapse after conversion hepatectomy is common. However, few studies have focused on the assessment and management of relapse following conversion hepatectomy for IU-CRLM.

METHODS

In the retrospective cohort study, 255 patients with IU-CRLM received conversion therapy and underwent subsequent R0 resection. The treatment effects of repeated liver-directed treatment (RLDT) versus non-RLDT for liver relapse were examined. Survival analysis was evaluated with the use of Cox proportional hazards methods. The importance of RLDT was further confirmed in the propensity score matching (PSM) and subgroup analyses.

RESULTS

The 5-year overall survival (OS) rate after conversion hepatectomy was 34.9%. Liver relapse was observed in 208 patients. Of these patients, 106 underwent RLDT (65 underwent repeated hepatectomy and the remainder underwent ablation treatment), while 102 received only palliative chemotherapy. The relapse patients who underwent RLDT had a significantly longer OS than those who did not (hazard ratio (HR): 0.382, 95% CI: 0.259-0.563; P<0.001). In a multivariable analysis, RLDT was independently associated to prolonged survival (HR: 0.309, 95%CI: 0.181-0.529; P<0.001). In the PSM and subgroup analyses, RLDT consistently showed evidence of prolonging OS significantly.

CONCLUSION

For IU-CRLM patients with liver relapse following conversion hepatectomy, the RLDT is essential for cure and prolonged survival. To avoid missing the opportunity for RLDT, intensive disease surveillance should be proposed.

Surgical strategy for colorectal cancer with synchronous liver and extrahepatic metastases: A scoring system and decision tree model

BACKGROUND

The role of hepatectomy in a specific group of patients with synchronous colorectal cancer with liver metastases (SCRLM) and synchronous extrahepatic disease (SEHD) is still unclear. The aim of this study was to evaluate the efficacy of liver surgery and define the selection criteria for surgical candidates in patients with SCRLM + SEHD.

METHODS

Between July 2007 and October 2018, 475 patients with colorectal cancer with liver metastases (CRLM) who underwent liver resection were retrospectively reviewed. Sixty-five patients with SCRLM + SEHD were identified and included in the study. Clinical pathological data of these patients were analyzed to evaluate the influence on survival. Important prognostic factors were identified by univariate and multivariate analyses. The risk score system and decision tree analysis were generated according to the important prognostic factors for better patient selection.

RESULTS

The 5-year survival rate of patients with SCRLM + SEHD was 21.9%. The most important prognostic factors were SCRLM number of more than five, site of SEHD other than the lung only, inability to achieve SCRLM + SEHD R0 resection, and BRAF mutation of cancer cells. The proposed risk score system and decision tree model easily discriminated between patients with different survival rates and identified the profile of suitable surgical patients.

CONCLUSION

Liver surgery should not be a contraindication for patients with SCRLM + SEHD. Patients with complete SCRLM + SEHD R0 resection, SCRLM number less than or equal to five, SEHD confined to the lung only, and wild-type BRAF could have favorable survival outcomes. The proposed scoring system and decision tree model may be beneficial to patient selection in clinical use.

Minimizing the risk of small-for-size syndrome after liver surgery

BACKGROUND

Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS).

DATA SOURCES

This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS.

RESULTS

Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS.

CONCLUSIONS

With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.

Laparoscopic synchronous resection of rectal cancer and liver metastases: A case report and review of the literature

Introduction and importance

During the past decade, there are several studies which showed the advantages of the laparoscopic approach for treating colorectal cancer (CRC) or colorectal cancer liver metastasis (CRCLM). However, in contrast, there are only a few reports of combined one stage synchronous laparoscopic colorectal and liver metastasis resection, cold one stage minimally invasive approach (MIA).

Case presentation

Our patient was 51 years old woman.

Rectal adenocarcinoma was verified three centimeters from the anal verge. Magnetic resonance imaging (MRI) with rectal protocol modification indicated T1N0MO stage. We decided to do transanal local excision and achieved R0 resection. Half a year after the operation on the control MRI, lymphadenopathy was found along the rectum and possible recurrence of cancer. Also on the MRI was shown solitary, 4.7 × 2.7 × 3.8 cm big metastasis in the IVa/VIII segment of the liver. The patient was shown on a multidisciplinary team and it was decided to do laparoscopic synchronous resection of rectum and liver metastases.

Clinical discussion

During the last decades many articles with different strategies for treating CRC and liver metastasis were published. Some of them prefered two-stage surgical treatment, like liver first approach which allows initial control of liver metastases, and delivery of preoperative radiotherapy for rectal cancer without the fear that liver metastases will meanwhile progress beyond the possibility of cure. Alternatively, the colon first approach is where the adjuvant chemotherapy is combined with the resection of the primary colorectal tumour with liver resection being undertaken (if at all) as a subsequent operation. By developing surgery, anaesthesia and critical care, the one stage approach for patients with CRC and liver metastasis started to be a reasonable option.

Conclusion

Totally laparoscopic synchronous resection of the colorectal cancer and synchronous colorectal liver metastasis is technically feasible and safe in the hands of the experienced abdominal surgeon. This type of approach offers all the benefits of the laparoscopic minimally invasiveness associated with good oncological outcomes, and it is indicated in well-selected patients. However, the real scientific answer to this question can be given just with randomised control trial which will be a real challenge for endoscopic surgeons in the future.

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Colorectal cancer is the third most common cancer in the world.

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TLSR of the colorectal cancer and SCRLM is technically feasible and safe in the hands of the experienced abdominal surgeon

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This type of approach offers all the benefits of the laparoscopic minimally invasiveness associated with good outcomes

Venous hepatic segmentation in dogs (Canis lupus familiaris-L. 1758)

The external shape of the liver is varied and determines specific vascular arrangements. This morphological relationship is important to establish hepatic segmentation in different species submitted to surgeries that aim to preserve a larger area of liver parenchyma. After observing 60 livers injected with Neoprene Latex and three plastic moulds obtained by corrosion, eight hepatic venous segments were identified, drained by six hepatic veins agrouped into segmental veins, which drained one sector (segments I, VI, VII and VIII) and intersegmental veins, which drained more than one sector (segments II/III and IV/V). They were described as follows: left intersegmental vein, formed by a segmental vein from the papillary process (segment I), two to three lateral left segmental veins that drained the segment II, and one to five left paramedian segmental veins that drained the segment III; sagittal intersegmental vein, formed by the confluence between segmental vein of the quadrate lobe (segment IV) and the medial right paramedian segmental vein, which derived from the segment V; lateral right paramedian vein drained the dorsocranial sector of the segment VI; the lateral right segmental vein, formed by one to four vessels that drained segment VII, and the segmental vein of the caudate process, which drained the segment VIII. Understanding the number and disposition of the hepatic veins in lobate livers is essential to reduce bleeding risks in surgeries. The nomenclature based on segmentation analogy of non-lobate liver could be less confusing and, therefore, be more useful in the surgical approaches of lobate livers.

Analysis of Treatment Option for Synchronous Liver Metastases and Colon Rectal Cancer

Colorectal or bowel cancer is one of the major causes of cancer worldwide. Research has shown that 15 to 20% colorectal cancer patients are also diagnosed with synchronous liver metastases (LM) at presentation and about one third eventually develop liver lesions. Management of cases with colorectal cancer comorbid with liver metastases is more complex. This highlights the need for suggesting the need for effective treatment while optimizing timing during surgical and medical treatment of primary plus metastatic disease. Such patients cases are likely to present with severe cancer biology and thereby less likely to be long-term survivors.

Analysis of Response Evaluation Criteria in Solid Tumors reduction ratio of primary chemotherapy in unresectable advanced or recurrent colorectal cancer

Response Evaluation Criteria in Solid Tumors (RECIST) is used to assess the objective response of solid tumors to treatment. However, it remains unclear to what extent the response rate assessed by RECIST reflects a reduction of tumor size in multiple organs in patients with unresectable advanced or recurrent colorectal cancer (CRC) with multiple organ metastases. It is also unclear whether the management of liver metastases with systemic chemotherapy in CRC patients with multiple organ metastases improves their prognosis, although surgical resection has been shown to be the most effective treatment approach to CRC cases with liver metastases. A total of 38 CRC patients who underwent systemic chemotherapy in Kyushu Medical Center Hospital between January 2013 and April 2016 were examined. The patients had measurable lesions in multiple organs, including the liver, and did not undergo curative surgery for metastatic lesions after initiation of chemotherapy. The association between the total reduction ratio (TRR) of all lesions and liver lesion reduction ratio (LRR) was retrospectively analyzed. A total of 18 patients (47%) had H3 liver metastases, and the median liver lesion occupancy rate in the sum of the measured lesions with RECIST was 76%. TRR and LRR were strongly correlated, regardless of the volume of the liver metastases. Although a TRR of >30% was significantly associated with improved overall survival (OS), this improvement was not observed in patients with H3 liver metastases. TRR was correlated with LRR and was associated with a better OS. CRC patients with both multiple organ and H3 liver metastases exhibited poor survival, even with a high reduction ratio by chemotherapy.

Advances in Biomaterials and Technologies for Vascular Embolization

Minimally invasive transcatheter embolization is a common nonsurgical procedure in interventional radiology used for the deliberate occlusion of blood vessels for the treatment of diseased or injured vasculature. A wide variety of embolic agents including metallic coils, calibrated microspheres, and liquids are available for clinical practice. Additionally, advances in biomaterials, such as shape-memory foams, biodegradable polymers, and in situ gelling solutions have led to the development of novel preclinical embolic agents. The aim here is to provide a comprehensive overview of current and emerging technologies in endovascular embolization with respect to devices, materials, mechanisms, and design guidelines. Limitations and challenges in embolic materials are also discussed to promote advancement in the field.

Sporamin suppresses growth of xenografted colorectal carcinoma in athymic BALB/c mice by inhibiting liver β-catenin and vascular endothelial growth factor expression

BACKGROUND

Colorectal cancer (CRC) is the third most common malignancy of the digestive tract and the fifth leading cause of cancer-related mortality in China. Sporamin, a Kunitz-type trypsin inhibitor isolated from sweet potato, is a potential anti-cancer agent with activities against a number of malignant tumor cells in vitro. The liver secretes a myriad of endocrine factors that may facilitate the growth and transformation of tumors in the development of CRC.

AIM

To investigate the effects of sporamin on liver morphology and biomarkers of xenografted CRC in the liver of athymic BALB/c mice.

METHODS

Twenty-seven male BALB/c nude mice were randomly divided into control, vehicle, and sporamin groups. Mice in the latter two groups were intraperitoneally xenografted with LoVo colorectal carcinoma cells and intragastrically infused with saline or sporamin (0.5 g/kg body weight/d), respectively, for 3 wk. Hematoxylin and eosin (HE) staining of the sections was performed to observe morphological changes in hepatic tissue and real-time fluorescent quantitative PCR (qPCR) and enzyme-linked immunosorbent assay (ELISA) were used to measure the expression of β-catenin and vascular endothelial growth factor (VEGF) in the liver.

RESULTS

Sporamin significantly reduced the number and weight of tumor nodules formed in the abdominal cavity. Compared with the vehicle group, the mean tumor weight (± SD) in the sporamin group was significantly reduced (0.44 ± 0.10 g vs 0.26 ± 0.15 g) and the total number of tumors decreased from 93 to 55. HE staining showed that enlargement of the nucleus and synthesis of proteins within hepatocytes, as well as infiltration of inflammatory cells into the liver, were attenuated by sporamin. Immunohistochemical staining and ELISA showed that the concentrations of β-catenin and VEGF in the liver were significantly reduced by sporamin. Compared with the vehicle group, the expression of β-catenin measured in integrated optical density units per area was reduced in the sporamin group (47.29 ± 9.10 vs 26.14 ± 1.72; P = 0.003). Expression of VEGF was also reduced after sporamin intervention from 20.78 ± 2.06 in the vehicle group to 15.80 ± 1.09 in the sporamin group (P = 0.021). Compared with the vehicle group, the concentration of β-catenin decreased from 134.42 ± 22.04 pg/mL to 109.07 ± 9.65 pg/mL after sporamin intervention (P = 0.00002). qPCR indicated that compared to the vehicle group, relative mRNA expression of β-catenin and VEGF in the liver of mice in the sporamin-treated group was significantly reduced to 71% ± 1% (P = 0.000001) and 23% ± 7% (P = 0.00002), respectively, of the vehicle group levels.

CONCLUSION

Sporamin down-regulates the expression and secretion of β-catenin and VEGF in the liver, which subsequently inhibits the transcription of downstream genes involved in cancer progression and angiogenesis.

Impact of Hepatitis B Carrier Status on the Outcomes of Surgical Treatment of Colorectal Liver Metastases

BACKGROUND

Chronic hepatitis B virus (HBV) infection is associated with a lower incidence of colorectal liver metastases. We explored the impact of HBV carrier status on outcomes of surgical treatment of colorectal liver metastases.

METHODS

A retrospective analysis was conducted for consecutive patients undergoing liver resection for colorectal liver metastases from 2000 to 2016. HBV carriers were matched with controls by propensity scoring.

RESULTS

304 patients with known HBV carrier status who underwent resection of colorectal liver metastases were studied. From the 21 (6.9%) hepatitis B carriers, a more prolonged prothrombin time (12.1 vs. 11.3 s, OR 1.42, p = 0.027) was observed, and fewer major resections were performed (19.0 vs. 47.3%, OR 0.262, p = 0.018). After 1:5 propensity score matching, they were compared with 105 controls with similar liver function, tumour status and receiving similar treatments. Patients with chronic hepatitis B enjoyed better median disease-free survival (15.8 vs. 9.20 month, p = 0.032). Overall survivals (50.0 vs. 43.6 month, p = 0.15) were similar. Operating time (227 vs. 240 min, OR 1.00, p = 0.33), blood loss (0.50 vs. 0.37 L, OR 1.15, p = 0.62), hospital stay (6 vs. 6 day, OR 1.02, p = 0.48), operative morbidity (9.5 vs. 16.2%, OR 0.545, p = 0.44) and mortality (0 vs. 1.0%, OR 1.62, p = 0.77) were comparable. The use of antiviral agents did not affect survival of HBV carriers.

CONCLUSIONS

Chronic HBV infection confers oncological benefit to surgical treatment of colorectal liver metastases. Given satisfactory liver reserve, HBV carrier status did not affect operative morbidity or mortality.

Neoadjuvant Oxaliplatin-based Chemotherapy for Liver Metastases from Colorectal Cancer. An Italian Survey

Background

Only 10% to 25% of patients with liver metastases from colorectal cancer are suitable for resection. Methods for increasing the resectability of liver metastases are based on specific surgical techniques and neoadjuvant chemotherapy.

Methods

We collected retrospective data on patients from various Italian hospitals from 1996 to 2002. Data from colorectal cancer patients with liver metastases treated with oxaliplatin-based neoadjuvant chemotherapy were considered. Analysis focused on patients and treatment description and on long-term survival. We considered 107 patients from 36 Italian hospitals.

Results

Of the 105 patients assessable for response, 8.4% achieved a complete response, 70.1% a partial response and 19.6% stable disease. Ninety-nine patients were treated with surgery for liver metastases. A radical resection was achieved in 79% of patients. Median survival time was 42 months. Thirteen patients experienced grade 3-4 hematologic toxicity, and 10 patients had grade 3-4 nonhematologic toxicity. Neurologic toxicity of grade >1 was observed in 21% of patients.

Conclusions

Neoadjuvant chemotherapy can be useful to increase the number of liver resections for metastatic colorectal cancer patients. Nevertheless, randomized trials are necessary to confirm this retrospective survey as well as the few single-institution experiences reported so far in the medical literature.

Plants and Surgery: The Protective Effects of Thymoquinone on Hepatic Injury-A Systematic Review of In Vivo Studies

Multimodal treatment concepts including liver transplantation for hepatocellular carcinoma (HCC), extended resection methods and neoadjuvant chemotherapy for colorectal liver metastasis significantly improve patients’ outcome. However, surgery-induced hepatic ischemia-reperfusion injury (IRI) and chemotherapy-associated hepatotoxicity result in hepatocellular damage and compromised liver function. Activation of common key pathways in ischemic liver and hepatotoxic injury results in oxidative stress, inflammatory responses and apoptosis causing organ damage. Controlling liver damage before and during surgery is essential for the postoperative outcome. Nigella sativa has a long tradition as a natural remedy. In the essential oil, Thymoquinone (TQ) was identified as the main component and responsible for most of the therapeutic effects. Therefore, this systematic review aimed to summarize the hepatoprotective effects of TQ and its potential suitability to improve surgical outcome by reducing surgical ischemic injury and hepatotoxicity of neoadjuvant chemotherapy. The key findings can be summarized as TQ having strong antioxidant, anti-inflammatory, antifibrotic, anti-/proapoptotic and anticarcinogenic effects. Almost no side effects were reported irrespective of a large dose range, suggesting a wide therapeutic window. These results give rise to the expectation that TQ could evolve to a novel powerful drug to reduce hepatic injury.

Emergency resection surgery for colorectal cancer: Patterns of recurrent disease and survival

AIM

To evaluate prognostic pathological factors associated with early metachronous disease and adverse long-term survival in these patients.

METHODS

Clinical and histological features were analysed retrospectively over an eight-year period for prognostic impact on recurrent disease and overall survival in patients undergoing curative resection of a primary colorectal cancer.

RESULTS

A total of 266 patients underwent curative surgery during the study period. The median age of the study cohort was 68 year (range 26 to 91) with a follow-up of 7.9 years (range 4.6 to 12.6). Resection was undertaken electively in 225 (84.6%) patients and emergency resection in 35 (13.2%). Data on timing of surgery was missing in 6 patients. Recurrence was noted in 67 (25.2%) during the study period and was predominantly early within 3 years (82.1%) and involved hepatic metastasis in 73.1%. Emergency resection (OR = 3.60, P = 0.001), T4 stage (OR = 4.33, P < 0.001) and lymphovascular invasion (LVI) (OR = 2.37, P = 0.032) were associated with higher risk of recurrent disease. Emergency resection, T4 disease and a high lymph node ratio (LNR) were strong independent predictors of adverse long-term survival.

CONCLUSION

Emergency surgery is associated with adverse disease free and long-term survival. T4 disease, LVI and LNR provide strong independent predictive value of long-term outcome and can inform surveillance strategies to improve outcomes.

Investigation of Metastasis-Related Genes: A Rat Model Mimicking Liver Metastasis of Colorectal Carcinoma

Liver is the main target of colorectal cancer (CRC) metastasis. Currently, the number of reports is small, which describe changes in gene expression supporting liver metastasis. Here, a rat model was used for analyzing mRNA modulations during liver colonization and compared with available literature. In the model, CC531 rat CRC cells were injected via a mesenteric vein into isogenic WAG/Rij rats and re-isolated at early, intermediate, advanced, and terminal stages of liver colonization. These cells were used for RNA isolation. Microarrays were used for analyzing mRNA profiles of expression. The number of deregulated genes is comparatively large and only part of it has been studied so far. As reported to date, claudins and insulin-like growth factor-binding proteins (IGFBPs) were found to be deregulated. The fact that the chosen method is efficient is confirmed by the study of claudins and IGFBPs, which show altered expression in the initial stages of liver colonization and then return to normalcy. In addition, cadherin was described to be downregulated in epithelial-mesenchymal transition models. It can, therefore, be concluded that the models used are helpful in finding genes, which are instrumental for metastatic liver colonization.

Colorectal cancer with Synchronous liver-limited Metastases: the protocol of an Inception Cohort study (CoSMIC)

INTRODUCTION

Colorectal cancer is the fourth most common cancer in the UK and an important cause of cancer-related death. In 20% of patients, there is metastasis to the liver or beyond at the time of diagnosis. The management of synchronous disease is complex. Conventional surgery removes the colorectal primary first, followed by chemotherapy, with resection of liver metastases as a final step. Advances in the availability and safety of liver surgery, anaesthesia and critical care have made two alternative options feasible. The first is synchronous resection of the primary and liver metastases. The second is resection of the metastatic disease as the first step, termed the reverse or liver-first approach. Currently, evidence is inadequate to inform the selection of care pathway for patients with colorectal cancer and synchronous liver-limited metastases. Specifically, optimal pathways are not defined and there is a dearth of prospectively recorded cohort-defining factors influencing treatment selection or outcome.

METHODS AND ANALYSIS

Colorectal cancer with Synchronous liver-limited Metastases: an Inception Cohort (CoSMIC) is an inception cohort study of patients with a new diagnosis of colorectal cancer with synchronous liver-limited metastases. The sequence of treatment received, and factors influencing treatment decisions, will be evaluated against European Society of Medical Oncology guidelines. Clinical data will be collected, and quality of life, morbidity, mortality and long-term outcome compared for different treatment sequences adjusted for prognostic factors. Disease-free survival or progression will be measured at 1, 2 and 5 years. A nested qualitative study will ascertain patient experiences and clinician perspectives on delivery of care.

ETHICS AND DISSEMINATION

The full study protocol was independently peer reviewed by Professor Kees de Jong (University of Maastricht, Holland). CoSMIC has ethical approval from the National Health Service Research Ethics Committee (14/NW/1397). Results will be disseminated to healthcare professionals and patient groups, and may be used to design a definitive trial addressing areas of equipoise in treatment pathways, as well as optimising current pathways to improve outcomes and experiences.

TRIAL REGISTRATION NUMBER

NCT02456285, pre-results.

Hepatotoxicity following systemic therapy for colorectal liver metastases and the impact of chemotherapy-associated liver injury on outcomes after curative liver resection

Patients with colorectal liver metastases (CLM) have remarkably benefited from the advances in medical multimodal treatment and surgical techniques over the last two decades leading to significant improvements in long-term survival. More patients are currently undergoing liver resection following neoadjuvant chemotherapy, which has been increasingly established within the framework of curative-indented treatment strategies. However, the use of several cytotoxic agents has been linked to specific liver injuries that not only impair the ability of liver tissue to regenerate but also decrease long-term survival. One of the most common agents included in modern chemotherapy regimens is oxaliplatin, which is considered to induce a parenchymal damage of the liver primarily involving the sinusoids defined as sinusoidal obstruction syndrome (SOS). Administration of bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF), has been reported to improve response of CLM to chemotherapy in clinical studies, concomitantly protecting the liver from the development of SOS. In this review, we aim to summarize current data on multimodal treatment concepts for CLM, give an in-depth overview of liver damage caused by cytostatic agents focusing on oxaliplatin-induced SOS, and evaluate the role of bevacizumab to improve clinical outcomes of patients with CLM and to protect the liver from the development of SOS.

Surgery for Colorectal Cancer - Trends, Developments, and Future Perspectives

BACKGROUND

Although colorectal surgery is long established as the mainstay treatment for colon cancer, certain topics regarding technical fine-tuning to increase postsurgical recurrence-free survival have remained a matter of debate throughout the past years. These include complete mesocolic excision (CME), treatment strategies for metastatic disease, significance of hyperthermic intraperitoneal chemotherapy (HIPEC), and surgical techniques for the treatment of colorectal cancer recurrence. In addition, new surgical techniques have been introduced in oncologic colorectal surgery, and their potential to provide sufficiently radical resection has yet to be proven.

METHODS

A structured review of the literature was performed to identify the current state of the art with regard to the mentioned key issues in colorectal surgery.

RESULTS

This article provides a comprehensive review of the current literature addressing the above-mentioned current challenges in colorectal surgery. The focus lies on the impact of CME and, in relation to this, on lymph node dissection, as well as on treatment of metastatic disease including peritoneal spread, and finally on the treatment of recurrent disease.

CONCLUSION

Uniformly, the current literature reveals that surgery aiming at complete malignancy elimination within multimodal treatment approaches represents the fundamental quantum leap for the achievement of long-term tumor-free survival.

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

OBJECTIVE

Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery.

MATERIALS AND METHODS

We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0.

RESULTS

12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0.

CONCLUSION

Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

A multidisciplinary approach for peritoneal carcinomatosis and bilobar liver metastases from colorectal cancer: case report and review of the literature

Background

Peritoneal carcinomatosis develops in 15 % of patients with primary colorectal cancer (CRC) and in 25 % of those with recurrence. Liver metastases are also frequent and appear at some time in 35–55 % of patients with CRC. When both conditions are present and treated palliatively, the expected median survival is 5–6 months. Recent publications suggest survival is improved when R0 resection of both peritoneal and liver diseases is achieved.

Case presentation

A 36-year-old woman with synchronous peritoneal and liver metastases of colorectal origin was treated with a stepwise approach consisting of initial cytoreductive surgery, minor liver resection, intraperitoneal intraoperative hyperthermic chemotherapy, adjuvant chemotherapy, right portal embolization, and finally, right hepatectomy achieving an R0 resection. The patient is alive and free of disease after 30 months of follow-up.

Discussion

Patients with peritoneal carcinomatosis and liver metastases from CRC must be carefully evaluated by multidisciplinary oncological teams in order to offer the possibility of surgery to obtain an R0 resection in selected patients (especially if the peritoneal cancer index is <19 and there is resectable or potentially resectable metastatic liver disease).

Transcatheter embolization therapy in liver cancer: an update of clinical evidences

Transarterial chemoembolization (TACE) is a form of intra-arterial catheter-based chemotherapy that selectively delivers high doses of cytotoxic drug to the tumor bed combining with the effect of ischemic necrosis induced by arterial embolization. Chemoembolization and radioembolization are at the core of the treatment of liver hepatocellular carcinoma (HCC) patients who cannot receive potentially curative therapies such as transplantation, resection or percutaneous ablation. TACE for liver cancer has been proven to be useful in local tumor control, to prevent tumor progression, prolong patients' life and control patient symptoms. Recent evidence showed in patients with single-nodule HCC of 3 cm or smaller without vascular invasion, the 5-year overall survival (OS) with TACE was similar to that with hepatic resection and radiofrequency ablation. Although being used for decades, Lipiodol(®) (Lipiodol(®) Ultra Fluid(®), Guerbet, France) remains important as a tumor-seeking and radio-opaque drug delivery vector in interventional oncology. There have been efforts to improve the delivery of chemotherapeutic agents to tumors. Drug-eluting bead (DEB) is a relatively novel drug delivery embolization system which allows for fixed dosing and the ability to release the anticancer agents in a sustained manner. Three DEBs are available, i.e., Tandem(®) (CeloNova Biosciences Inc., USA), DC-Beads(®) (BTG, UK) and HepaSphere(®) (BioSphere Medical, Inc., USA). Transarterial radioembolization (TARE) technique has been developed, and proven to be efficient and safe in advanced liver cancers and those with vascular complications. Two types of radioembolization microspheres are available i.e., SIR-Spheres(®) (Sirtex Medical Limited, Australia) and TheraSphere(®) (BTG, UK). This review describes the basic procedure of TACE, properties and efficacy of some chemoembolization systems and radioembolization agents which are commercially available and/or currently under clinical evaluation. The key clinical trials of transcatheter arterial therapy for liver cancer are summarized.

Clinical features and prognosis in hepatectomy for colorectal cancer with centrally located liver metastasis

BACKGROUND

Hepatic metastasectomy for patients with primary colorectal cancer offers better long-term outcome, and chemotherapy can increase the rate of hepatic resectability for patients with initially inoperable disease. The pattern of liver metastasis and status of the primary tumor are rarely discussed in the analysis of long-term outcome. In this report, we evaluate the influence of the pattern of metastasis on clinical features and prognosis.

METHODS

One hundred and fifty-nine patients who underwent hepatic metastasectomy with curative intent for liver metastasis of colorectal cancer between October 1991 and December 2006 were enrolled. Patients were grouped according to whether liver metastasis was centrally or peripherally located, based on imaging and operative findings. Patient demographics, characteristics of the primary and metastatic tumors, and surgical outcomes were analyzed for long-term survival.

RESULTS

A greater proportion of patients with centrally located metastases were male, as compared with those with peripherally located metastases. Compared with patients with peripherally located metastases, patients with centrally located metastases were more likely to have multiple lesions (P = 0.016), involvement of multiple segments (P = 0.006), large metastases (P < 0.001), and bilobar distribution of metastases (P < 0.001). The estimated 5-year recurrence-free and overall survival rates were 22.4% and 34.2%, respectively. Univariate analysis revealed that centrally located metastasis, primary tumor in the transverse colon, metastasis in regional lymph nodes, initial extrahepatic metastasis, synchronous liver metastasis, multiple lesions, poorly differentiated tumor, and resection margin <10 mm were significant poor prognostic factors for recurrence-free survival and overall survival. Cox regression analysis showed that inadequate resection margin and centrally located liver metastasis were significant predictors of shorter overall survival.

CONCLUSIONS

In colorectal cancer, centrally located liver metastasis represents a poor prognostic factor after hepatectomy, and is associated with early recurrence. Neoadjuvant chemotherapy may be used to downstage centrally located liver metastases to improve outcome.

Vascular anatomy of canine hepatic venous system: a basis for liver surgery

Detailed knowledge of the vascular anatomy is important for improving surgical approaches to the liver. Twelve canine livers were skeletonized to describe the anatomy of their portal and hepatic veins in details. Our data suggest that the liver can be divided into two sections, three divisions, seven lobes and two to four sub-lobes. This differs from the classic division into four lobes, four sub-lobes and two processes. The right section was perfused by the right portal branch and drained by independent hepatic veins, while most of the left section, perfused by the left portal branch, was drained by the main hepatic vein deriving from the middle and the left hepatic vein confluence. Part of the right medial lobe, and in some cases the papillary process of the caudate lobe, drained directly into the caudal vena cava. A proper right hepatic vein draining blood from more than one lobe was never observed. Portal connections between the quadrate and the left medial lobe were frequently recorded. Two sub-lobes with different portal blood supply and venous drainage could be identified in the right lateral (33.3% of cases) and the left lateral (100% of cases) lobes. From our results, the classic nomenclature of the liver lobes does not reflect their vascularization. Based on similarities between canine lobes and human segments, a new nomenclature is possible and may be less confounding in surgical settings.

Primary tumor resection in colorectal cancer with unresectable synchronous metastases: A review

At the time of diagnosis, 25% of patients with colorectal cancer (CRC) present with synchronous metastases, which are unresectable in the majority of patients. Whether primary tumor resection (PTR) followed by chemotherapy or immediate chemotherapy without PTR is the best therapeutic option in patients with asymptomatic CRC and unresectable metastases is a major issue, although unanswered to date. The aim of this study was to review all published data on whether PTR should be performed in patients with CRC and unresectable synchronous metastases. All aspects of the management of CRC were taken into account, especially prognostic factors in patients with CRC and unresectable metastases. The impact of PTR on survival and quality of life were reviewed, in addition to the characteristics of patients that could benefit from PTR and the possible underlying mechanisms. The risks of both approaches are reported. As no randomized study has been performed to date, we finally discussed how a therapeutic strategy's trial should be designed to provide answer to this issue.

[Current management of liver metastases from colorectal cancer: recommendations of the São Paulo Liver Club]

Approximately half of patients with colorectal cancer present with liver metastases during the course of their disease, which directly affect prognosis and is responsible for two thirds of deaths related to the disease. In the last two decades the treatment of liver metastases from colorectal cancer (CRCLM) provided significant gain in survival when all treatment options are available to the patient. In this context, surgical treatment remains as the only chance of cure, with five-year survival rates of 25-58%. However, only 1/4 of the patients have resectable disease at diagnosis. For this reason, one of the key points in the current management of patients with CRCLM is the development of strategies that facilitate complete resection of liver lesions. The advent and refinement of ablative methods have expanded the possibilities of surgical therapy. The emergence of new chemotherapy regimens and the introduction of targeted therapies has provided high response rates and has permanently altered the management of these patients. The multimodal therapy and the involvement of different medical specialties has increasingly enabled CRCLM treatment to approached the ideal treatment, i.e., an individualized one. Based on an extensive review of literature and on experience from some of the most important specialized centers of Brazil, the São Paulo Liver Club began a process of multi-institutional discussions that resulted in the recommendations that follow. These recommendations, however, are not intended to be absolute, but useful tools in the therapeutic decision process for this complex group of patients.

Transarterial chemoembolization of hepatocellular carcinoma. Agents and drugs: an overview. Part 1

INTRODUCTION

Hepatocellular carcinoma (HCC) is one of the most common lethal malignancies. The prognosis is poor despite progress in early diagnosis. The initial treatment of choice is hepatic resection; unfortunately, not all patients are eligible for liver resection. Moreover, there are significant recurrences. Different liver-directed therapies have been developed to increase the number of patients eligible for liver resection. Among them, transarterial chemoembolization (TACE) is a technique of improving importance that involves the intra-arterial administration of anticancer drugs and embolization agents into the liver tumor. In the first part of this review, an overview of the present situation in the field of TACE has been made, referring in particular to the use of Lipiodol.

AREAS COVERED

Clinical overview of TACE with attention to the present limits and problems of this technique.

EXPERT OPINION

The use of TACE techniques is important in the treatment of HCCs. However, this technique needs to be improved in particular taking into account the use of new materials for the preparation of embolizing agents able to control the drug release.

Ischemia/reperfusion in clamped lobes facilitates liver regeneration of non-clamped lobes after selective portal vein ligation

BACKGROUND

Hypertrophy of non-clamped liver lobes and the atrophy of clamped lobes have been shown to be interactive. Here, a rat model of selective lobe occlusion was established to study the effect of contralateral ischemia/reperfusion (I/R) on regeneration of non-clamped lobes.

METHODS

Left lateral and middle liver lobes were pretreated with I/R. In the experimental (IR + PVL) group, portal veins of the left and middle lobes were ligated. A group given similar portal vein ligation but no I/R (PVL) was the positive control.

RESULTS

Compared with the PVL group, the IR + PVL had higher, but not remarkable, levels of serum transaminases; weights of non-clamped lobes in the IR + PVL group comparatively increased much more notably. At 24-h post-surgery, the IR + PVL group's PCNA mRNA was up-regulated compared with the PVL group. At 72-h post-surgery, PCNA protein was up-regulated significantly, while TGF-β1 was down-regulated in the IR + PVL group notably, compared with the PVL group.

CONCLUSION

The I/R pretreatment given to the clamped lobes facilitates liver regeneration of non-clamped lobes after selective portal vein ligation, which may result from down-regulated TGF-β1 expression in non-clamped lobes.

Comparison of percutaneous transhepatic portal vein embolization and unilateral portal vein ligation

AIM: To compare the effect of percutaneous transhepatic portal vein embolization (PTPE) and unilateral portal vein ligation (PVL) on hepatic hemodynamics and right hepatic lobe (RHL) atrophy.

METHODS: Between March 2005 and March 2009, 13 cases were selected for PTPE (n = 9) and PVL (n = 4) in the RHL. The PTPE group included hilar bile duct carcinoma (n = 2), intrahepatic cholangiocarcinoma (n = 2), hepatocellular carcinoma (n = 2) and liver metastasis (n = 3). The PVL group included hepatocellular carcinoma (n = 2) and liver metastasis (n = 2). In addition, observation of postoperative hepatic hemodynamics obtained from computed tomography and Doppler ultrasonography was compared between the two groups.

RESULTS: Mean ages in the two groups were 58.9 ± 2.9 years (PVL group) vs 69.7 ± 3.2 years (PTPE group), which was a significant difference (P = 0.0002). Among the indicators of liver function, including serum albumin, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, platelets and indocyanine green retention rate at 15 min, no significant differences were observed between the two groups. Preoperative RHL volumes in the PTPE and PVL groups were estimated to be 804.9 ± 181.1 mL and 813.3 ± 129.7 mL, respectively, with volume rates of 68.9% ± 2.8% and 69.2% ± 4.2%, respectively. There were no significant differences in RHL volumes (P = 0.83) and RHL volume rates (P = 0.94), respectively. At 1 mo after PTPE or PVL, postoperative RHL volumes in the PTPE and PVL groups were estimated to be 638.4 ± 153.6 mL and 749.8 ± 121.9 mL, respectively, with no significant difference (P = 0.14). Postoperative RHL volume rates in the PTPE and PVL groups were estimated to be 54.6% ± 4.2% and 63.7% ± 3.9%, respectively, which was a significant difference (P = 0.0056). At 1 mo after the operation, the liver volume atrophy rate was 14.3% ± 2.3% in the PTPE group and 5.4% ± 1.6% in the PVL group, which was a significant difference (P = 0.0061).

CONCLUSION: PTPE is a more effective procedure than PVL because PTPE is able to occlude completely the portal branch throughout the right peripheral vein.

Radiofrequency ablation or percutaneous ethanol injection for the treatment of liver tumors

The liver is a common location of both primary and secondary malignancies. For unresectable liver cancer, many local ablative therapies have been developed. These include e.g., percutaneous ethanol injection (PEI), percutaneous acetic acid injection, radiofrequency ablation (RFA), cryoablation, microwave ablation, laser-induced thermotherapy, and high-intensity focused ultrasound. RFA has recently gained interest and is the most widely applied thermoablative technique. RFA allows more effective tumor control in fewer treatment sessions compared with PEI, but with a higher rate of complications. However, there are certain circumstances where PEI therapy represents a better strategy to control liver tumors than RFA, especially in situations where RFA is difficult, for example when large vessels surround the tumor. In the context of hepatocellular carcinoma (HCC), both RFA and PEI are feasible and of benefit in non-operable patients. RFA seems superior to PEI in HCC > 2 cm, and the combination of interventions may be of benefit in selected patients. Liver resection is superior to RFA for patients with HCC meeting the Milan criteria, but RFA can be employed in tumors ≤ 3 cm and where there is an increased expected operative mortality. In addition, some lines of evidence indicate that RFA and PEI can be employed as a bridge to liver transplantation. The use of RFA in colorectal liver metastases is currently limited to unresectable disease and for patients unfit for surgery. The aim of this article is to summarize the current status of RFA in the management of liver tumors and compare it to the cheap and readily available technique of PEI.

Simultaneous bile duct and portal venous branch ligation in two-stage hepatectomy

Hepatectomy is an effective surgical treatment for multiple bilobar liver metastases from colon cancer; however, one of the primary obstacles to completing surgical resection for these cases is an insufficient volume of the future remnant liver, which may cause postoperative liver failure. To induce atrophy of the unilateral lobe and hypertrophy of the future remnant liver, procedures to occlude the portal vein have been conventionally used prior to major hepatectomy. We report a case of a 50-year-old woman in whom two-stage hepatectomy was performed in combination with intraoperative ligation of the portal vein and the bile duct of the right hepatic lobe. This procedure was designed to promote the atrophic effect on the right hepatic lobe more effectively than the conventional technique, and to the best of our knowledge, it was used for the first time in the present case. Despite successful induction of liver volume shift as well as the following procedure, the patient died of subsequent liver failure after developing recurrent tumors. We discuss the first case in which simultaneous ligation of the portal vein and the biliary system was successfully applied as part of the first step of two-stage hepatectomy.

Chemoembolization agents for cancer treatment

Chemoembolization has been used in the field of interventional oncology. Although practiced widely, it has only recently been demonstrated that the use of transarterial chemoembolization (TACE) provides a survival benefit based on randomized controlled trials. TACE combines the effect of targeted chemotherapy with the effect of ischemic necrosis induced by arterial embolization. Most of the TACE procedures have been based on iodized oil utilizing its microembolic and drug-carrying characteristics. Recently, there have been efforts to improve the delivery of chemotherapeutic agents to a tumor, which leads to the development of drug-eluting particles. In this review, we will describe the properties and efficacy of some chemoembolization agents which are commercially available and/or currently under clinical investigations. The potential and future of this new form of transcatheter arterial therapy for liver cancer will be discussed.

Prognostic factors in primary and iterative surgery of colorectal liver metastases

The aim of this study was to evaluate the results of surgery of colorectal liver metastases and assess prognostic factors influencing the outcome. A total of 135 hepatic resections performed in 107 patients was reviewed. The following prognostic factors were analyzed: primary tumor localization, Dukes stage, number and presence of metastases in one or two lobes, synchronous or metachronous occurrence, type of resection, use and modality of chemotherapy. The perioperative morbidity rate was 6.5% and mortality was 1.9%. Overall survival was 41.2% and disease-free survival 31.5% at 5 years. Survival at 5 years was better for patients with metachronous than for those with synchronous lesions (60.9% vs 28.1%; p<0.05). There were no significant differences in terms of long-term survival between patients with synchronous metastases that were excised simultaneously or with a delay of 3-6 months (p=n.s.). Site of the primary tumor, Dukes stage, number of metastases and type of resection did not influence survival. A favorable survival trend was observed in those patients who underwent both neoadjuvant and adjuvant chemotherapy. The overall survival rate at 5 years was 45.3% for patients undergoing a second hepatic resection and 50% for those with a third or a fourth hepatic resection. Liver resection remains the "gold standard" for the treatment of patients with colorectal liver metastases, with metachronous type having a better outcome than synchronous. Simultaneous or delayed surgery for synchronous metastases does not influence prognosis. Iterative resection is very encouraging and justifies an aggressive surgical approach.

Portal vein embolization (prior to major hepatectomy) effects on regeneration, resectability, and outcome

Portal vein embolization (PVE) is used to increase the volume and function of the liver that will remain after extensive liver resection. Operative outcomes are improved in properly selected patients who undergo PVE and experience adequate future liver remnant (FLR) hypertrophy. Absolute volume and volume change of the FLR after PVE (interpreted in context of liver disease) predict adequate liver function postresection. Oncologic outcomes following resection in patients with appropriately applied PVE are excellent.

Milestones in the evolution of hepatic surgery

This paper describes the rapid evolution of modern liver surgery, starting in the middle of the twentieth century. Claude Couinaud studied and described the segmental anatomy of the liver, Thomas Starzl performed the first liver transplantations, and Henri Bismuth introduced the concept of anatomical resections. Hepatic surgery has developed significantly since those early days. To date, innovative techniques are applied, using cutting-edge technologies: Intraoperative ultrasound, techniques of vascular exclusion of the liver, new devices for performing homeostasis and dissection, laparoscopy for resections, and new drugs that allow the resection of previously unresectable tumors. The next stage in liver surgery will probably be the implementation of a multidisciplinary holistic approach to the liver-diseased patient that will ensure the best and most efficient treatments in the future.

[Surgical treatment of liver metastasis in colorectal cancer with simultaneous liver resection]

Metastatic liver disease is a challenging and life-threatening situation often with dismal prognosis. Nearly half of the patients with colorectal cancer develop liver metastasis during the course of their diseases. Hepatic resection is the treatment of choice in patients with colorectal liver metastasis. This study was conducted to compare the results of patients undergoing simultaneous liver and colorectal resection for synchronous liver metastasis and of those for whom a colorectal and liver resection was made separately. A retrospective analysis was performed on 1597 patients who underwent surgery because of colorectal cancer between January 1999 and December 2008. The results of the treatment were separately evaluated in case of the 152 patients who had liver metastasis. The proportion of the liver metastasis was 9.52%. The metastases arose in 40.8% from the rectum and in 31.8% from the sigmoid colon. It proved to be inoperable in 109 (71.7%) of the 152 patients who had liver metastasis. Simultaneous liver resection was performed because of synchronous metastasis in 14 (32.6%) cases (Group 1) and two step resection in 29 (67.4%) cases (Group 2). In case of synchronous operations only minor liver surgery was done. The mean size of the metastasis was 2.6 cm in diameter in Group 1 and 4.6 cm in Group 2 (p<0.005). The transfused blood volume was 0.3 U/patient. Only minor complications could be observed in Group 1. The hospitalization was 13.1 days in Group 1 and 11.7 days in Group 2. The mean survival time was 37.3 and 47.9 months (p<0.005). Simultaneous liver resection seems to be a safe procedure on those patients who develop small metastases with a limited number. However, the optimal timing of the liver resection and the identification of patients who will have the greatest benefit in survival still remain obscure.

[Surgery of hepatobiliary tumors]

Surgical R0 resection of primary and secondary hepatobiliary tumors, such as colorectal liver metastases, hepatocellular carcinoma, cholangiocellular carcinoma and gall bladder carcinoma, remains the only potentially curative treatment option. The extent of involvement of lymph node metastases seems to be an independent prognostic factor in these tumors. The prognostic value of a systematic lymph node dissection in hepatobiliary tumors still remains unclear as there is a lack of prospective randomized trials. However, local lymphadenectomy (hepatoduodenal ligament and retropancreaticoduodenal lymph nodes) can be easily performed with low mortality and morbidity rates and may be helpful in better staging of the patients. Further randomized trials are necessary in order to define the relevance of lymph node dissection in hepatobiliary surgery.

Alternating systemic and hepatic artery infusion therapy for resected liver metastases from colorectal cancer: a North Central Cancer Treatment Group (NCCTG)/ National Surgical Adjuvant Breast and Bowel Project (NSABP) phase II intergroup trial, N9945/CI-66

PURPOSE Prior trials have shown that surgery followed by hepatic artery infusion (HAI) of floxuridine (FUDR) alternating with systemic fluorouracil improves survival rates. Oxaliplatin combined with capecitabine has demonstrated activity in advanced colorectal cancer. Based on this observation a trial was conducted to assess the potential benefit of systemic oxaliplatin and capecitabine alternating with HAI of FUDR. The primary end point was 2-year survival. PATIENTS AND METHODS Patients with liver-only metastases from colorectal cancer amenable to resection or cryoablation were eligible. HAI and systemic therapy was initiated after metastasectomy. Alternating courses of HAI consisted of 0.2 mg/m(2)/d FUDR and dexamethasone, day 1 through 14 weeks 1 and 2. Systemic therapy included oxaliplatin 130 mg/m(2) day 1 with capecitabine at 1,000 mg/m(2) twice daily, days 1 through 14, weeks 4 and 5. Two additional 3-week courses of systemic therapy were given. Capecitabine was reduced to 850 mg/m(2) twice daily after interim review of toxicity. Results Fifty-five of 76 eligible patients were able to initiate protocol-directed therapy and completed median of six cycles (range, one to six). Three postoperative or treatment-related deaths were reported. Overall, 88% of evaluable patients were alive at 2 years. With a median follow-up of 4.8 years, a total of 30 patients have had disease recurrence, 11 involving the liver. Median disease-free survival was 32.7 months. CONCLUSION Alternating HAI of FUDR and systemic capecitabine and oxaliplatin met the prespecified end point of higher than 85% survival at 2 years and was clinically tolerable. However, the merits of this approach need to be established with a phase III trial.

Prognostic factors and time-related changes influence results of colorectal liver metastases surgical treatment: A single-center analysis

AIM: To analyze the prognostic factors involved in survival and cancer recurrence in patients undergoing surgical treatment for colorectal liver metastases (CLM) and to describe the effects of time-related changes on survival and recurrence in these patients.

METHODS: From January 1994 to January 2006, 236 patients with CLM underwent surgery with the aim of performing curative resection of neoplastic disease at our institution and 189 (80%) of these patients underwent resection of CLM with curative intention. Preoperative, intraoperative and postoperative data, including primary tumor and CLM pathology results, were retrospectively reviewed. Patients were divided into two time periods: a first period from January 1994 to January 2000 (n = 93), and a second period from February 2000 to January 2006 (n = 143).

RESULTS: Global survival at 1, 3 and 5 years in patients undergoing hepatic resection was 91%, 54% and 47%, respectively. Patients with preoperative extrahepatic disease, carcinoembryonic antigen (CEA) levels over 20 ng/dL, more than four nodules or extrahepatic invasion at pathological analysis had worse survival. Tumor recurrence rate at 1 year was 48.3%, being more frequent in patients with preoperative and pathological extrahepatic disease and CEA levels over 20 ng/dL. Although patients in the second time period had more adverse prognostic factors, no differences in overall survival and recurrence were observed between the two periods.

CONCLUSION: Despite advances in surgical technique and better adjuvant treatments and preoperative imaging, careful patient staging and selection is crucial to continue offering a chance of cure to patients with CLM.

Hypertrophy of the non-embolized liver after chemotherapy

BACKGROUND

Neoadjuvant chemotherapy (NC(+)) and portal vein embolization (PVE) enables curative resection in more patients with colorectal-liver metastases (CRLM). However, after NC(+), structural alterations have been reported with the risk of post-operative hepatic failure. We undertook to determine if NC(+) toxicity limits future remnant liver (FRL) hypertrophy after PVE.

METHODS

PVE was performed in 20 patients, 13 (65%) of whom previously received a mean FOLFIRI (5-fluorouracil + leucovorin + irinotecan) regimen (NC(+)) of 6.6 cycles. The seven remaining patients served as the control group without NC (NC(-)).

RESULTS

CRLM were bilateral in 69% (NC(+)) and 57% (NC(-)), and synchronous in 84% (NC(+)) and 14% (NC(-)). The FRL hypertrophy rate was 54.1% (NC(+)) and 43.7% (NC(-)) (P= 0.3). CRLM were unresectable in four of our 20 patients, i.e. group NC(+): one insufficient FRL hypertrophy and one severe steatosis; and group NC(-): two tumoral progressions. In both groups, the operative parameters were comparable except for pedicular clamping: 8 (NC(+)) and 36 min (NC(-)), respectively (P < 0.05). Also, the surgical outcome rate and hospital stay were comparable. No significant pathological difference was observed between the two groups. No mortality occurred in either group.

CONCLUSION

In view of our limited experience, we conclude that hypertrophy of the non-embolized liver (FRL) is not altered after FOLFIRI-based NC.

The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.

Strategies for resection using portal vein embolization: metastatic liver cancer

The oncological landscape is constantly changing with the development of new curatively intended therapeutic strategies. More and more, liver metastases are amenable to resection following the progress achieved as a result of new oncological concepts (i.e., treat detectable disease with surgery and ablative therapies and treat the remaining nondetectable disease with efficient chemotherapy) as well as improved chemotherapeutic and ablation techniques. One of the major limitations to extending the indications for liver resection is the volume of the future remnant liver (FRL). To overcome these limitations, portal vein embolization (PVE) has played a key role in obtaining preoperative hypertrophy of the FRL and thus has reduced postoperative morbidity and mortality. Interestingly, thermal ablation of multiple bilateral liver metastases makes it difficult to predict the volume of parenchyma scheduled for ablation. Furthermore, prolonged chemotherapy impairs liver parenchyma function, which has a negative impact on liver hypertrophy. In the future, both volumetric and functional assessment of the FRL will be used to determine whether PVE is necessary before hepatectomy in individual patients and new strategies (e.g., PVE used alone or combined with other treatments; timing of PVE may vary) will be based on these principles. This article presents various current strategies for the use of PVE in patients with metastatic liver cancer.

[Evaluation of liver function before living donor liver transplantation and liver resection]

Liver resection is the curative therapeutic option for hepatocellular carcinoma, biliary tumors, metastases of colorectal and other extrahepatic tumors, living donor liver transplantation and other benign liver diseases.

AIM OF STUDY

To summarize the evaluation methods of liver function before living donor liver transplantation and liver resection.

METHOD

We summarize the literature about the evaluation of liver function.

RESULTS

Perioperative mortality is determined mostly by the extent of preoperative evaluation focused on the liver. After resection the remnant liver parenchyma must cope with the challenge caused by increased metabolism, portal overflow, decreased vascular bed and biliary tract and oxidative stress following the operation. If the remnant liver is unable to grow up to this challenge, acute liver failure occurs. This maintains the necessity of determining the hepatic functional reserve and the hepatic remnant volume. Child-Pugh classification is widely spread to predict outcome. Dynamic functional tests such as indocyanine green retention test, galactosyl human serum albumin scintigraphy and aminopyrine breath tests can be used to evaluate hepatic reserve. To determine remnant liver volume modern imaging processes such as CT volumetry and hepatobiliary scintigraphy are available.

CONCLUSION

After the detailed evaluation resection can be limited to an extent which is oncologically radical enough (1% remnant liver tissue/kg) and spares parenchyma which can ensure survival yet. With careful preoperative examination mortality can be reduced even to reach zero.