Liver Metastases

N-cadherin: A diagnostic marker to help discriminate primary liver carcinomas from extrahepatic carcinomas

Distinguishing primary liver cancer (PLC), namely hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA), from liver metastases is of crucial clinical importance. Histopathology remains the gold standard, but differential diagnosis may be challenging. While absent in most epithelial, the expression of the adherens junction glycoprotein N-cadherin is commonly restricted to neural and mesenchymal cells, or carcinoma cells that undergo the phenomenon of epithelial-to-mesenchymal transition (EMT). However, we recently established N- and E-cadherin expression as hallmarks of normal hepatocytes and cholangiocytes, which are also preserved in HCC and iCCA. Therefore, we hypothesized that E- and/or N-cadherin may distinguish between carcinoma derived from the liver vs carcinoma of other origins. We comprehensively evaluated E- and N-cadherin in 3359 different tumors in a multicenter study using immunohistochemistry and compared our results with previously published 882 cases of PLC, including 570 HCC and 312 iCCA. Most carcinomas showed strong positivity for E-cadherin. Strong N-cadherin positivity was present in HCC and iCCA. However, except for clear cell renal cell carcinoma (23.6% of cases) and thyroid cancer (29.2%), N-cadherin was only in some instances faintly expressed in adenocarcinomas of the gastrointestinal tract (0%-0.5%), lung (7.1%), pancreas (3.9%), gynecological organs (0%-7.4%), breast (2.2%) as well as in urothelial (9.4%) and squamous cell carcinoma (0%-5.6%). As expected, N-cadherin was detected in neuroendocrine tumors (25%-75%), malignant melanoma (46.2%) and malignant mesothelioma (41%). In conclusion, N-cadherin is a useful marker for the distinction of PLC vs liver metastases of extrahepatic carcinomas (P < .01).

Transplant Oncology: An Emerging Discipline of Cancer Treatment

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.

Surgical debulking is associated with improved survival for patients with neuroendocrine liver metastases of unknown primary

BACKGROUND

Resection of neuroendocrine tumors (NET) with surgical debulking of liver metastasis (NETLM) is associated with improved survival. In patients with an unknown primary (UP-NETLM), the effects of debulking remains unclear.

METHODS

The National Cancer Database (2004-2016) was queried for patients with small intestine (SI) and pancreas (P) NETLMs. If the liver was listed as the primary site, the patient's disease was classified as UP-NETLM.

RESULTS

Patients with UP-NETLM, SI-NETLM, and P-NETLM who were managed non-operatively demonstrated a significant difference in 5-year overall survival (OS) (21.5% vs. 39.2% vs. 17.1%; p < 0.0001). OS in patients who underwent debulking was higher (63.7% vs. 73.2% vs. 54.2%). Patients with UP-NETLMs who underwent debulking had similar OS to patient with SI-NETLM (p = 0.051), but significantly higher OS, depending on tumor differentiation, compared to patients with P-NETLMs. If well-differentiated, surgery for UP-NETLMs was associated with a higher rate of OS (p = 0.009), while no difference was observed if moderately (p = 0.209) or poorly/undifferentiated (p = 0.633). P-NETLMs were associated with worse OS (p < 0.001) on multivariate analysis.

DISCUSSION

Debulking in patients with UP-NETLMs was associated with similar OS compared to patients with SI-NETLMs and better or similar OS compared to patient with P-NETLMs.

Surgery, Liver Directed Therapy and Peptide Receptor Radionuclide Therapy for Pancreatic Neuroendocrine Tumor Liver Metastases

Pancreatic neuroendocrine tumors (PNETs) are described by the World Health Organization (WHO) classification by grade (1–3) and degree of differentiation. Grade 1 and 2; well differentiated PNETs are often characterized as relatively “indolent” tumors for which locoregional therapies have been shown to be effective for palliation of symptom control and prolongation of survival even in the setting of advanced disease. The treatment of liver metastases includes surgical and non-surgical modalities with varying degrees of invasiveness; efficacy; and risk. Most of these modalities have not been prospectively compared. This paper reviews literature that has been published on treatment of pancreatic neuroendocrine liver metastases using surgery; liver directed embolization and peptide receptor radionuclide therapy (PRRT). Surgery is associated with the longest survival in patients with resectable disease burden. Liver-directed (hepatic artery) therapies can sometimes convert patients with borderline disease into candidates for surgery. Among the three embolization modalities; the preponderance of data suggests chemoembolization offers superior radiographic response compared to bland embolization and radioembolization; but all have similar survival. PRRT was initially approved as salvage therapy in patients with advanced disease that was not amenable to resection or embolization; though the role of PRRT is evolving rapidly

Role of surgical treatments in high-grade or advanced gastroenteropancreatic neuroendocrine neoplasms

Over the last 40 years, the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) have continued to increase. Compared to other epithelial neoplasms in the same organ, GEP-NENs exhibit indolent biological behavior, resulting in more chances to undergo surgery. However, the role of surgery in high-grade or advanced GEP-NENs is still controversial. Surgery is associated with survival improvement of well-differentiated high-grade GEP-NENs, whereas poorly differentiated GEP-NENs that may benefit from resection require careful selection based on Ki67 and other tissue biomarkers. Additionally, surgery also plays an important role in locally advanced and metastatic disease. For locally advanced GEP-NENs, isolated major vascular involvement is no longer an absolute contraindication. In the setting of metastatic GEP-NENs, radical intended surgery is recommended for patients with low-grade and resectable metastases. For unresectable metastatic disease, a variety of surgical approaches, including cytoreduction of liver metastasis, liver transplantation, and surgery after neoadjuvant treatment, show survival benefits. Primary tumor resection in GEP-NENs with unresectable metastatic disease is associated with symptom control, prolonged survival, and improved sensitivity toward systemic therapies. Although there is no established neoadjuvant or adjuvant strategy, increasing attention has been given to this emerging research area. Some studies have reported that neoadjuvant therapy effectively reduces tumor burden, improves the effectiveness of subsequent surgery, and decreases surgical complications.

Management of Small Bowel Neuroendocrine Tumors

Small bowel neuroendocrine tumors (SBNETS) are slow-growing neoplasms with a noted propensity toward metastasis and comparatively favorable prognosis. The presentation of SBNETs is varied, although abdominal pain and obstructive symptoms are the most common presenting symptoms. In patients with metastases, hypersecretion of serotonin and other bioactive amines results in diarrhea, flushing, valvular heart disease, and bronchospasm, termed carcinoid syndrome. The treatment of SBNETs is multimodal and includes surgery, liver-directed therapy, somatostatin analogues, targeted therapy, and peptide receptor radionuclide therapy.

Surgical Management of Neuroendocrine Tumor Liver Metastases

Patients with neuroendocrine tumor liver metastases (NETLMs) may develop carcinoid syndrome, carcinoid heart disease, or other symptoms from overproduction of hormones. Hepatic resection and cytoreduction is the most direct treatment of NETLMs in eligible patients, and cytoreduction improves symptoms, may reduce the sequelae of carcinoid syndrome, and extends survival. Parenchymal-sparing procedures, such as ablation and enucleation, should be considered during cytoreduction to maximize treatment of multifocal tumors while preserving healthy liver tissue. For patients with large hepatic tumor burdens, high-grade disease, or comorbidities precluding surgery, liver-directed and systemic therapies can be used to palliate symptoms and improve progression-free survival.

The Landmark Series: Neuroendocrine Tumor Liver Metastases

BACKGROUND

Neuroendocrine tumors are becoming increasingly prevalent, with many patients presenting with or developing metastatic disease to the liver.

METHODS

In this landmark series paper, we highlight the critical studies that have defined the surgical management of neuroendocrine tumor liver metastases, as well as several randomized control trials which have investigated strategies for systemic control of metastatic disease.

RESULTS

Liver-directed surgical approaches and locally ablative procedures are recommended for patients with limited, resectable, and in some cases, nonresectable tumor burden. Angiographic liver-directed techniques, such as transarterial embolization, chemoembolization, and radioembolization, offer another approach for management in patients with liver-predominant disease. Peptide receptor radionuclide therapy is a promising therapy for patients with hepatic and/or extrahepatic metastases. Various systemic medical therapies are also available as adjunct or definitive therapy for patients with metastatic disease.

CONCLUSIONS

This article reviews current data regarding management of neuroendocrine liver metastases and highlights areas for future study.

The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors

This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.

Utility of rapid on-site evaluation for needle core biopsies and fine-needle aspiration cytology done for diagnosis of mass lesions of the liver

BACKGROUND

Fine-needle aspiration (FNA) and core biopsy (CB) are used to diagnose liver lesions. Rapid onsite evaluation (ROSE) can improve the adequacy of the procedures and help triage diagnostic material appropriately. There are very few studies evaluating the role of ROSE for CB and FNA of mass lesions of the liver.

METHODS

Liver cases with ROSE material from 2007 to 2017 were retrieved and reviewed. The ROSE material was re-evaluated by 2 cytopathologists who were blinded to the final diagnosis. Data including age, number of lesions, number of passes, adequacy assessed at time of procedure, and diagnosis made by cytopathologist on ROSE material at time of re-review was compiled.

RESULTS

A total of 82 cases were identified; 33 were primary lesions (group A) and 49 were metastatic lesions (group B). ROSE done by cytotechnologist at time of procedure showed an adequacy rate of 84%. During re-review of ROSE material by cytopathologists, the overall adequacy rates were similar, although the adequacy rates in group B increased (to 100% from 92%) and it dropped in group A (from 73% to 52%). The overall accuracy rate was 90%. Hepatocellular adenoma, regenerative nodules, well-differentiated hepatocellular carcinoma, and angiosarcoma were not possible to diagnose on smears alone during ROSE.

CONCLUSIONS

ROSE for liver lesions is useful for assessing adequacy. Certain lesions cannot be accurately diagnosed on ROSE alone. ROSE material when assessed by cytopathologist can improve adequacy rate and possibly decrease number of nondiagnostic specimens in group A, though the cost effectiveness needs to be assessed.

Adoptive immunotherapy with MUC1-mRNA transfected dendritic cells and cytotoxic lymphocytes plus gemcitabine for unresectable pancreatic cancer

Background

We previously reported the clinical efficacy of adoptive immunotherapy (AIT) with dendritic cells (DCs) pulsed with mucin 1 (MUC1) peptide and cytotoxic T lymphocytes (CTLs). We also reported that gemcitabine (GEM) enhances anti-tumor immunity by suppressing regulatory T cells. Therefore, in the present study, we performed combination therapy with AIT and GEM for patients with unresectable or recurrent pancreatic cancer.

Patients and methods

Forty-two patients with unresectable or recurrent pancreatic cancer were treated. DCs were generated by culture with granulocyte macrophage colony-stimulating factor and interleukin-4 and then exposed to tumor necrosis factor-α. Mature DCs were transfected with MUC1-mRNA by electroporation (MUC1-DCs). MUC1-CTLs were induced by co-culture with YPK-1, a human pancreatic cancer cell line, and then with interleukin-2. Patients were treated with GEM, while MUC1-DCs were intradermally injected, and MUC1-CTLs were intravenously administered.

Results

Median survival time (MST) was 13.9 months, and the 1-year survival rate was 51.1%. Of 42 patients, one patient had complete response (2.4%), three patients had partial response (7.1%) and 22 patients had stable disease (52.4%). The disease control ratio was 61.9%. The MST and 1-year survival rate of 35 patients who received more than 1 × 10⁷ MUC1-DCs per injection was 16.1 months and 60.3%, respectively. Liver metastasis occurred in only 5 patients among 35 patients without liver metastasis before treatment. There were no severe toxicities associated with AIT.

Conclusion

AIT with MUC1-DCs and MUC1-CTLs plus GEM may be a feasible and effective treatment for pancreatic cancer.

[Liver hemostasis using a dry electrocautery or greased with lidocaine or neomycin or glycerin or vaseline, in rabbit]

OBJECTIVE

To assess the hemostasis and healing of the hepatic parenchyma after segmental hepatectomy, using a dry electrocautery or an electrocautery greased with lidocaine gel, neomycin pomade, glycerin lotion, or a vaseline pomade.

METHODS

Rabbits were submitted to partial hepatectomy and divided into six groups of 10 animals each: Group 1: untreated; Group 2: treated with a dry electrocautery; Group 3: treated with an electrocautery greased with lidocaine gel; Group 4: with neomycin pomade; Group 5: with glycerine lotion; Group 6: with vaseline pomade. Resected liver weight, bleeding volume and time spent to achieve hemostasis were determined. Five rabbits from each group were re-operated upon after 24 hours and five after 7 days in order to obtain a biopsy of the hepatic wound and to explore he abdominal cavity. Red blood cell levels and markers of hepatic function and injury were determined before surgery and before re-operation.

RESULTS

Lidocaine gel and glycerine lotion reduced the bleeding volume and the time to achieve hemostasis and conducted the thermal energy of the electrocautery, causing hydropic cell degeneration after 24 hours and deeper necrosis of hepatic tissue after 7 days. All substances increased the aminotransferase concentrations. These values returned to normal after a maximum of seven days.

CONCLUSION

The electrocautery coated with lidocaine gel and glycerine lotion were the most effective methods for the hemostasis of hepatic parenchyma.

Angiotensin-II administration is useful for the detection of liver metastasis from pancreatic cancer during pharmacoangiographic computed tomography

AIM: To improve the preoperative diagnosis of liver metastasis from pancreatic cancer, we estimated computed tomography during arterial angiography (CTA) with/without administration of angiotensin-II (AT-II).

METHODS: Thirty-five patients with pancreatic cancer were examined in this study. After conventional CTA was performed, pharmacoangiographic CTA was performed with a 1-3 microgram/5 mL solution of angiotensin  IIinjected through a catheter into the celiac artery during spiral computed tomography. We prospectively analyzed the relative region of interest (ROI) ratio of tumor to liver with/without AT-II.

RESULTS: In all patients, the relative ratio of each computed tomography (CT) number in the ROI was larger at pharmacoangiographic CT than at conventional angiographic CT. Administration of angiotensin-II enhanced the metastatic liver tumor as compared with normal tissue. Intratumoral blood flow increased in all patients with malignant tumors due to the pressure effect of AT-II. Furthermore, the metastatic lesions in the liver of three patients were represented by only pharmacoangiographic CT, not by conventional CT and conventional CT angiography. In even peripheral and central areas of metastatic liver tumor, the lesions were enhanced after administration of AT-II.

CONCLUSION: These results support that high detection rate of liver metastasis revealed by pharmacoangiographic CT suggests the improvement of diagnosis on preoperative staging. Moreover, chemotherapy under AT-II induced hypertension may have a better effect on the treatment of metastatic liver tumors.

Hepatic resection for metastatic melanoma: distinct patterns of recurrence and prognosis for ocular versus cutaneous disease

BACKGROUND

Resection of melanoma metastatic to the liver remains controversial. We evaluated the efficacy of hepatic resection in patients with metastatic ocular and cutaneous melanoma and assessed factors that could affect survival after resection.

METHODS

Forty patients with hepatic melanoma metastasis underwent resection at four major hepatobiliary centers. Clinicopathologic factors were evaluated with regard to recurrence and survival by using chi(2) and log-rank tests.

RESULTS

The primary tumor was ocular in 16 patients and cutaneous in 24. The median disease-free interval from the time of primary tumor treatment to hepatic metastasis was the same for both groups (ocular, 62.9 months; cutaneous, 63.1 months; P = .94). Most patients underwent either an extended hepatic resection (37.5%) or hemihepatectomy (22.5%). Twenty-six patients (65%) received perioperative systemic therapy. Thirty (75.0%) of 40 patients developed tumor recurrence. The median time to recurrence after hepatic resection was 8.3 months (ocular, 8.8 months; cutaneous, 4.7 months; P = .3). Patients with primary ocular melanoma were more likely to experience recurrence within the liver (53.3% vs. 17.4%; P = .015), whereas patients with a cutaneous primary tumor more often developed extrahepatic involvement. The 5-year survival rate for patients with a primary ocular melanoma was 20.5%, whereas there were no 5-year survivors for patients with cutaneous melanoma (P = .03).

CONCLUSIONS

Patterns of recurrence and prognosis after resection of hepatic melanoma metastasis differ depending on whether the primary melanoma is ocular or cutaneous. Resection should be performed as part of a multidisciplinary approach, because recurrence is common.

PET and PET-CT for evaluation of colorectal carcinoma

The evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for positron emission tomography using (18)F-fluorodeoxyglucose (FDG-PET) imaging. FDG-PET does not replace imaging modalities such as computed tomography (CT) for preoperative anatomic evaluation but is indicated as the initial test for diagnosis and staging of recurrence and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG-PET imaging is valuable for the differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic and pulmonary lesions), and the evaluation of patients with rising tumor markers in the absence of a known source. The addition of FDG-PET to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. Although initial staging at the time of diagnosis is often performed during colectomy, FDG-PET imaging is recommended for a subgroup of patients at high risk (with elevated CEA levels) and normal CT and for whom surgery can be avoided if FDG-PET shows metastases. Screening for recurrence in patients at high risk has also been advocated. FDG-PET imaging seems promising for monitoring patient response to therapy but larger studies are necessary. The diagnostic implications of integrated PET-CT imaging include improved detection of lesions on both the CT and FDG-PET images, better differentiation of physiologic from pathologic foci of metabolism, and better localization of the pathologic foci. This new powerful technology provides more accurate interpretation of both CT and FDG-PET images and therefore more optimal patient care. PET-CT fusion images affect the clinical management by guiding further procedures (biopsy, surgery, radiation therapy), excluding the need for additional procedures, and changing both inter- and intramodality therapy.

Interventional treatment of the carcinoid syndrome

Liver metastases imply a major problem in patients with carcinoid tumours and hormone overproduction. Patients with distant metastases can undergo resection for potential cure or for symptom palliation. In patients with bilobar liver metastases other interventions are at hand, e.g. local ablation or hepatic arterial embolization. In selected cases liver transplantation can be a treatment alternative. Prior to all interventions patients with midgut carcinoids are protected with somatostatin analogues to reduce hormone secretion. Patients with foregut carcinoids may present special problems with life-threatening release of histamine during interventions.

FDG-PET scanning in the diagnosis of gastrointestinal cancers

This review deals with the current, well-established indications for two-(18F)-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scanning in patients with gastrointestinal cancers. FDG-PET is a non-invasive, functional imaging technique. FDG exploits the native glucose transporter to enter the cell. Since many tumours have enhanced glucose uptake, FDG is readily accumulated in malignant cells and can be detected by a PET camera. FDG-PET has been established as an important diagnostic tool in clinical oncology. This review deals with the current, well-established indications for FDG-PET scanning in patients with gastrointestinal cancers. In the current practice, FDG-PET is most commonly used to stage oesophageal carcinoma, to detect and stage recurrence of colorectal carcinoma and to differentiate between benign and malignant pancreatic lesions. The benefit of FDG-PET scanning in patients with oesophagus carcinoma is best established in stage IV disease, as the diagnostic accuracy to detect metastatic disease is higher compared to the combination of computed tomography (CT) and endoscopic ultrasound (EUS). In patients with a history of colorectal carcinoma, FDG-PET scanning is particularly effective in diagnosing recurrent disease, especially in those with a rising carcinoembryonic antigen without a suspect lesion on conventional imaging. Large series have indicated that the sensitivity and specificity for detecting recurrent colorectal carcinoma are in the range of 87%-100% and 66%-100%, respectively. Equally, FDG-PET has a high sensitivity (68%-96%) and specificity (78%-100%) in detecting pancreatic carcinoma in patients with a suspicious-looking pancreatic mass on CT scan. Lastly, we focus on the use of FDG-PET as a modality for early monitoring of treatment response in patients with gastrointestinal stromal cell tumours. Without doubt, future developments will further establish the diagnostic role of the FDG-PET scan in the care of patients with gastrointestinal cancers.

Patterns of failure following curative resection of colorectal liver metastases

AIMS

Several studies have focused on factors determining recurrence and survival rate after curative resection of colorectal liver metastases (LM). Data are lacking with regard to patterns of failure indicating where and when recurrences arise.

METHODS

One-hundred-and-five consecutive patients [F/M: 31/74; mean age 61 years (range 36-80 y)] with primary colorectal liver metastases underwent surgical R0 curative resection between 1990-1999. Patient follow-up was closed in January 2002. The common closing date method was used for survival analysis. Multivariate analysis was performed with the Cox proportional hazard technique.

RESULTS

The overall (OS) vs disease free survival (DFS) rates at 1, 2, and 5 years were 88.5 vs 63.3, 73.4 vs 40.2, and 36.8 vs 18.1%, respectively. Elevated serum CEA level was the only factor independently related to recurrent disease. Elevated serum CEA level, maximum diameter of liver metastases (LM), and satellitosis were factors significantly related to poor OS. Recurrent liver metastases developed in 43% and extra-hepatic metastases in 60% of the patients. In about half of the patients cancer recurrence was observed within 18 months, almost equally distributed between hepatic and extra-hepatic sites.

CONCLUSION

Despite optimal patient selection and curative resection of colorectal liver metastases, more than a half of the patients developed cancer recurrence within 2 years.

A critical review of the major indicators of prognosis after resection of hepatic metastases from colorectal carcinoma

Hepatic resections for metastatic colorectal cancer have dramatically increased, and there is clear evidence of the effectiveness of this type of surgery. Controversy, however, persists regarding appropriate patient selection, extent and timing of liver resection, and adjuvant or alternative therapeutic options. This article reviews the authors' experience with more than 600 hepatic resections and the relevant literature is discussed. The results underscore the importance of macroscopically and histologically complete tumor clearance, a so-called "R0 resection."

Positron emission tomography for evaluation of colorectal carcinoma

Evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for FDG PET imaging. FDG PET does not replace imaging modalities such as CT for preoperative anatomic evaluation but is indicated as the initial test for diagnosis and staging of recurrence and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG PET imaging is valuable for differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic and pulmonary lesions), and evaluation of patients with rising tumor markers in the absence of a known source. Addition of FDG PET to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. Although initial staging at the time of diagnosis is often performed during colectomy, FDG PET imaging is recommended for a subgroup of patients at high risk (with elevated CEA levels) and normal CT and for whom surgery can be avoided if FDG PET shows metastases. Screening for recurrence in patients at high risk has also been advocated. FDG PET imaging seems promising for monitoring therapy, but larger studies are necessary.

Metastasectomy for liver metastases of non-colorectal primaries

BACKGROUND

Resection of liver metastases of non-colorectal primary malignancies has been reported to prolong survival. We studied the results in our hospital and compared the survival data with that described in the literature.

PATIENTS AND METHODS

Since 1991, a prospective database has been kept at The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital of patients undergoing hepatic surgery (n=180). Between 1991 and 1999, 32 patients underwent laparotomy for hepatic metastases of non-colorectal primaries. This study evaluates the operative technical aspects and determines morbidity, mortality, disease-free and overall survival.

RESULTS

There were 11 males and 21 females with a median age of 52 (25-69) years. Histology of the primary tumour were various carcinomas (n=22), melanomas (n=4) and sarcomas (n=6). Resection was performed in 28 patients; four patients appeared to be irresectable. There was no perioperative mortality. Morbidity was 23%. One re-operation was necessary because of haemorrhage. The median disease-free survival for the 28 patients was 12 months with an actuarial 5-year disease-free survival of 20% (Kaplan-Meier). The 5-year overall survival was 35% with a median survival of 21 months.

CONCLUSION

Liver metastasectomy for selected types of non-colorectal primary tumours is relatively safe and shows in selected patients long-term survival comparable to that of metastasectomies for colorectal origin.

Positron emission tomography and colorectal cancer

BACKGROUND

The oncological applications of positron emission tomography (PET) have gained widespread acceptance. This rapidly evolving technology has been applied successfully to colorectal cancer, but has not yet become part of routine clinical practice. This review considers (1) the biological basis for the use of PET in colorectal cancer, (2) the technical aspects of PET relevant to the referring clinician and (3) the application of PET to the management of primary and recurrent disease.

METHODS

A Medline database search was performed for the period 1980-2000. Experience was also drawn from the first 40 patients with colorectal cancer investigated at this institution.

RESULTS AND CONCLUSION

PET has a proven role, and is cost effective in the management of recurrent cancer and the monitoring of therapy. However, further evaluation is still required to justify its routine use for other indications in colorectal cancer. Development of new positron-labelled radio- pharmaceuticals, in parallel with advances in detector technology and innovative models for tracer production and distribution, means that the availability of PET and its applications in the management of colorectal cancer will expand over the coming years.

Result of liver resection as treatment for metastases from noncolorectal cancer

BACKGROUND AND OBJECTIVES

While liver resection for metastatic disease from colorectal cancer extends survival in selected patients, the efficacy of hepatectomy for metastases from other malignancies has not been defined.

METHODS

Between 1988 and 1998, 20 hepatic resections were performed in 18 patients (2 underwent a double resection due to recurrence) as treatment of noncolorectal metastases. One-, 2-, and 5-year overall and disease-related actuarial survival rates were calculated.

RESULTS

No intraoperative or early postoperative deaths were reported. Seven minor (30%) and 1 major (5%) postoperative complications occurred; mean blood loss was 401 +/- 324 ml. In 25% of patients, intra- or postoperative blood transfusion was needed. The mean postoperative hospital stay was 13. 2 days (range 9-23). The overall actuarial survival rate was 54% at 1 year, 42% at 2 years, and 21% at 5 years (mean 38 +/- 11 months). Survival is related to the primary tumor nature.

CONCLUSIONS

Hepatic resection for metastases from noncolorectal carcinoma is safe and feasible, with a relatively low incidence of intra- or postoperative complications and a short hospital stay. Although it achieves good results in terms of survival in patients suffering from neuroendocrine metastases, it could also have a cytoreductive effect for other tumors.

Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period

OBJECTIVE

To describe a large single-center experience with hepatic resection for metastatic leiomyosarcoma.

SUMMARY BACKGROUND DATA

Liver resection is the treatment of choice for hepatic metastases from colorectal carcinoma. In contrast, the role of liver resection for hepatic metastases from leiomyosarcoma has not been defined.

METHODS

The records of 26 patients who between 1982 and 1996 underwent a total of 34 liver resections for hepatic metastases from leiomyosarcoma were reviewed. There were 23 first, 9 second, and 2 third liver resections. The records were analyzed with regard to survival and predictive factors.

RESULTS

In the 23 first liver resections, there were 15 R0, 3 R1, and 5 R2 resections. Median survival was 32 months after R0 resection and 20.5 months after R1/2 resection. The 5-year survival rate was 13% for all patients and 20% after R0 resection. In 10 patients with extrahepatic tumor at the time of the first liver resection, 6 R0 and 4 R2 resections were achieved. After R0 resection, the median survival was 40 months (range 5-84 months), with a 5-year survival rate of 33%. After repeat liver resection, the median survival was 31 months (range 5-51 months); after R0 resection, median survival was 31 months and after R1/2 resection it was 28 months. There was no 5-year survivor in the overall group after repeat liver resection.

CONCLUSIONS

Despite frequent tumor recurrence, the long-term outcome after liver resection for hepatic metastases from leiomyosarcoma is superior to that after chemotherapy and chemoembolization. Although survival after tumor debulking also seems to be more favorable than after nonoperative therapy, these data indicate that only an R0 resection offers the chance of long-term survival. The presence of extrahepatic tumor should not be considered a contraindication to liver resection if complete removal of all tumorous masses appears possible. In selected cases of intrahepatic tumor recurrence, even repeated liver resection might be worthwhile. In view of the poor results of chemoembolization and chemotherapy in hepatic metastases from leiomyosarcoma, liver resection should be attempted whenever possible.

Comparison of survival between malignant neuroendocrine tumours of midgut and pancreatic origin

The survival of 64 consecutive patients with disseminated midgut carcinoid tumours was compared in a retrospective study with that of 25 consecutive patients with sporadic malignant endocrine pancreatic tumours treated according to similar surgical principles. The presence of hepatic metastases implied a worse prognosis in neuroendocrine tumours of pancreatic rather than midgut origin. This infers that these tumour types must be separated when treatments are evaluated.

Intraoperative abdominal ultrasonography

BACKGROUND

Ultrasonography during abdominal surgery has been reported since the 1960s, but its use did not become widespread until the recent availability of high-frequency, high-resolution transducers. This review discusses the application of intraoperative ultrasonography to open and laparoscopic abdominal surgery.

METHODS

A literature search (Medline) was undertaken. All papers pertaining to the subject matter that were located were included in the review.

RESULTS

Intraoperative ultrasonography influences surgical strategy in up to 50 per cent of liver resections for malignancy. It is the single most sensitive technique for the detection of occult hepatic metastases at the time of primary colorectal resection. In pancreatic surgery, intraoperative ultrasonography is of value in the localization of islet cell tumours and in the assessment of resectability of adenocarcinoma. The technique may also have a role in staging laparoscopy, and in the operative management of kidney and gastrointestinal diseases.

CONCLUSION

Ultrasonography is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. It should be regarded as an essential component of major hepatobiliary and pancreatic procedures. The recent availability of flexible laparoscopic probes is likely to lead to a similar impact on minimal access surgery.

Results of surgical resection of liver metastases from non-colorectal primaries

BACKGROUND

Advances in the field of liver surgery have lowered its associated mortality and morbidity rates, and hepatic resection for metastatic disease is increasingly performed. There are few well defined guidelines for the heterogeneous group of non-colorectal metastases. This study analysed the risks and benefits of surgical resection for liver metastases from non-colorectal primaries.

METHODS

A retrospective study was performed of 34 patients who underwent 37 operations over a 10-year period. Compilation of data from 141 patients from eight additional recent series was performed in order to analyse the effect of histological type on survival.

RESULTS

There were no perioperative deaths. Complications occurred after seven of 37 procedures. Actuarial survival rates were 61, 43 and 27 per cent at 1, 2 and 5 years. Survival was significantly improved for curative versus palliative resection (P < 0.05), and for single versus multiple metastases (P < 0.05). A strong correlation was observed between time to presentation with metastasis and length of survival (P< 0.0001). Survival was significantly better for patients with secondaries from neuroendocrine tumours (P < 0.0001), worse for those with intestinal adenocarcinomas (P < 0.0001) and similar for patients with breast carcinoma (P > 0.5) when compared with the whole group.

CONCLUSION

The low mortality and morbidity rates and the satisfactory survival figures reported justify this type of surgery for selected patients, in the absence of therapeutic alternatives.

Cryosurgical palliation of metastatic neuroendocrine tumors resistant to conventional therapy

BACKGROUND

Hepatic cryosurgery is a well-recognized modality for hepatic colon metastases. We examined its potential use for refractory neuroendocrine tumors causing progressive symptoms.

METHODS

Between July 1992 and February 1997, 19 patients (with islet cell, 7; carcinoid, 8; vasoactive intestinal peptide, 1; gastrinoma, 3) underwent cryosurgery with ultrasonography. The number of lesions frozen ranged from 1 to 16 (median, 8), and their diameters ranged from 2 to 15 cm with an average of 4 cm. Patients underwent resection of the primary tumor either before (37%) or concurrent with (32%) cryosurgery, and half underwent excision of metastases with cryosurgery. Before cryosurgery, patients received chemotherapy (63%), somatostatin (47%), interferon (10%), hepatic artery ligation (5%), radiation (10%), and/or omeprazole (16%).

RESULTS

The reduction in tumor markers reached 90% (5-hydroxyindoleacetic acid), 80% (vasoactive intestinal peptide), 90% (gastrin), 90% (pancreatic polypeptide), and 80% (serotonin). At a median follow-up of 17 months, the metastases had progressed in 11 patients (two underwent a second cryosurgical procedure that eliminated symptoms) and five had died. Subsequently an additional five patients received chemotherapy and three somatostatin. Median symptom-free and overall survival were 10 months and more than 49 months, respectively.

CONCLUSIONS

Cryosurgery dramatically relieved symptoms with significant reduction in tumor markers. The reduced tumor burden may explain the subsequent response to systemic therapy. Cryosurgery is a useful adjuvant in symptomatic patients with refractory hepatic neuroendocrine metastases.

Management strategies for colorectal liver metastases--Part I

Colorectal cancer is a common malignancy and the incidence of this disease is increasing. Approximately 50% of patients with colorectal cancer die from recurrent disease following an apparently curative resection of the primary tumour and the liver is the most frequent site of relapse. Although only a small proportion of patients will benefit from resection of liver metastases, this form of treatment offers the only possibility of cure. In selected patients, 5-year survival rates of 25-35% may be achieved following liver resection. A poor prognosis after resection of hepatic metastases is likely when there are more than three metastatic deposits, involved resection margins often as a result of ¿wedge' resections, when there is extrahepatic disease, or when there is nodal involvement at the primary tumour site. Regional hepatic artery infusion chemotherapy may provide palliation and possibly even prolongation of survival for some patients with unresectable metastases. Cytoreductive techniques may also provide palliation in selected patients with hepatic metastases unsuitable for resection; cryotherapy is the most promising of these methods.

The aetiology and management of hepatic metastases

Hepatic metastases are a common event in the metastatic spread of primary tumours and indicate advanced disease. However, the presence of hepatic metastases does not necessarily imply incurability; in selected patients resection of hepatic metastases may result in 5-year survival rates of 25-35%, usually in patients with colorectal liver metastases in whom solitary metastases are more frequent than with other primary tumours. However, hepatic metastases from Wilm's tumours, adrenal tumours, renal cell carcinoma, and neuroendocrine tumours may also be resected with similar success rates. A poor prognosis after resection of hepatic metastases is likely when there are more than three metastatic deposits, involved resection margins (often as a result of 'wedge' resections), when there is extrahepatic disease, or nodal involvement at the primary tumour site. Cyto-reductive procedures may provide excellent palliation and possibly long-term survival in selected patients with hepatic metastases unsuitable for resection. However, further study is required to establish the appropriate role for these treatments.

Repeat hepatectomy for colorectal liver metastases

OBJECTIVE

The authors assess the long-term results of repeat hepatectomies for recurrent metastases of colorectal cancer and determine the factors that can predict survival.

SUMMARY BACKGROUND DATA

Safer techniques of hepatic resection have allowed surgeons to consider repeat hepatectomy for colorectal metastases in an increasing number of patients. However, higher operative bleeding and increased morbidity have been reported after repeat hepatectomies, and the long-term benefit of these procedures needs to be evaluated.

STUDY POPULATION

Sixty-four patients from a group of 243 patients resected for colorectal liver metastases were submitted to 83 repeat hepatectomies (64 second, 15 third, and 4 fourth hepatectomies). Combined extrahepatic surgery was performed in 21 (25%) of these 83 repeat hepatectomies.

RESULTS

There was no intraoperative or postoperative mortality. Operative bleeding was not significantly increased in repeat hepatectomies as compared to first resections. Morbidity and duration of hospital stay were comparable to first hepatectomies. Overall and disease-free survival after a second hepatectomy were 60% and 42%, respectively, at 3 years and 41% and 26%, respectively, at 5 years. Factors of prognostic value on univariate analysis included the curative nature of first and second hepatectomies (p = 0.04 and p = 0.002, respectively), an interval between the two procedures of more than 1 year (p = 0.003), the number of recurrent tumors (p = 0.002), serum carcinoembryonic antigen levels (p = 0.03), and the presence of extrahepatic disease (p = 0.03). Only the curative nature of the second hepatectomy and an interval of more than 1 year between the two procedures were independently related to survival on multivariate analysis.

CONCLUSIONS

Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies, with no mortality and comparable morbidity. Combined extrahepatic surgery can be required to achieve tumor eradication. Repeat hepatectomies appear worthwhile when potentially curative.

Hepatic resection for noncolorectal nonneuroendocrine metastases

The experience with hepatic resection for metastatic lesions, exclusive of colorectal and neuroendocrine tumors, is anecdotal. The reduction in operative mortality leads to a reconsideration of the subject. A review of the literature suggests a selective approach. There is little improvement to be anticipated for resection of metastases from tumors of the esophagus, stomach, small intestine, or pancreas. Resection of metastases from primary renal cell carcinoma, Wilms' tumor, and adrenocortical carcinoma is indicated. There is little to recommend resection of metastases from gynecologic or breast primary carcinomas. Resection as palliation is to be considered for all lesions, particularly bulky metastases from ocular melanomas.

The regional treatment of liver metastases from breast cancer

To determine the effect of aggressive regional therapy for liver metastasis from breast cancer, we retrospectively reviewed data on 74 patients identified with liver metastases. Forty had only liver metastases. In this group of 40 patients, 18 were treated with regional therapy only, i.e., surgical resection and/or regional chemotherapy via hepatic artery or portal vein catheters whereas 22 patients had systemic chemotherapy. The two groups were comparable. The regional chemotherapy regimen was 5-FU, Adriamycin, methotrexate, and cytoxan. Median survival (27 months) for those patients treated with regional therapy (N = 18) was significantly longer than for those (N = 22) treated with systemic therapy (5 months) (P = 0.001). Only 45% of the regional treatment group failed in the liver. Our data, although retrospective and selective, suggest that certain subgroups of breast cancer patients with metastatic liver disease may benefit from aggressive regional therapy.

Cytoreductive surgery prior to interleukin-2-based therapy in patients with metastatic renal cell carcinoma

From May 1985 to December 1990, 93 patients with the clinical diagnosis of metastatic renal cell carcinoma and their primary tumor in place were evaluated for cytoreductive surgery as preparation for systemic therapy with regimens based on interleukin-2. These patients had typical sites of metastatic disease and manifestations of paraneoplastic syndromes. Patients underwent removal of the primary tumor, as well as debulking when this could be performed safely. Thirty-two percent of patients (30/93) had a second surgical resection in addition to their nephrectomy, frequently because of the large size of the primary tumor and its invasion of adjacent structures. Thirteen percent of patients (12/93) experienced postoperative complications. There were no perioperative mortalities. Forty percent of patients (37/93) who underwent nephrectomy could not be treated with immunotherapy, usually because of progression of disease. A preoperative ECOG status greater than or equal to 2 was the only significant risk factor associated with failure to undergo immunotherapy (P = 0.043). The response rate to immunotherapy in the 56 patients receiving interleukin-2 was 27 percent (4 CR, 11 PR).

Is follow-up of colorectal cancer patients worthwhile?

Between 1978 and 1989, 1,045 of 1,399 patients (580 male and 474 female) underwent curative surgery for colorectal carcinoma. Of these patients, 350 (33 percent) had recurrences, another 16 (1.5 percent) developed a metachronous colorectal cancer, and 23 (2 percent) had cancers of other organs. An isolated locoregional recurrence was found in 75/350 (21 percent). The remaining 275/350 patients (79 percent) showed systemic dissemination of the carcinoma. Reoperations with curative intent were performed on 56/350 patients (16 percent). Only 21 of the 56 resected patients (38 percent), i.e., 21/350 (6 percent), were without recurrence at the end of the follow-up period on December 31, 1990. Despite a curative reoperation, 62 percent of the patients again developed recurrent growths. There is an imbalance between the efforts invested in tumor follow-up and the benefits gained. Further follow-up programs should be investigated in a controlled, prospective fashion.