Management of colorectal cancer presenting with synchronous liver metastases

CircDIAPH1 Promotes Liver Metastasis and Development of Colorectal Cancer by Initiation of CEACAM6 Expression

Liver metastasis is a critical factor influencing the 5-year survival rate in colorectal cancer (CRC). However, the biological function of most circRNAs in liver metastasis of CRC is still unknown. In this study, we identified differentially expressed circRNAs associated with liver metastasis (LM-DE-circRNAs). A total of 247 LM-DE-circRNAs were identified, and crucial signaling pathways, including the regulation of actin cytoskeleton, were significantly enriched, featuring six LM-DE-circRNAs. Notably, circDIAPH1 (hsa_circ_0074323), with the highest AUC value, emerged as a potential biomarker for CRC liver metastasis (CRLM). Functional assays following circDIAPH1 knockdown demonstrated induced apoptosis, suppressed proliferation, reduced metastasis, and invasion in CRC cell lines in vitro. The circDIAPH1 knockdown attenuated tumor growth in a cell-derived xenograft model. Furthermore, circDIAPH1 knockdown lessened the liver metastasis. Transcriptome profiling revealed that CEACAM6 was the most downregulated gene while circDIAPH1 was knocked down, and possesses high expression value in CRC. Most importantly, we found that circDIAPH1 recruited transcription factor FOXA1 to bind in the promoter region of CEACAM6 and initiated CEACAM6 expression. Additionally, the study identified the transcription factor BRD4 as a regulator of circDIAPH1 expression in CRC. In conclusion, this study reveals that circDIAPH1 recruits FOXA1 to initiate CEACAM6 expression, promoting liver metastasis and development of CRC.

A CT-based deep learning-driven tool for automatic liver tumor detection and delineation in patients with cancer

Liver tumors, whether primary or metastatic, significantly impact the outcomes of patients with cancer. Accurate identification and quantification are crucial for effective patient management, including precise diagnosis, prognosis, and therapy evaluation. We present SALSA (system for automatic liver tumor segmentation and detection), a fully automated tool for liver tumor detection and delineation. Developed on 1,598 computed tomography (CT) scans and 4,908 liver tumors, SALSA demonstrates superior accuracy in tumor identification and volume quantification, outperforming state-of-the-art models and inter-reader agreement among expert radiologists. SALSA achieves a patient-wise detection precision of 99.65%, and 81.72% at lesion level, in the external validation cohorts. Additionally, it exhibits good overlap, achieving a dice similarity coefficient (DSC) of 0.760, outperforming both state-of-the-art and the inter-radiologist assessment. SALSA's automatic quantification of tumor volume proves to have prognostic value across various solid tumors (p = 0.028). SALSA's robust capabilities position it as a potential medical device for automatic cancer detection, staging, and response evaluation.

Repression of apelin Furin cleavage sites provides antimetastatic strategy in colorectal cancer

The adipokine apelin has been directly implicated in various physiological processes during embryogenesis and human cancers. Nevertheless, the importance of the conversion of its precursor proapelin to mature apelin in tumorigenesis remains unknown. In this study, we identify Furin as the cellular proprotein convertase responsible for proapelin cleavage. We explore the therapeutic potential of targeting proapelin cleavage sites in metastatic colorectal cancer by introducing apelin-dm, a modified variant resulting from alteration in proapelin cleavage sites. Apelin-dm demonstrates efficacy in inhibiting tumor growth, promoting cell death, suppressing angiogenesis, and early colorectal liver metastasis events. Proteomic analysis reveals reciprocal regulation between apelin and apelin-dm on proteins associated with clinical outcomes in colon cancer patients. Apelin-dm emerges as a modulator of apelin receptor dynamics, influencing affinity, internalization, and repression of apelin signaling linked to various protein kinases. Pharmacokinetic and toxicity assessments confirm the specificity, safety, and stability of apelin-dm, as well as its facile hepatic metabolism. These findings position targeting proapelin cleavage as a promising therapeutic strategy against metastatic colorectal cancer, paving the way for further clinical exploration.

Targeting SLITRK4 Restrains Proliferation and Liver Metastasis in Colorectal Cancer via Regulating PI3K/AKT/NFκB Pathway and Tumor-Associated Macrophage

Liver metastasis is the major cause of death in colorectal cancer (CRC) due to the lack of effective treatment. To explore novel drivers of CRC liver metastasis, the transcriptomes of primary paracancerous, colorectal tumors and metastases from human patients are profiled. It is found that SLIT- and NTRK-like family member 4 (SLITRK4) is the top upregulated gene in liver metastases and is associated with worse overall survival of CRC patients. Multiple in vitro and in vivo models suggested SLITRK4 promoted CRC tumorigenesis, invasion, migration, and angiogenesis, and inhibition of it restrained CRC tumor growth and liver metastasis with a more profound effect on the tumor microenvironment (TME). Mechanistically, SLITRK4 overexpression significantly activated the PI3K/AKT/NFκB pathway, regulated extracellular matrix organization, and multiple cytokines expression. Furthermore, the results from coculture models and single-cell RNA sequencing analyses suggested SLITRK4 promoted tumor-associated macrophages (TAMs) infiltration and polarization. In addition, macrophage depletion significantly inhibited SLITRK4-induced liver metastasis in CRC. Finally, pharmacological inhibition of SLITRK4 by using lipid-polymer hybrid nanoparticles (NPs) for systemic siRNA delivery can effectively inhibit CRC liver metastasis. Taken together, these results pinpoint that SLITRK4 regulates CRC tumorigenesis and liver metastasis, and siRNA delivering NPs agents validate the therapeutic potential of targeting SLITRK4 in CRC.

Liver-first approach to the treatment of patients with synchronous colorectal liver metastases: a systematic review and meta-analysis

OBJECTIVE

The optimal approach to the treatment of colorectal carcinoma and synchronous liver metastases remains controversial. The objective of this review was to analyze the outcomes of adopting the liver-first approach for the treatment of patients with colorectal cancer with synchronous hepatic metastases who initially underwent systemic chemotherapy and/or resection of the metastatic lesions and primary colorectal carcinoma.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, EMBASE, LILACS, and Cochrane Central Register of Controlled Trials databases were searched for the identification and retrieval of eligible studies. Studies that included details of using the liver-first approach for the treatment of synchronous liver metastases of colorectal cancer and its outcomes, including the patients' survival data, were included. Proportional meta-analysis was performed using the random-effects restricted maximum likelihood method to summarize the three- and five-year overall survival and recurrence rates of the patients.

RESULTS

Eight hundred and fifty-five articles describing the results of studies on the liver-first approach were identified. Three independent reviewers screened the titles and abstracts of the articles and excluded 750 articles. Thereafter, 29 retrospective and comparative studies that met the inclusion criteria were included. No randomized controlled trials were identified in the database search.

CONCLUSION

Neoadjuvant treatment with systemic chemotherapy for hepatic metastasis can prepare a patient for resection of liver metastases, offering the opportunity for potentially curative treatment of synchronous hepatic metastases initially considered unresectable. The decision regarding the resection of primary colorectal carcinoma and liver metastases should be based on individualized patient response. Prospero database registration ID: CRD42022337047 (www.crd.york.ac.uk/prospero).

Management of Colorectal Cancer with Synchronous Liver Metastases: A systematic review of national and International Clinical Guidelines (CoSMIC-G)

Introduction

The contemporary management of patients with colorectal cancer and synchronous liver metastases is complex. This study appraises the recommendations made by national/international guidelines for the diagnosis and management of patients with synchronous liver metastases from colorectal cancer.

Methods

A systematic review of national and international guidelines published between 2011 and 2024 was carried out using PubMed, OvidSP and Guidelines International Network databases. The quality of guidelines was evaluated using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. Guidelines were assessed for the quality of advice for specific scenarios. The protocol was registered with PROSPERO (CRD42021243744).

Results

The search strategy returned ninety unique articles with 11 guidelines eligible for inclusion. Of these, one (9 %) guideline defined 'synchronous disease' at outset, eight (73 %) recommended neoadjuvant chemotherapy as first intervention. Seven (64 %) guidelines supported synchronous hepatic resection with colectomy. One (9 %) recommended against synchronous surgery.

Conclusions

This study demonstrates important variations between international clinical guidelines on diagnostic workup and management of synchronous liver metastases in colorectal cancer. [167 words].

Prognostic implications of margin status in association with systemic treatment in a cohort study of patients with resection of colorectal liver metastases

BACKGROUND

This study investigates the impact of margin status after colorectal liver metastasis (CLM) resection on outcomes of patients after neoadjuvant treatment versus those who underwent upfront resection.

METHODS

An international collaborative database of CLM patients who underwent surgical resection was used. Proportional hazard regression models were created for single and multivariable models to assess the relationship between independent measures and median overall survival (mOS).

RESULTS

R1 was associated with worse OS in the neoadjuvant group (mOS: 51.8 m for R0 vs. 26.0 m for R1; HR: 2.18). In the patients who underwent upfront surgery, R1 was not associated with OS. (mOS: 46.7 m for R0 vs. 42.6 m for R1). When patients with R1 in each group were stratified by adjuvant treatment, there was no significant difference in the neoadjuvant group, while in the upfront surgery group with R1, adjuvant treatment was associated with significant improvement in OS (mOS: 42.6 m for adjuvant vs. 25.0 m for no adjuvant treatment; HR: 0.21).

CONCLUSION

R1 is associated with worse outcomes in the patients who receive neoadjuvant treatment with no significant improvement with the addition of adjuvant therapy, likely representing an aggressive tumor biology. R1 did not impact OS in patients with upfront surgery who received postoperative chemotherapy.

Tuning Tumor Targeting and Ratiometric Photoacoustic Imaging by Fine-Tuning Torsion Angle for Colorectal Liver Metastasis Diagnosis

Photoacoustic (PA) tomography is an emerging biomedical imaging technology for precision cancer medicine. Conventional small-molecule PA probes usually exhibit a single PA signal and poor tumor targeting that lack the imaging reliability. Here, we introduce a series of cyanine/hemicyanine interconversion dyes (denoted Cy-HCy) for PA/fluorescent dual-mode probe development that features optimized ratiometric PA imaging and tunable tumor-targeting ability for precise diagnosis and resection of colorectal cancer (CRC). Importantly, Cy-HCy can be presented in cyanine (inherent tumor targeting and long NIR PA wavelength) and hemicyanine (poor tumor targeting and short NIR PA wavelength) by fine-tuning torsion angle and the ingenious transformation between cyanine and hemicyanine through regulation optically tunable group endows the NIR ratiometric PA and tunable tumor-targeting properties. To demonstrate the applicability of Cy-HCy dyes, we designed the first small-molecule tumor-targeting and NIR ratiometric PA probe Cy-HCy-H2S for precise CRC liver metastasis diagnosis, activated by H2S (a CRC biomarker). Using this probe, we not only visualized the subcutaneous tumor and liver metastatic cancers in CRC mouse models but also realized PA and fluorescence image-guided tumor excision. We expect that Cy-HCy will be generalized for creating a wide variety of inherently tumor-targeting NIR ratiometric PA probes in oncological research and practice.

A nomogram for predicting colorectal cancer liver metastasis using circulating tumor cells from the first drainage vein

PURPOSE

To use circulating tumor cells (CTC) from the first drainage vein (FDV) of the primary lesion and other clinically relevant parameters to construct a nomogram for predicting liver metastasis in colorectal cancer (CRC) patients, and to provide a theoretical basis for clinical diagnosis and treatment.

METHODS

Information from 343 CRC patients was collected and a database was established. Multivariate logistic analysis was used to identify independent factors for colorectal cancer liver metastasis(mCRC) and nomograms were constructed. Receiver operating characteristic curves(ROC), calibration plots, and decision curve analysis (DCA) were used to assess discrimination, agreement with actual risk, and the clinical utility of the prediction model, respectively.

RESULT

CTC levels in FDV were significantly higher in patients with liver metastasis than in those without liver metastasis. Logistic multivariate analysis showed that vascular invasion, T stage, carcinoembryonic antigen (CEA), CA19-9, and CTC could be used as predictors to construct nomograms. The nomograms showed good discriminatory ability in predicting mCRC, with area under the curve (AUC) values of 0.871 [95 % CI: 0.817-0.924) and 0.891 (95 % CI: 0.817-0.964) for the training and validation sets, respectively.] The calibration curves of both the training and validation sets showed that the model was effective in predicting the probability of mCRC. DCA was used to evaluate this predictive model and showed good net clinical benefit.

CONCLUSION

We developed and validated a nomogram model based on the combination of CTC in the FDV with other clinical parameters to better predict the occurrence of mCRC.

Predictive risk factors for resection surface-related complications after laparoscopic simultaneous resection of primary colorectal tumor and synchronous liver metastases: a single-center retrospective study

BACKGROUND

Laparoscopic simultaneous resection (LSR) of primary colorectal tumors and synchronous colorectal liver metastases (sCRLM) has been recently performed. This study aimed to evaluate the postoperative outcomes after LSR and determine the risk factors for resection surface-related complications (RSRC), such as postoperative biliary fistula and liver-transection surface abscess.

METHODS

Between 2009 and 2022, consecutive patients with sCRLM who underwent LSR were included. We retrospectively analyzed clinicopathological data, including intraoperative factors and postoperative outcomes. The difficulty level of all liver resections was classified according to the IWATE difficulty scoring system (DSS). We then performed univariate and multivariate analyses to identify the risk factors for RSRC.

RESULTS

Of the 112 patients, 94 (83.9%) underwent partial hepatectomy and colorectal surgery. The median DSS score was 5 points (1-11), with 12 (10.7%) patients scoring ≥ 7 points. Postoperative complications were observed in 41 (36.6%) patients, of whom 16 (14.3%) experienced severe complications classified as Clavien-Dindo grade IIIa or higher. There was no postoperative mortality. The most common complication was RSRC (19 patients, 17.0%). Multivariate analysis identified American Society of Anesthesiologists (ASA) classification ≥ 3 [odds ratio (OR) 10.3, 95% confidence interval (CI) 1.37-77.8; P = 0.023], DSS score ≥ 7 points (OR 5.08, 95% CI 1.17-20.0; P = 0.030), and right-sided colectomy (OR 4.67, 95% CI 1.46-15.0; P = 0.009) as independent risk factors for RSRC. Postoperative hospital stays were significantly longer for patients with RSRC than for those without RSRC (22 days vs. 11 days; P < 0.001).

CONCLUSION

Short-term outcomes of LSR for patients with sCRLM were acceptable in an experienced center. RSRC was the most common complication, and high-difficulty hepatectomy, right-sided colectomy, and ASA classification ≥ 3 were independent risk factors for RSRC.

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center

INTRODUCTION

Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLM) and its indication and results have varied in the last 30 years.

METHODS

All patients operated on for CRLM in our centre from 1990 to 2021 were prospectively collected, establishing 3 subgroups based on the year of the first surgery: group A 1990-1999, group B 2000-2010, group C 2011-2021. Clinical characteristics and the results of survival, recurrence and prognostic factors were compared.

RESULTS

1736 hepatectomies were included (Group A n = 208; Group B n = 770; Group C n = 758). Patients in group C had better survival at 5 and 10 years (A 40.5%/28.2%; B 45.9%/32.2%; C 51.6%/33.1%, p = 0.013), although there were no differences between groups in overall recurrence at 5 and 10 years (A 73%/75.7%; B 67.6%/69.2%, and C 63.9%/66%, p = 0.524), nor in liver recurrence (A 46.4%/48.2%; B 45.8%/48.2%; and C 44.4%/48.4%, p = 0.899). An improvement was observed in median survival after recurrence, being 19 months, 23 months, and 31 months (groups A, B and C respectively). Prognostic factors of long-term survival changed over the 3 study periods. The only ones that remained relevant in the last decade were the presence of >4 liver metastasis, extrahepatic disease at the time of hepatectomy, and intraoperative blood transfusion.

CONCLUSIONS

Survival after surgery for CRLM has improved significantly, although this cannot be explained by a reduction in overall and hepatic recurrence, but rather by an improvement in post-recurrence survival. Involvement of the resection margin has lost prognostic value in the last decade.

Liver Transplantation for Nonresectable Colorectal Liver Metastases (CRLM)

Transplantation represents the most radical locoregional therapy through removal of the liver, associated vasculature and locoregional lymph nodes, and replacing it with an allograft. Recent evidence has demonstrated that transplantation for unresectable CRLM is feasible with acceptable post-transplant outcomes in a highly selected cohort of patients. Controversy exists regarding whether transplantation is an appropriate treatment for such patients, due to concerns regarding disease recurrence in the transplanted graft in an immunosuppressed recipient along with utilising a donor liver which are in short supply. Expanding the indications for liver transplantation may also limit access for other patients with end-stage liver disease having ethical implications due to the effect of increasing the waiting list. In this review, we summarise the current evidence for liver transplantation in patients with nonresectable CRLM and highlight unresolved controversies and future directions for this type of treatment.

FOLFOXIRI plus cetuximab as conversion therapy for unresectable RAS/BRAF wild-type left-sided colorectal cancer with liver-limited metastases: a prospective dual-center pilot study

Purpose

To explore the efficacy and safety of FOLFOXIRI plus cetuximab regimen as conversion therapy for patients with unresectable RAS/BRAF wild-type colorectal liver-limited metastases (CLM).

Patients and methods

This was a dual-center, phase II trial with the rate of no evidence of disease (NED) achieved as the primary endpoint. All enrolled patients with initially unresectable left-sided RAS/BRAF wild-type colorectal liver-limited metastases received a modified FOLFOXIRI plus cetuximab regimen as conversion therapy.

Results

Between October 2019 and October 2021, fifteen patients were enrolled. Nine patients (60%) achieved NED. The overall response rate (ORR) was 92.9%, and the disease control rate (DCR) was 100%. The median relapse-free survival (RFS) was 9 (95% CI: 0-20.7) months. The median progression-free survival (PFS) was 13.0 months (95% CI: 5.7-20.5), and the median overall survival (OS) was not reached. The most frequently occurring grade 3-4 adverse events were neutropenia (20%), peripheral neurotoxicity (13.3%), diarrhea (6.7%), and rash acneiform (6.7%).

Conclusion

The FOLFOXIRI plus cetuximab regimen displayed tolerable toxicity and promising anti-tumor activity in terms of the rate of NED achieved and response rate in patients with initially unresectable left-sided RAS/BRAF wild-type CLM. This regimen merits further investigation.

Postoperative morbidity after simultaneous versus staged resection of synchronous colorectal liver metastases: Impact of hepatic tumor burden

BACKGROUND

We sought to characterize the risk of postoperative complications relative to the surgical approach and overall synchronous colorectal liver metastases tumor burden score.

METHODS

Patients with synchronous colorectal liver metastases who underwent curative-intent resection between 2000 and 2020 were identified from an international multi-institutional database. Propensity score matching was employed to control for heterogeneity between the 2 groups. A virtual twins analysis was performed to identify potential subgroups of patients who might benefit more from staged versus simultaneous resection.

RESULTS

Among 976 patients who underwent liver resection for synchronous colorectal liver metastases, 589 patients (60.3%) had a staged approach, whereas 387 (39.7%) patients underwent simultaneous resection of the primary tumor and synchronous colorectal liver metastases. After propensity score matching, 295 patients who underwent each surgical approach were analyzed. Overall, the incidence of postoperative complications was 34.1% (n = 201). Among patients with high tumor burden scores, the surgical approach was associated with a higher incidence of postoperative complications; in contrast, among patients with low or medium tumor burden scores, the likelihood of complications did not differ based on the surgical approach. Virtual twins analysis demonstrated that preoperative tumor burden score was important to identify which subgroup of patients benefited most from staged versus simultaneous resection. Simultaneous resection was associated with better outcomes among patients with a tumor burden score <9 and a node-negative right-sided primary tumor; in contrast, staged resection was associated with better outcomes among patients with node-positive left-sided primary tumors and higher tumor burden score.

CONCLUSION

Among patients with high tumor burden scores, simultaneous resection of the primary tumor and liver metastases was associated with an increased incidence of postoperative complications.

Endoscopic Rectal Ultrasound-Based Radiomics Analysis for the Prediction of Synchronous Liver Metastasis in Patients With Primary Rectal Cancer

OBJECTIVES

To develop and validate an ultrasound-based radiomics model to predict synchronous liver metastases (SLM) in rectal cancer (RC) patients preoperatively.

METHODS

Two hundred and thirty-nine RC patients were included in this study and randomly divided into training and validation cohorts. A total of 5936 radiomics features were calculated on the basis of ultrasound images to build a radiomic model and obtain a radiomics score (Rad-score) using logistic regression. Meanwhile, clinical characteristics were collected to construct a clinical model. The radiomics-clinical model was developed and validated by integrating the radiomics features with the selected clinical characteristics. The performances of three models were evaluated and compared through their discrimination, calibration, and clinical usefulness.

RESULTS

The radiomics model was developed based on 13 radiomic features. The radiomics-clinical model, which incorporated Rad-score, CEA, and CA199, exhibited favorable discrimination and calibration with areas under the receiver operating characteristic curve (AUC) of 0.920 (95% CI: 0.874-0.965) in the training cohorts and 0.855 (95% CI: 0.759-0.951) in the validation cohorts. And the AUC of the radiomics-clinical model was 0.849 (95% CI: 0.771-0.927) for the training cohorts and 0.780 (95% CI: 0.655-0.905) for the validation cohorts, the clinical model was 0.811 (95% CI: 0.718-0.905) for the training cohorts and 0.805 (95% CI: 0.645-0.965) for the validation cohorts. Moreover, decision curve analysis (DCA) further confirmed the clinical utility of the radiomics-clinical model.

CONCLUSIONS

The radiomics-clinical model performed satisfactory predictive performance, which can help improve clinical diagnosis performance and outcome prediction for SLM in RC patients.

Impact of prognostic nutritional index change on prognosis after colorectal cancer surgery under propofol or sevoflurane anesthesia

BACKGROUND

The alteration of the prognostic nutritional index (PNI) or the utilization of distinct anesthesia strategies has been linked to the prognosis of various cancer types, but the existing evidence is limited and inconclusive, particularly for colorectal cancer (CRC). Our objective was to evaluate the association between PNI change and progression free survival (PFS) and overall survival (OS) in patients treated with CRC surgery after propofol-based or sevoflurane-based anesthesia.

METHODS

We conducted a retrospective analysis of 414 patients with CRC who underwent surgical resection. Among them, 165 patients received propofol-based total intravenous anesthesia (TIVA-P), while 249 patients received sevoflurane-based inhalation anesthesia (IA-S). The PNI change (ΔPNI) was calculated by subtracting the pre-surgery PNI from the post-surgery PNI, and patients were categorized into high (≥ -2.25) and low (< -2.25) ΔPNI groups. Univariate and multivariate analyses were employed to evaluate the effects of the two anesthesia methods, ΔPNI, and their potential interaction on PFS and OS.

RESULTS

The median duration of follow-up was 35.9 months (interquartile range: 18-60 months). The five-year OS rates were 63.0% in the TIVA-P group and 59.8% in the IA-S group (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.70-1.35; p = 0.864), while the five-year PFS rates were 55.8% and 51.0% (HR: 0.92; 95% CI: 0.68-1.26; p = 0.614), respectively. In comparison to patients in the low ΔPNI group, those in the high ΔPNI group exhibited a favorable association with both OS (HR: 0.57; 95% CI: 0.40-0.76; p < 0.001) and PFS (HR: 0.58; 95% CI: 0.43-0.79; p < 0.001). Stratified analysis based on ΔPNI revealed significant protective effects in the propofol-treated participants within the high ΔPNI group, whereas such effects were not observed in the low ΔPNI group, for both OS (p for interaction = 0.004) and PFS (p for interaction = 0.024).

CONCLUSIONS

Our data revealed that among patients who underwent CRC surgery, those treated with TIVA-P exhibited superior survival outcomes compared to those who received IA-S, particularly among individuals with a high degree of PNI change.

Prognostic potential of whole exome sequencing in the clinical management of metachronous colorectal cancer liver metastases

BACKGROUND

Colorectal cancer is a highly prevalent and deadly. The most common metastatic site is the liver. We performed a whole exome sequencing analysis of a series of metachronous colorectal cancer liver metastases (mCLM) and matched non-malignant liver tissues to investigate the genomic profile of mCLM and explore associations with the patients' prognosis and therapeutic modalities.

METHODS

DNA samples from mCLM and non-malignant liver tissue pairs (n = 41) were sequenced using whole exome target enrichment and their germline and somatic genetic variability, copy number variations, and mutational signatures were assessed for associations with relapse-free (RFS) and overall survival (OS).

RESULTS

Our genetic analysis could stratify all patients into existing targeted therapeutic regimens. The most commonly mutated genes in mCLM were TP53, APC, and KRAS together with PIK3CA and several passenger genes like ABCA13, FAT4, PCLO, and UNC80. Patients with somatic alterations in genes from homologous recombination repair, Notch, and Hedgehog pathways had significantly prolonged RFS, while those with altered MYC pathway genes had poor RFS. Additionally, alterations in the JAK-STAT pathway were prognostic of longer OS. Patients bearing somatic variants in VIPR2 had significantly shorter OS and those with alterations in MUC16 prolonged OS. Carriage of the KRAS-12D variant was associated with shortened survival in our and external datasets. On the other hand, tumor mutation burden, mismatch repair deficiency, microsatellite instability, mutational signatures, or copy number variation in mCLM had no prognostic value.

CONCLUSIONS

The results encourage further molecular profiling for personalized treatment of colorectal cancer liver metastases discerning metachronous from synchronous scenarios.

Resection of the primary tumor improves the prognosis of gastrointestinal neuroendocrine neoplasms with liver metastases: mutual validation based on SEER database and institutional data

BACKGROUND

Gastrointestinal Neuroendocrine Neoplasms (GI-NENs) often result in liver metastases, and the role of Primary Tumor Resection (PTR) in managing GI-NENs with liver metastases (GI-NENLM) is still debated. This study aimed to investigate the potential benefits of PTR in treating GI-NENLM by analyzing data from the Surveillance, Epidemiology, and End Results Program (SEER) and the First Affiliated Hospital of Sun Yat-sen University (FAH).

METHODS

The SEER Registry 17 database and the FAH clinical pathology database were used to collect clinicopathology data for GI-NENLM diagnosed between 2010 and 2019 and between 2011 and 2022, respectively. Propensity score matching (PSM) was used to match the clinicopathological characteristics of patients from both cohorts. Inverse probability weighting (IPTW) was used to weigh the PTR and non-PTR groups. The primary endpoint was overall survival (OS).

RESULTS

After matching, 155 patients from the SEER database were matched to the FAH cohort. PTR was significantly associated with better prognosis in PSM-matched/unmatched SEER cohorts (P < 0.01) and in the FAH cohort even after eliminating selection bias using IPTW (p < 0.01). Subgroup analysis suggests that the cohort consisting of patients aged 55 years or older, individuals with colorectal primary tumors, those at the T1 disease stage, and those without extrahepatic metastasis may potentially benefit from PTR. Interaction analysis showed no significant interaction between PTR and other clinical and pathological factors except for age.

CONCLUSION

The employment of PTR in patients with GI-NENLM is significantly correlated with individual survival benefits. We support performing PTR on carefully evaluated patients.

Photothermal-Starvation Therapy Nanomodulator Capable of Inhibiting Colorectal Cancer Recurrence and Metastasis by Energy Metabolism Reduction

The recurrence and metastasis of colorectal cancer (CRC) have been considered as a severe challenge in clinical treatment. Recent studies have demonstrated that matrix metalloproteinases (MMPs) and lactate can promote local tumor angiogenesis, recurrence, and metastasis. The expression of MMPs is highly dependent on energy metabolism, and lactate is considered an alternative energy source for tumor proliferation and metastasis. Therefore, using a rational approach, a photothermal-starvation therapy nanomodulator that can reduce energy metabolism to suppress CRC recurrence and metastasis is designed. To design a suitable nanomodulator, glucose oxidase (GOX), indocyanine green (IR820), and α-cyano-4-hydroxycinnamic acid (CHC) into nanoparticles by a coassembly method are combined. The photothermal properties of IR820 provide the appropriate temperature and oxygen supply for the enzymatic reaction of GOX to promote intracellular glucose consumption. CHC inhibits the expression of monocarboxylate transporter 1 (MCT1), the transporter of lactic acid into cells, and also reduces oxygen consumption and promotes the GOX reaction. Additionally, altering adenosine triphosphate synthesis to block heat shock proteins expression can be an effective means to prevent IR820-mediated photothermal therapy resistance. Thus, this dual photothermal-starvation therapy nanomodulator efficiently suppresses the recurrence and metastasis of CRC by depleting intracellular nutrients.

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

BACKGROUND

Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management.

METHODS

This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements.

RESULTS

Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term "early metachronous metastases" applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with "late metachronous metastases" applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed.

CONCLUSIONS

The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

A CT-based radiomics nomogram for predicting histopathologic growth patterns of colorectal liver metastases

PURPOSE

To develop a computed tomography (CT)-based radiomics nomogram for pre-treatment prediction of histopathologic growth patterns (HGPs) in colorectal liver metastases (CRLM) and to validate its accuracy and clinical value.

MATERIALS AND METHODS

This retrospective study included a total of 197 CRLM from 92 patients. Lesions from CRLM were randomly divided into the training study (n = 137) and the validation study (n = 60) with the ratio of 3:1 for model construction and internal validation. The least absolute shrinkage and selection operator (LASSO) was used to screen features. Radiomics score (rad-score) was calculated to generate radiomics features. A predictive radiomics nomogram based on rad-score and clinical features was developed using random forest (RF). The performances of clinical model, radiomic model and radiomics nomogram were thoroughly evaluated by the DeLong test, decision curve analysis (DCA) and clinical impact curve (CIC) allowing for generation of an optimal predictive model.

RESULTS

The radiological nomogram model consists of three independent predictors, including rad-score, T-stage, and enhancement rim on PVP. Training and validation results demonstrated the high-performance level of the model of area under curve (AUC) of 0.86 and 0.84, respectively. The radiomic nomogram model can achieve better diagnostic performance than the clinical model, yielding greater net clinical benefit compared to the clinical model alone.

CONCLUSIONS

A CT-based radiomics nomogram can be used to predict HGPs in CRLM. Preoperative non-invasive identification of HGPs could further facilitate clinical treatment and provide personalized treatment plans for patients with liver metastases from colorectal cancer.

Identification of high-risk factors for recurrence of colon cancer following complete mesocolic excision: An 8-year retrospective study

BACKGROUND

Colon cancer recurrence is a common adverse outcome for patients after complete mesocolic excision (CME) and greatly affects the near-term and long-term prognosis of patients. This study aimed to develop a machine learning model that can identify high-risk factors before, during, and after surgery, and predict the occurrence of postoperative colon cancer recurrence.

METHODS

The study included 1187 patients with colon cancer, including 110 patients who had recurrent colon cancer. The researchers collected 44 characteristic variables, including patient demographic characteristics, basic medical history, preoperative examination information, type of surgery, and intraoperative information. Four machine learning algorithms, namely extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM), and k-nearest neighbor algorithm (KNN), were used to construct the model. The researchers evaluated the model using the k-fold cross-validation method, ROC curve, calibration curve, decision curve analysis (DCA), and external validation.

RESULTS

Among the four prediction models, the XGBoost algorithm performed the best. The ROC curve results showed that the AUC value of XGBoost was 0.962 in the training set and 0.952 in the validation set, indicating high prediction accuracy. The XGBoost model was stable during internal validation using the k-fold cross-validation method. The calibration curve demonstrated high predictive ability of the XGBoost model. The DCA curve showed that patients who received interventional treatment had a higher benefit rate under the XGBoost model. The external validation set's AUC value was 0.91, indicating good extrapolation of the XGBoost prediction model.

CONCLUSION

The XGBoost machine learning algorithm-based prediction model for colon cancer recurrence has high prediction accuracy and clinical utility.

The potential of exome sequencing of paired colorectal tumors and synchronous liver metastases to improve treatment

Tweetable abstract Sequencing exomes of synchronous and metachronous liver metastases of colorectal cancer has potential to enhance treatment, since they can have molecular profiles distinct from primary tumors.

A multi-modal deep neural network for multi-class liver cancer diagnosis

Liver disease is a potentially asymptomatic clinical entity that may progress to patient death. This study proposes a multi-modal deep neural network for multi-class malignant liver diagnosis. In parallel with the portal venous computed tomography (CT) scans, pathology data is utilized to prognosticate primary liver cancer variants and metastasis. The processed CT scans are fed to the deep dilated convolution neural network to explore salient features. The residual connections are further added to address vanishing gradient problems. Correspondingly, five pathological features are learned using a wide and deep network that gives a benefit of memorization with generalization. The down-scaled hierarchical features from CT scan and pathology data are concatenated to pass through fully connected layers for classification between liver cancer variants. In addition, the transfer learning of pre-trained deep dilated convolution layers assists in handling insufficient and imbalanced dataset issues. The fine-tuned network can predict three-class liver cancer variants with an average accuracy of 96.06% and an Area Under Curve (AUC) of 0.832. To the best of our knowledge, this is the first study to classify liver cancer variants by integrating pathology and image data, hence following the medical perspective of malignant liver diagnosis. The comparative analysis on the benchmark dataset shows that the proposed multi-modal neural network outperformed most of the liver diagnostic studies and is comparable to others.

Exome Sequencing of Paired Colorectal Carcinomas and Synchronous Liver Metastases for Prognosis and Therapy Prediction

PURPOSE

Analysis of somatic variant profiles in retrospectively collected pairs of primary tumors and synchronous liver metastases from surgically treated patients with colorectal carcinomas. Mutational profiles were compared between groups of patients stratified by response to chemotherapy and survival.

PATIENTS AND METHODS

The study used whole-exome sequencing of tumor sample pairs from 20 patients diagnosed and treated at a single center. The Cancer Genome Atlas COAD-READ data set (n = 380) was used for validation in silico, where possible.

RESULTS

The most frequently altered oncodrivers were APC (55% in primaries and 60% in metastases), TP53 (50/45), TRIP11 (30/5), FAT4 (20/25), and KRAS (15/25). Harboring variants with a high or moderate predicted functional effect in KRAS in primary tumors was significantly associated with poor relapse-free survival in both our sample set and the validation data set. We found a number of additional prognostic associations, including mutational load, alterations in individual genes, oncodriver pathways, and single base substitution (SBS) signatures in primary tissues, which were not confirmed by validation. Altered ATM, DNAH11, and MUC5AC, or a higher share of SBS24 signature in metastases seemed to represent poor prognostic factors, but because of a lack of suitable validation data sets, these results must be treated with extreme caution. No gene or profile was significantly associated with response to chemotherapy.

CONCLUSION

Taken together, we report subtle differences in exome mutational profiles between paired primary tumors and synchronous liver metastases and a distinct prognostic relevance of KRAS in primary tumors. Although the general scarcity of primary tumor-synchronous metastasis sample pairs with high-quality clinical data makes robust validation difficult, this study provides potentially valuable data for utilization in precision oncology and could serve as a springboard for larger studies.

Irreversible Electroporation for Liver Metastases from Colorectal Cancer: A Systematic Review

BACKGROUND

Irreversible electroporation (IRE) is a non-thermal form of ablation based on the delivery of pulsed electrical fields. It has been used to treat liver lesions, particularly those in proximity to major hepatic vasculature. The role of this technique in the portfolio of treatments for colorectal hepatic metastases has not been clearly defined. This study undertakes a systematic review of IRE for treatment of colorectal hepatic metastases.

METHODS

The study protocol was registered with the PROSPERO register of systematic reviews (CRD42022332866) and reports in compliance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The Ovid MEDLINE^®, EMBASE, Web of Science and Cochrane databases were queried in April 2022. The search terms 'irreversible electroporation', 'colon cancer', 'rectum cancer' and 'liver metastases' were used in combinations. Studies were included if they provided information on the use of IRE for patients with colorectal hepatic metastases and reported procedure and disease-specific outcomes. The searches returned 647 unique articles and the exclusions left a total of eight articles. These were assessed for bias using the methodological index for nonrandomized studies (MINORS criteria) and reported using the synthesis without meta-analysis guideline (SWiM).

RESULTS

One hundred eighty patients underwent treatment for liver metastases from colorectal cancer. The median transverse diameter of tumours treated by IRE was <3 cm. Ninety-four (52%) tumours were adjacent to major hepatic inflow/outflow structures or the vena cava. IRE was undertaken under general anaesthesia with cardiac cycle synchronisation and with the use of either CT or ultrasound for lesion localisation. Probe spacing was less than 3.2 cm for all ablations. There were two (1.1%) procedure-related deaths in 180 patients. There was one (0.5%) post-operative haemorrhage requiring laparotomy, one (0.5%) bile leak, five (2.8%) post-procedure biliary strictures and a zero incidence of post-IRE liver failure.

CONCLUSIONS

This systematic review shows that IRE for colorectal liver metastases can be accomplished with low procedure-related morbidity and mortality. Further prospective study is required to assess the role of IRE in the portfolio of treatments for patients with liver metastases from colorectal cancer.

Staged or Simultaneous Surgery for Colon or Rectal Cancer with Synchronous Liver Metastases: Implications for Study Design and Clinical Endpoints

In patients presenting with colorectal cancer and synchronous liver metastases, the disease burden related to the liver metastasis is the driving cause of limited longevity and, eventually, risk of death. Surgical resection is the potentially curative treatment for colorectal cancer liver metastases. In the synchronous setting where both the liver metastases and the primary tumor are resectable with a relative low risk, the oncological surgeon and the patient may consider three potential treatment strategies. Firstly, a "staged" or a "simultaneous" surgical approach. Secondly, for a staged strategy, a 'conventional approach' will suggest removal of the primary tumor first (either colon or rectal cancer) and plan for liver surgery after recovery from the first operation. A "Liver first" strategy is prioritizing the liver resection before resection of the primary tumor. Planning a surgical trial investigating a two-organ oncological resection with highly variable extent and complexity of resection as well as the potential impact of perioperative chemo(radio)therapy makes it difficult to find the optimal primary endpoint. Here, we suggest running investigational trials with carefully chosen composite endpoints as well as embedded risk-stratification strategies to identify subgroups of patients who may benefit from simultaneous surgery.

Machine Learning Models for Predicting the Outcomes of Surgical Treatment of Colorectal Liver Metastases

BACKGROUND

Surgical intervention remains the cornerstone of a multidisciplinary approach in the treatment of colorectal liver metastases (CLM). Nevertheless, patient outcomes vary greatly. While predictive tools can assist decision-making and patient counseling, decades of efforts have yet to result in generating a universally adopted tool in clinical practice.

STUDY DESIGN

An international collaborative database of CLM patients who underwent surgical therapy between 2000 and 2018 was used to select 1,004 operations for this study. Two different machine learning methods were applied to construct 2 predictive models for recurrence and death, using 128 clinicopathologic variables: gradient-boosted trees (GBTs) and logistic regression with bootstrapping (LRB) in a leave-one-out cross-validation.

RESULTS

Median survival after resection was 47.2 months, and disease-free survival was 19.0 months, with a median follow-up of 32.0 months in the cohort. Both models had good predictive power, with GBT demonstrating a superior performance in predicting overall survival (area under the receiver operating curve [AUC] 0.773, 95% CI 0.743 to 0.801 vs LRB: AUC 0.648, 95% CI 0.614 to 0.682) and recurrence (AUC 0.635, 95% CI 0.599 to 0.669 vs LRB: AUC 0.570, 95% CI 0.535 to 0.601). Similarly, better performances were observed predicting 3- and 5-year survival, as well as 3- and 5-year recurrence, with GBT methods generating higher AUCs.

CONCLUSIONS

Machine learning provides powerful tools to create predictive models of survival and recurrence after surgery for CLM. The effectiveness of both machine learning models varies, but on most occasions, GBT outperforms LRB. Prospective validation of these models lays the groundwork to adopt them in clinical practice.

The prognostic significance of clinicopathological characteristics in early-onset versus late-onset colorectal cancer liver metastases

PURPOSE

This study aimed to explore the prognostic significance of clinicopathological characteristics in early-onset versus late-onset colorectal liver metastases (CRLM).

METHODS

The data of CRLM patients who underwent hepatectomy from September 2010 to September 2020 were retrospectively analyzed. According to the age of primary cancer diagnosis, patients were divided into early-onset CRLM (EOCRLM) and late-onset CRLM (LOCRLM) groups. Clinicopathological parameters were compared between the two groups. Cox regression model and Kaplan-Meier method were used to analyze the effect of clinicopathological parameters on overall survival (OS) and recurrence-free survival (RFS).

RESULTS

In total, 431 CRLM patients were identified, 130 with EOCRLM and 301 with LOCRLM. Compared with LOCRLM patients, EOCRLM patients had lower American Society of Anesthesia (ASA) grade and longer operation time (204 vs. 179 min). More aggressive features were presented in EOCRLM patients including synchronous liver metastases (76.9% vs. 61.1%) and bilobar involvement (43.8% vs. 33.2%). No significant difference in OS or RFS was found between the two groups. Multivariate analysis of EOCRLM group showed that preoperative CA19-9 level and RAS/BRAF status were predictive of OS, while bilobar involvement and preoperative CEA level were associated with RFS. In LOCRLM group, the number of CRLM, preoperative CA19-9 level, and BRAF status were associated with OS, while the number of CRLM was associated with RFS.

CONCLUSIONS

The preoperative CA19-9 level, RAS/BRAF status, bilobar involvement, and preoperative CEA level were predictive of EOCRLM patient prognosis, while the number of CRLM, preoperative CA19-9 level, and BRAF status were predictive of LOCRLM patient prognosis.

A retrospective case-series of influence of chronic hepatitis B on synchronous liver metastasis of colorectal cancer

Main point

Our retrospective analysis of a large number of cases found in patients with primary colorectal cancer (CRC) carrying positive HBsAg inhibited the occurrence of synchronous liver metastases (SLM). However, liver cirrhosis caused by non-HBV factors promoted the occurrence of SLM.

Objectives

This study aimed to investigate the effect of HBV on the occurrence of synchronous liver metastases (SLM) of colorectal cancer (CRC).

Methods

Univariate and multivariate analyses were used to analyze the influence of clinical parameters on the occurrence of SLM.

Results

A total of 6, 020 patients with primary CRC were included in our study, of which 449 patients carrying HBsAg(+) accounted for 7.46%. 44 cases of SLM occurred in the HBsAg(+) group, accounting for 9.80%, which was much lower than 13.6% (758/5571) in the HBsAg(-) group (X=5.214, P=0.022). Among CRC patients with HBsAg(-), the incidence of SLM was 24.9% and 14.9% in the group with high APRI and FIB-4 levels, respectively, which were significantly higher than that in the compared groups (12.3% and 12.5%, all P<0.05). Compared with the control group, female patients, late-onset patients, and HBV-infective patients had lower risks of SLM (HR=0.737, 95%CI: 0.614-0.883, P<0.001; HR=0.752, 95%CI: 0.603-0.943, P=0.013; HR=0.682, 95%CI: 0.473-0.961, P=0.034).

Conclusions

The carriage of HBsAg(+) status inhibited the occurrence of SLM from CRC. HBV-causing liver cirrhosis did not further influence the occurrence of SLM, whereas non-HBV-factor cirrhosis promoted the occurrence of SLM. Nevertheless, this still required prospective data validation.

Differences in genome, transcriptome, miRNAome, and methylome in synchronous and metachronous liver metastasis of colorectal cancer

Despite distant metastases being the critical factor affecting patients' survival, they remain poorly understood. Our study thus aimed to molecularly characterize colorectal cancer liver metastases (CRCLMs) and explore whether molecular profiles differ between Synchronous (SmCRC) and Metachronous (MmCRC) colorectal cancer. This characterization was performed by whole exome sequencing, whole transcriptome, whole methylome, and miRNAome. The most frequent somatic mutations were in APC, SYNE1, TP53, and TTN genes. Among the differently methylated and expressed genes were those involved in cell adhesion, extracellular matrix organization and degradation, neuroactive ligand-receptor interaction. The top up-regulated microRNAs were hsa-miR-135b-3p and -5p, and the hsa-miR-200-family while the hsa-miR-548-family belonged to the top down-regulated. MmCRC patients evinced higher tumor mutational burden, a wider median of duplications and deletions, and a heterogeneous mutational signature than SmCRC. Regarding chronicity, a significant down-regulation of SMOC2 and PPP1R9A genes in SmCRC compared to MmCRC was observed. Two miRNAs were deregulated between SmCRC and MmCRC, hsa-miR-625-3p and has-miR-1269-3p. The combined data identified the IPO5 gene. Regardless of miRNA expression levels, the combined analysis resulted in 107 deregulated genes related to relaxin, estrogen, PI3K-Akt, WNT signaling pathways, and intracellular second messenger signaling. The intersection between our and validation sets confirmed the validity of our results. We have identified genes and pathways that may be considered as actionable targets in CRCLMs. Our data also provide a valuable resource for understanding molecular distinctions between SmCRC and MmCRC. They have the potential to enhance the diagnosis, prognostication, and management of CRCLMs by a molecularly targeted approach.

Machine learning based prognostic model of Chinese medicine affecting the recurrence and metastasis of I-III stage colorectal cancer: A retrospective study in China

Background

To construct prognostic model of colorectal cancer (CRC) recurrence and metastasis (R&M) with traditional Chinese medicine (TCM) factors based on different machine learning (ML) methods. Aiming to offset the defects in the existing model lacking TCM factors.

Methods

Patients with stage I-III CRC after radical resection were included as the model data set. The training set and the internal verification set were randomly divided at a ratio of 7: 3 by the "set aside method". The average performance index and 95% confidence interval of the model were calculated by repeating 100 tests. Eight factors were used as predictors of Western medicine. Two types of models were constructed by taking "whether to accept TCM intervention" and "different TCM syndrome types" as TCM predictors. The model was constructed by four ML methods: logistic regression, random forest, Extreme Gradient Boosting (XGBoost) and support vector machine (SVM). The predicted target was whether R&M would occur within 3 years and 5 years after radical surgery. The area under curve (AUC) value and decision curve analysis (DCA) curve were used to evaluate accuracy and utility of the model.

Results

The model data set consisted of 558 patients, of which 317 received TCM intervention after radical resection. The model based on the four ML methods with the TCM factor of "whether to accept TCM intervention" showed good ability in predicting R&M within 3 years and 5 years (AUC value > 0.75), and XGBoost was the best method. The DCA indicated that when the R&M probability in patients was at a certain threshold, the models provided additional clinical benefits. When predicting the R&M probability within 3 years and 5 years in the model with TCM factors of "different TCM syndrome types", the four methods all showed certain predictive ability (AUC value > 0.70). With the exception of the model constructed by SVM, the other methods provided additional clinical benefits within a certain probability threshold.

Conclusion

The prognostic model based on ML methods shows good accuracy and clinical utility. It can quantify the influence degree of TCM factors on R&M, and provide certain values for clinical decision-making.

Role of radiomics in the diagnosis and treatment of gastrointestinal cancer

Gastrointestinal cancer (GIC) has high morbidity and mortality as one of the main causes of cancer death. Preoperative risk stratification is critical to guide patient management, but traditional imaging studies have difficulty predicting its biological behavior. The emerging field of radiomics allows the conversion of potential pathophysiological information in existing medical images that cannot be visually recognized into high-dimensional quantitative image features. Tumor lesion characterization, therapeutic response evaluation, and survival prediction can be achieved by analyzing the relationships between these features and clinical and genetic data. In recent years, the clinical application of radiomics to GIC has increased dramatically. In this editorial, we describe the latest progress in the application of radiomics to GIC and discuss the value of its potential clinical applications, as well as its limitations and future directions.

Recent Advance in the Surgical Treatment of Metastatic Colorectal Cancer-An English Version

Stage IV colorectal cancer (CRC) has heterogeneous characteristics in tumor extent and biology. The overall survival of patients with metastatic CRC has improved with the development of multimodal treatments and new chemotherapeutic drugs. Resection of metastatic CRC is performed for liver, lung, or peritoneal metastases. Conversion surgeries to resect oligometastatic lesions have been developed with tumor regression using chemotherapeutic agents. Two-stage hepatectomy has extended the surgical indications for patients with metastatic CRC. Synchronous liver and primary tumor resection can be considered in patients with adequate conditions. Local ablation with radiotherapy can be used to treat lung metastasis. In the treatment of patients with CRC with peritoneal metastasis, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy can be considered. Surgical treatments should be performed in patients with symptomatic primary tumors with unresectable metastasis. However, primary tumor resection in patients with asymptomatic CRC with synchronous, unresectable metastases did not show overall survival benefits in recent studies. Therefore, the treatment of metastatic CRC is challenging due to the variable tumor extent and heterogenous characteristics. Tailored surgical treatments and multidisciplinary approaches may improve survival and the quality of life in patients with metastatic CRC.

Practical Implications of KRAS Mutation Status and Sidedness of Primary Tumour in Patients with Colorectal Cancer and Synchronous Liver Metastases: A Subset Analysis of the CoSMIC Study

Patients with colorectal cancer presenting with synchronous liver metastases have less favourable outcomes than those with primary-only disease. There is evidence of different genetic mutational signatures according to the sidedness of the primary tumour. KRAS mutations are key driver mutations in colorectal cancer progression. This post hoc analysis of the previously reported CoSMIC inception cohort explores the association between primary tumour sidedness and KRAS mutational status on the outcome of patients with colorectal cancer and synchronous liver metastases. Patients diagnosed with synchronous disease were recruited between April 2014 and March 2017 and, after exclusions, 83 patients undergoing colorectal primary KRAS mutation testing constituted the final study population. Data were collected prospectively on demographic profiles, treatment, and outcomes. Twenty-one patients (25%) had right-sided tumours and 62 (75%) had left-sided tumours, with 46 (55%) and 37 (45%) exhibiting wildtype and mutated KRAS, respectively. There was no difference in distribution of liver metastases by KRAS status (unilobar vs. bi-lobar; p = 0.58; Fisher’s Exact test) and no difference in 5-year survival according to KRAS mutation status (Log-rank test, p = 0.82) or tumour sidedness (p = 0.16). In summary, in this cohort of patients with colorectal cancer and synchronous liver metastases, neither KRAS mutation status nor tumour sidedness influenced survival.

Surgical treatment for metastatic colorectal cancer

Background: Stage IV colorectal cancer (CRC) exhibits heterogeneous characteristics in tumor extent and biology. The overall survival of patients with metastatic CRC has improved with the development of multimodal treatments and new chemotherapeutic drugs.Current Concepts: Resection of metastatic CRC is performed for liver, lung, or peritoneal metastases. Conversion surgeries to resect oligometastatic lesions have been developed with tumor regression using chemotherapeutic agents. Two-stage hepatectomy has extended the surgical indications for patients with metastatic CRC. Synchronous liver and primary tumor resection can be considered in patients with adequate conditions. Local ablation with radiotherapy can be used to treat lung metastasis. Meanwhile, for treating patients with CRC with peritoneal metastasis, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy can be considered. Surgical treatments should be performed in patients with symptomatic primary tumors with unresectable metastasis. However, in recent studies, primary tumor resection in patients with asymptomatic CRC with synchronous, unresectable metastases did not show overall survival benefits.Discussion and Conclusion: The treatment of metastatic CRC is challenging because of the variable tumor extent and heterogenous characteristics. Tailored surgical treatments and multidisciplinary approaches may improve the survival and quality of life of patients with metastatic CRC.

Outcomes of simultaneous resection for elderly patients with colorectal liver metastasis: A propensity score matching analysis

BACKGROUND

Evidence on simultaneous resection for elderly patients (age ≥ 70 years) with colorectal liver metastasis (CRLM) is lacking.

METHODS

Four hundred and eighty-two CRLM patients treated by simultaneous resection were categorised into young group (age < 70 years) and elderly group (age ≥ 70 years). Propensity score matching (PSM1) was performed to adjust for differences in baseline characteristics and compare short-term outcomes. An additional propensity score matching (PSM2) including short-term outcomes was performed to analyse survival. Subgroup analysis was performed in patients stratified by the Clinical Risk Score (CRS).

RESULTS

After PSM1, 87 young group patients were matched to 50 elderly group patients. Patients in the elderly group had a significantly higher rate of overall post-operative complications (68.0% vs. 46.0%, p = 0.013). After PSM2, 89 young group patients were matched to 47 elderly group patients. Progression-free survival (PFS) was comparable between the two groups (median 11.0 months vs. 9.8 months, p = 0.346). Age ≥ 70 independently predicted worse overall survival (OS) (Hazard ratio, HR = 2.57, 95% confidence interval, CI 1.37-4.82) in multivariate analysis. In the subgroup multivariate analysis of patients with CRS score 3-5, age ≥ 70 was independently associated with worse PFS (HR = 1.62, 95% CI 1.01-2.62) and OS (HR = 2.34, 95% CI 1.26-4.35).

CONCLUSIONS

Simultaneous resection for elderly CRLM patients is acceptable. Further studies are required to determine the optimal treatment for elderly CRLM patients with high CRS scores.

Long disease-free interval diminishes the prognostic value of primary tumor stage for patients with colorectal cancer liver metastases

BACKGROUND

It is assumed that the impact of primary tumor stage (PTS) on prognosis gradually weakens with increasing disease-free interval (DFI) from colorectal cancer resection to liver metastases.

METHODS

Data from 733 patients undergoing hepatectomy in the Hepato-pancreato-biliary Surgery Department I of Peking University Cancer Hospital were retrospectively analyzed. Early and late metastases were defined as DFI ≤ and >12 months, respectively.

RESULTS

In early metastases group, patients with T₄ stage had a significantly worse recurrence-free survival (RFS) and overall survival (OS) than those with T_1-3 stage (P = 0.002 and P < 0.001, respectively). Patients with N_1-2 stage disease also demonstrated a worse RFS and OS than those with N₀ stage (P = 0.006 and P = 0.007, respectively). In late metastases group, patients with T₄ and T_1-3 stages as well as patients with N_1-2 and N₀ stages, had comparable RFS (P = 0.395 and P = 0.996, respectively) and OS (P = 0.387 and P = 0.684, respectively). T and N stages were independent prognostic predictors only in patients with early metastases.

CONCLUSION

The impact of PTS on prognosis is diminished with increasing DFI and limited only to patients with early metastases.

Simultaneous or staged resection for synchronous liver metastasis and primary rectal cancer: a propensity score matching analysis

Background

Colorectal cancer is the third most common cancer in France and by the time of the diagnosis, 15–25% of patients will suffer from synchronous liver metastases. Surgery associated to neoadjuvant treatment can cure these patients, but few studies focus only on rectal cancer. This study was meant to compare the outcomes of patients who underwent a simultaneous resection to those who underwent a staged resection (rectum first or liver first) in the University Hospital of Tours, France.

Methods

We assessed retrospectively a prospective maintained data base about the clinical, pathological and survival outcomes of patients who underwent a simultaneous or a staged resection in our center between 2010 and 2018. A propensity score matching was used, considering the initial characteristics of our groups.

Results

There were 70 patients (55/15 males, female respectively) with median age 60 (54–68) years. After matching 48 (69%) of them underwent a staged approach and 22 (31%) a simultaneous approach were compared. After PSM, there were 22 patients in each group. No differences were found in terms of morbidity (p = 0.210), overall survival (p = 0.517) and disease-free survival (p = 0.691) at 3 years after matching. There were significantly less recurrences in the simultaneous group (50% vs 81.8%, p = 0.026).

Conclusions

Simultaneous resection of the rectal primary cancer and synchronous liver metastases is safe and feasible with no difference in terms of survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02250-9.

The CBS-H2S axis promotes liver metastasis of colon cancer by upregulating VEGF through AP-1 activation

BACKGROUND

The main therapy for colon cancer with liver metastasis is chemotherapy based on 5-fluorouracil combined with targeted drugs. However, acquired drug resistance and severe adverse reactions limit patients' benefit from standard chemotherapy. Here, we investigate the involvement of endogenous hydrogen sulfide (H₂S) in liver metastasis of colon cancer and its potential value as a novel therapeutic target.

METHODS

We used the CRISPR/Cas9 system to knockdown CBS gene expression in colon cancer cell lines. PCR arrays and proteome arrays were applied to detect the transcription and protein expression levels, respectively, of angiogenesis-related genes after knockdown. The molecular mechanism was investigated by western blot analysis, RT-qPCR, immunofluorescence staining, ChIP assays and dual-luciferase reporter assays. A liver metastasis mouse model was adopted to investigate the effect of targeting CBS on tumour metastasis in vivo.

RESULTS

Knockdown of CBS decreased the metastasis and invasion of colon cancer cells and inhibited angiogenesis both in vivo and in vitro. Tissue microarray analysis showed a positive correlation between CBS and VEGF expression in colon cancer tissues. Further analysis at the molecular level validated a positive feedback loop between the CBS-H₂S axis and VEGF.

CONCLUSIONS

Endogenous H₂S promotes angiogenesis and metastasis in colon cancer, and targeting the positive feedback loop between the CBS-H₂S axis and VEGF can effectively intervene in liver metastasis of colon cancer.

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

Deep Convolutional Neural Network Based Analysis of Liver Tissues Using Computed Tomography Images

Liver disease is one of the most prominent causes of the increase in the death rate worldwide. These death rates can be reduced by early liver diagnosis. Computed tomography (CT) is a method for the analysis of liver images in clinical practice. To analyze a large number of liver images, radiologists face problems that sometimes lead to the wrong classifications of liver diseases, eventually resulting in severe conditions, such as liver cancer. Thus, a machine-learning-based method is needed to classify such problems based on their texture features. This paper suggests two different kinds of algorithms to address this challenging task of liver disease classification. Our first method, which is based on conventional machine learning, uses texture features for classification. This method uses conventional machine learning through automated texture analysis and supervised machine learning methods. For this purpose, 3000 clinically verified CT image samples were obtained from 71 patients. Appropriate image classes belonging to the same disease were trained to confirm the abnormalities in liver tissues by using supervised learning methods. Our proposed method correctly quantified asymmetric patterns in CT images using machine learning. We evaluated the effectiveness of the feature vector with the K Nearest Neighbor (KNN), Naive Bayes (NB), Support Vector Machine (SVM), and Random Forest (RF) classifiers. The second algorithm proposes a semantic segmentation model for liver disease identification. Our model is based on semantic image segmentation (SIS) using a convolutional neural network (CNN). The model encodes high-density maps through a specific guided attention method. The trained model classifies CT images into five different categories of various diseases. The compelling results obtained confirm the effectiveness of the proposed model. The study concludes that abnormalities in the human liver could be discriminated and diagnosed by texture analysis techniques, which may also assist radiologists and medical physicists in predicting the severity and proliferation of abnormalities in liver diseases.

Prognostic factors of survival and a new scoring system for liver resection of colorectal liver metastasis

BACKGROUND

Hepatic resection has become the preferred treatment of choice for colorectal liver metastasis (CLM) patients.

AIM

To identify the prognostic factors and to formulate a new scoring system for management of CLM.

METHODS

Clinicopathologic and long-term survival data were analyzed to identify the significant predictors of survival by univariate and multivariate analyses with the Cox model. A clinical score was constructed based on the analysis results.

RESULTS

Three factors of worse overall survival were identified in the multivariate analysis. They were number of liver metastases ≥ 5, size of the largest liver lesion ≥ 4 cm, and the presence of nodal metastasis from the primary tumor. These three factors were chosen as criteria for a clinical risk score for overall survival. The clinical score highly correlated with median overall survival and 5-year survival (P = 0.002).

CONCLUSION

Priority over surgical resection should be given to the lowest score groups, and alternative oncological treatment should be considered in patients with the highest score.