Treatment of liver metastases from colorectal cancer: what is the best approach today?

The pre-operative rate of growth of colorectal metastases in patients selected for liver resection does not influence post-operative disease-free survival

AIMS

To assess the potential association between the change in diameter of colorectal liver metastases between pre-operative imaging and liver resection and disease-free survival in patients who do not receive pre-operative liver-directed chemotherapy.

MATERIALS AND METHODS

Analysis of a prospectively maintained database of patients undergoing liver resection for colorectal liver metastases between 2005 and 2012 was undertaken. Change in tumour size was assessed by comparing the maximum tumour diameter at radiological diagnosis determined by imaging and the maximum tumour diameter measured at examination of the resected specimen in 157 patients.

RESULTS

The median interval from first scan to surgery was 99 days and the median increase in tumour diameter in this interval was 38%, equivalent to a tumour doubling time (DT) of 47 days. Tumour DT prior to liver resection was longer in patients with T1 primary tumours (119 days) than T2-4 tumours (44 days) and shorter in patients undergoing repeat surgery for intra-hepatic recurrence (33 days) than before primary resection (49 days). The median disease-free survival of the whole cohort was 1.57 years (0.2-7.3) and multivariate analysis revealed no association between tumour DT prior to surgery and disease-free survival.

CONCLUSIONS

The rate of growth of colorectal liver metastases prior to surgery should not be used as a prognostic factor when considering the role of resection.

Major Hepatectomy for Colorectal Metastases in the Elderly: A Tertiary Center Experience

The purpose of this retrospective study was to investigate whether patients over 70 years old are at significantly higher risk for worse outcomes following major liver resection. Hepatic resection is the only treatment offering long-term survival for patients with colorectal liver metastases. As the population considered for metastasectomy is aging, there are still controversial published results regarding the safety of major hepatectomy in elderly patients. Between December 2002 and April 2010, 327 patients underwent major liver resection for colorectal liver metastasis. Patients were stratified into 2 groups: group A, <70 years old; and group B, ≥70 years old. Recorded, analyzed, and compared data across groups included the following: (1) patient characteristics including age, sex, American Society of Anesthesiologists performance status, primary tumor site and stage, adjuvant chemotherapy, number and size of metastatic lesions; (2) perioperative data including extent of resection, in-hospital mortality, postoperative morbidity, length of hospital stay, length of intensive treatment unit stay and blood loss; and (3) overall survival. The patients' characteristics were similar as were the characteristics of their tumors. There was no difference in overall morbidity (25% versus 22%) or postoperative mortality (2.6% versus 2.9%) (P = 0.44 and 0.57, respectively). The overall survival was 67% versus 62% in group A and B, respectively (P = 0.09). Elderly patients can safely undergo major liver resection for colorectal liver metastases with short- and long-term outcomes comparable with younger patients.

Socioeconomic status influences the likelihood but not the outcome of liver resection for colorectal liver metastasis

BACKGROUND

The aim of this study was to compare the socioeconomic profile of patients undergoing liver resection for colorectal liver metastasis (CLM) in a regional hepatopancreatobiliary unit with that of the local population. A further aim was to determine if degree of deprivation is associated with tumour recurrence after resection.

METHODS

A retrospective analysis of patients undergoing liver resection for CLM was performed. Geodemographic segmentation was used to divide the population into five categories of socioeconomic status (SES).

RESULTS

During a 7-year period, 303 patients underwent resection for CLM. The proportion of these patients in the two least deprived categories of SES was greater than that of the local population (50.2% versus 40.2%) and the proportion in the two most deprived categories was lower (18.3% versus 30.1%) (P < 0.001). There was no difference in recurrence rate (P = 0.867) or disease-free survival among categories of SES (P = 0.913). Multivariate analysis demonstrated no association between SES and tumour recurrence (P = 0.700).

CONCLUSIONS

Liver resection for CLM is performed more commonly among the least socioeconomically deprived population than among the most deprived. However, degree of deprivation was not associated with tumour recurrence after resection.

Mortality and morbidity of hepatectomy, radiofrequency ablation, and embolization for hepatocellular carcinoma: a national survey of 54,145 patients

BACKGROUND

Reported mortalities and morbidities of therapeutic procedures for liver tumors vary between studies, because of different designs and small sample sizes. We investigated the mortalities and complication rates for hepatectomy, radiofrequency ablation (RFA), and trans-catheter arterial embolization (TAE) for hepatocellular carcinoma (HCC) in a large sample, using a nationwide Japanese database (the Diagnosis Procedure Combination database).

METHODS

Data from the Diagnosis Procedure Combination database were analyzed for July 1 to December 31, 2007 and the same period in 2008. We identified 54,145 patients with HCC who underwent hepatectomy (n = 5,270), RFA (n = 11,688), or TAE (n = 37,187). In-hospital mortality and morbidity were analyzed for each procedure. The relationships between mortality and factors including patient characteristics and procedural backgrounds were assessed.

RESULTS

In-hospital mortalities associated with hepatectomy, RFA, and TAE were 2.6 % [95 % confidence interval (CI) 2.2-3.1], 0.3 % (0.2-0.4), and 1.0 % (0.9-1.1), and post-procedural complication rates were 14.5 % (13.5-15.5), 4.5 % (4.2-4.9), and 4.5 % (4.3-4.7), respectively. Increased mortality following hepatectomy was significantly associated with older age, extended lobectomy (vs. partial hepatectomy; odds ratio [OR] 3.80, p < 0.001), lower hospital volume (OR 2.74, p < 0.001), and renal comorbidity (OR 3.01, p = 0.02). Older age and cardiac comorbidity (OR 5.14, p = 0.001) were significantly associated with RFA-related mortality, and lower hospital volume was significantly associated with TAE-related mortality (OR 1.60, p < 0.001).

CONCLUSIONS

Mortalities and morbidities associated with therapeutic procedures for liver tumors were acceptably low in Japan, but were affected by patient and institutional characteristics.

Synergistic effects of genetically engineered stem cells expressing cytosine deaminase and interferon-β via their tumor tropism to selectively target human hepatocarcinoma cells

Stem cells have received a great deal of attention for their clinical and therapeutic potential for treating human diseases and disorders. Recent studies have shown that it is possible to genetically engineered stem cells (GESTECs) to produce suicide enzymes that convert non-toxic prodrugs to toxic metabolites, selectively migrate toward tumor sites and reduce tumor growth. In this study, we evaluated whether these GESTECs are capable of migrating to hepatocarcinoma cells and examined the potential therapeutic efficacy of gene-directed enzyme prodrug therapy against liver cancer cells in cellular and animal models. A modified transwell migration assay was performed to determine the migratory capacity of GESTECs to Hep3B hepatocarcinoma cells. GESTECs, that is, HB1.F3.CD or HB1.F3.CD.interferon-β (IFN-β) cells, engineered to express a suicide gene, cytosine deaminase (CD), selectively migrated toward liver cancer cells. Treatment of Hep3B, human liver cancer cells, with the prodrug 5-fluorocytosine (5-FC) in the presence of HB1.F3.CD or HB1.F3.CD.IFN-β cells resulted in the inhibition of Hep3B cell growth. In a xenografted mouse model injected with hepatocarcinoma, we investigated the therapeutic effect of these stem cells. For 9 weeks, the xenografted mice were treated with HB1.F3.CD or HB1.F3.CD.IFN-β in the presence of 5-FC. A growth of tumor mass was inhibited about 40-50% in the mice treated with GESTECs and a prodrug. In addition, we further confirmed the cytotoxic effect on tumor cells by histological analysis and migratory effect of therapeutic stem cells. Taken together, GESTECs expressing a fusion gene encoding CD and IFN-β may exert a synergistic antitumor effect on this type of tumor.

The results of surgical treatment of metastatic liver tumor

Background: The aim of our study was to analyze the survival of patients who were operated from liver metastases. This paper is a retrospective study of the case reports from the Clinic for Operative Oncology - Oncology Institute of Vojvodina. The study included all the patients treated operatively for secondary malignant liver tumors in the period from May 2003 to May 2007. Methods: The study included 33 patients (17 men and 16 women). The mean age of patients was 57.8 years (range, 27-75 years). In 23 patients, (69.7%) metastases were of colorectal origin, while in 10 patients (30.3%) metastases originated from some other organs. Results: Hepatectomies were performed in 54.54% and metastasectomies in 45.45% of patients. More severe postoperative complications (which required repeated surgery) were registered in 3.03% of patients. Intraoperative mortality was 3.03% and postoperative mortality was 12.12%. Liver re-resection was performed in 21.21% of patients. An overall one-year survival was 75.76%, and a tree-year survival was 43.75%. One-year survival in patients with colorectal metastases was 86.96% and three-year survival was 50%, while in patients with metastases originating from some other organs, one-year survival was 70% and three-year survival was only 25%. Intrahospital mortality in patients with colorectal metastases was 8.7% while in patients with non-colorectal metastases it was 30%. Conclusion: The aim of this paper was to show that only surgical removal of metastases can lead to life quality improvement and to prolongation of the overall survival and that modern neoadjuvant and biological therapies may increase resectability of the inoperable changes.

Liver resective surgery: a multivariate analysis of postoperative outcome and complication

INTRODUCTION

Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complications after surgical resection could be high. In this study, we analyzed causes and foreseeable risk factors linked to postoperative morbidity on the ground of data derived from a single center surgical population.

MATERIALS AND METHODS

From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc and 153 consecutive patients with liver metastasis (derived from either colorectal cancer or noncolorectal cancer) at our department. We performed 22 major hepatectomy, 20 left hepatectomy, 14 trisegmentectomy, 77 bisegmentectomy and/or left lobectomy, 74 segmentectomy, and 80 wedge resection.

RESULTS

In-hospital mortality rate was 4.5%, about 7% in Hcc cases and 2.6% in liver metastasis. Morbidity rate was 47.7%, caused by the rising of ascites (10%), temporary impairment liver function (19%), biliary fistula (6%), hepatic abscess (25%), hemoperitoneum (10%), and pleural effusion (30%) sometimes combined each other. Some variables, associated with the technical aspects of surgical procedure, are responsible of the rising of complication as: Pringle maneuver length of more than 20 minutes (p=0.001); the type of liver resection procedure [major hepatectomy (p=0.02), left hepatectomy (p=0.04), trisegmentectomy (p=0.04), bisegmentectomy and/or left lobectomy (p=0.04)]; and the request of an amount of blood transfusion of more than 600 cc (p=0.04). Also, both liver dysfunction, in particular Child A vs B and C (p=0.01), and histopathological grading (p=0.01) are associated with a high rate of postsurgical complication in Hcc cases.

CONCLUSION

We make the following recommendations: every liver resection should be planned after intraoperative ultrasonography, anatomical surgical procedure should be preferred instead of wedge resection, and modern devices should be used, like Argon Beam and Ligasure dissector, to reduce the incidence of both intraoperative and postoperative bleeding and biliary leakage.

Long-term follow-up of patients of intrahepatic malignancies treated with iodine-125 brachytherapy

PURPOSE

We investigated the role of intraoperative iodine-125 (125I) brachytherapy as a treatment option for unresectable primary and metastatic liver tumors.

METHODS AND MATERIALS

Between 1989 and 2002, 64 patients with unresectable or residual disease after surgical resection for intrahepatic malignancies underwent 160-Gy permanent 125I brachytherapy.

RESULTS

The median length of follow-up was 13.2 years. The overall 1-year, 3-year, and 5-year actuarial intrahepatic local control rates were 44%, 22%, and 22%, respectively, with a median time to liver recurrence of 9 months (95% CI, 6-12 months). The 5-year actuarial intrahepatic control was higher for patients with solitary metastasis (38%) than for those with multiple metastases (6%, p = 0.04). The 1-year, 3-year, and 5-year actuarial overall survival rates were 73%, 23%, and 5%, respectively (median, 20 months; 95% CI, 16-24; longest survival, 7.5 years). Overall survival was higher for patients with smaller-volume implants (p = 0.003) and for patients without prior liver resection (p = 0.002). No mortality occurred. Radiation-related complications were minimal.

CONCLUSIONS

For select patients with unresectable primary and metastatic liver tumors for whom curative surgical resection is not an option, 125I brachytherapy is a safe and effective alternative to other locally ablative techniques and can provide long-term local control and increased survival.

Tumour angiogenesis and mast cell density in the prognostic assessment of colorectal carcinomas

BACKGROUND

Tumour angiogenesis is essential for the growth, invasion and metastasis of solid tumours. There are several lines of evidence that the mast cells play an important role in tumour angiogenesis.

AIMS

The study focused to determine the correlation between the microvessel and mast cell densities, and to evaluate whether tumour angiogenesis and mast cell density could predict recurrence following curative surgery in patients with colorectal carcinomas.

PATIENTS

Microvessel and mast cell densities were investigated in tumour specimens from 60 patients with colorectal carcinoma.

METHODS

Microvessels were stained by immunohistochemical method using a monoclonal antibody anti-CD34. The routine Giemsa blue staining method was used to assess the mast cells. Microvessels and mast cells were counted in a x400 field.

RESULTS

The mean microvessel and mast cell counts were higher in patients with recurrence compared with those patients who were disease-free for at least 24 months (p<0.001). The Spearman's correlation coefficient revealed a significant correlation between mast cell and microvessel counts in colorectal carcinomas (r=0.684; p<0.001). Kaplan-Meier plots of survival showed that the high microvessel (>28) and mast cell (>6) counts correlated with a shorter disease-free survival (p=0.0003 and p=0.0013, respectively). Multivariate analysis showed that the depth of penetration (T4 versus T2) (p=0.004), liver metastasis (p=0.04) and microvessel density (p=0.003) were independent predictors of recurrence. In multivariate analysis, mast cell density did not reach significance.

CONCLUSIONS

Our results suggest that the microvessel density of the primary tumour may be an important independent predictor of tumour recurrence and time to recurrence in colorectal carcinomas. The significant correlation between mast cell and microvessel counts suggest that the mast cells may have a role in tumour progression via promoting angiogenesis.

T lymphocytes isolated from patients with advanced colorectal cancer are suitable for gene immunotherapy approaches

Despite improvements in treatment, the 5-year survival for metastatic colorectal cancer remains poor. Novel approaches such as gene immunotherapy are being investigated to improve treatment. Retroviral gene transfer methods have been shown to transduce primary human T lymphocytes effectively resulting in the expression of therapeutic genes. However, a number of defects have been identified in T lymphocytes isolated from patients bearing tumour, which may have critical implications for the development of gene-targeted T cells as an anticancer therapy. To address this issue, primary T lymphocytes were isolated from patients with advanced colorectal cancer and tested for their ability to be transduced and to express subsequently a chimeric immune receptor consisting of a single-chain antibody fragment antigen-binding moiety specific for carcinoembryonic antigen (CEA) fused to the T cell receptor (TCR) CD3zeta chain. In 10 out of 10 patients, T lymphocytes were transduced, expanded in the absence of selection and tested for functional activity against CEA-expressing tumour cells. In each case, functional-specific cytotoxic activity was observed. Negligible activity was found in control cultures. This study highlights the feasibility of patient-derived T lymphocytes as a source of immune cells for autologous gene immunotherapy approaches.

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40%. Unfortunately, only 25% of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.

Arterial chemotherapy of 5-fluorouracil and mitomycin C in the treatment of liver metastases of colorectal cancer

AIM: Regional chemotherapy using hepatic artery catheters is a good method of treating patients with colorectal cancer liver metastases. We investigated the survival of patients with liver metastases from colorectal cancer using 5-fluorouracil (5-FU) and mitomycin C Cthrough implantable hepatic arterial infusion port.

METHODS: Seventy-five patients with inoperable liver metastases from colorectal cancer were included between March, 1992 and November, 2001. We placed implantable hepatic arterial catheter (HAC) port by laparotomy.5-FU, 1000 mg/m²/d continuous infusion for five days every four weeks, was delivered in the hepatic arterial catheter through the port. Mitomycin C, 30 mg/m²/d infusion in the first day every cycle through the port. Response to the treatment was evaluated by serial determinations of plasma CEA and imaging techniques consisting of computerized tomography and sonography of liver.

RESULTS: Sixty-eight were performed hepatic artery chemotherapy and fifty-six were followed up among seventy-five HAC patients. Twenty-six patients (46.4%) have responded and 4 complete remission were achieved. Eight patients (14.3%) had stable liver metastases. Twenty-two patients (39.3%) were progressed with increased tumor size and number. Twenty-nine patients (51.8%) had a decreased serum CEA level, while 10 patients (17.9%) were stable and 17 patients (30.4%) had an increased serum CEA level. There were no operative death in this series. Complications, which occurred in 18 patients (32.1%), were as followed: hepatic artery thrombosis in 11, Upper gastric and intestinal bleeding in 3, liver abscess in 1, pocket infection in 1, cholangitis in 1, and hepatic artery pseudo-aneurysm in one patient.

CONCLUSION: Combined infusion of 5-FU and mitomycin C by hepatic artery catheter port is an effective treatment for liver metastases from colorectal cancer. The high response and lower complication rates prove the adjuvant treatment of colorectal cancer with this treatment.