Oxaliplatin combined with irinotecan and 5-fluorouracil/leucovorin (OCFL) in metastatic colorectal cancer: a phase I–II study

Survival Benefit of Primary Tumor Resection Combined With Chemotherapy in Patients With Unresectable Colorectal Mucinous Adenocarcinoma With Liver Metastasis

OBJECTIVE

To evaluate the survival benefit of combining primary tumor resection (PTR) and chemotherapy in patients with unresectable colorectal mucinous adenocarcinoma with liver metastasis (UCR-MAC-LM).

METHODS

We obtained data from the surveillance, epidemiology, and end results database for patients with UCR-MAC-LM from 2010 to 2017. Clinicopathological characteristics were analyzed using the χ2 test. Propensity score matching was performed to balance baseline characteristics. Kaplan-Meier analysis and log-rank tests were used to estimate and compare survival outcomes. Univariate and multivariate Cox regression analyses were conducted to identify the prognostic factors.

RESULTS

A total of 10,178 patients with unresectable colorectal adenocarcinoma with liver metastasis were included, of whom 6.01% (n=612) had UCR-MAC-LM. The UCR-MAC-LM group had a higher proportion of female patients, a greater number of elderly patients, an increased incidence of right colon localization, larger tumor size, and higher T and N staging than the unresectable colorectal non-mucinous adenocarcinoma with liver metastasis group (P<0.05). Multivariate analysis identified several independent prognostic factors (P<0.05). Patients with unresectable colorectal adenocarcinoma with liver metastasis who underwent PTR+C had superior survival rates compared with those who received PTR/C alone or no treatment (cancer-specific survival, P<0.05; overall survival, P<0.05). Subgroup analysis revealed that 17 of 22 groups of patients with UCR-MAC-LM who received PTR+C had significantly prolonged long-term survival compared with those who received PTR/C alone.

CONCLUSIONS

This surveillance, epidemiology, and end results-based study indicates that PTR+C may offer a survival advantage for a specific subgroup of patients with UCR-MAC-LM compared with PTR/C alone. Nonetheless, additional clinical trials are necessary to validate these findings.

Liver Immune Microenvironment and Metastasis from Colorectal Cancer-Pathogenesis and Therapeutic Perspectives

A drastic difference exists between the 5-year survival rates of colorectal cancer patients with localized cancer and distal organ metastasis. The liver is the most favorable organ for cancer metastases from the colorectum. Beyond the liver-colon anatomic relationship, emerging evidence highlights the impact of liver immune microenvironment on colorectal liver metastasis. Prior to cancer cell dissemination, hepatocytes secrete multiple factors to recruit or activate immune cells and stromal cells in the liver to form a favorable premetastatic niche. The liver-resident cells including Kupffer cells, hepatic stellate cells, and liver-sinusoidal endothelial cells are co-opted by the recruited cells, such as myeloid-derived suppressor cells and tumor-associated macrophages, to establish an immunosuppressive liver microenvironment suitable for tumor cell colonization and outgrowth. Current treatments including radical surgery, systemic therapy, and localized therapy have only achieved good clinical outcomes in a minority of colorectal cancer patients with liver metastasis, which is further hampered by high recurrence rate. Better understanding of the mechanisms governing the metastasis-prone liver immune microenvironment should open new immuno-oncology avenues for liver metastasis intervention.

A. I. Colorectal cancer stem cells: a review of targeted drug delivery by gold nanoparticles

The proposed schematic mechanismviawhich 5-fluorouracil-loaded gold nanoparticles conjugated with CD133 antibody target colorectal cancer stem cells.

Management of patients with colorectal liver metastasis in eleven questions and answers

INTRODUCTION

Colorectal liver metastasis (CRLM) is the most frequent indication for liver resection in many centers. Recent improvements in oncology, surgery, interventional radiology, pathology and anesthesiology allow curative treatment in a larger proportion of patients with CRLM. Areas covered: We illustrate the various aspects of the management of CRLM through 11 questions that summarize the topic, from the current obtained survival to future perspectives such as transplantation. The limits of a curative treatment are also presented from different angles, such as the benefits of pathology, the surgical options for extreme resections, the available chemotherapies and their efficacy, or the non-surgical ablative treatments. Expert commentary: Given the increasing therapeutic possibilities, we strengthen the importance to analyze the situation of each patient with CRLM in a dedicated multidisciplinary team, in order to offer the best individualized treatment combination.

Liver resection in patients with eight or more colorectal liver metastases

BACKGROUND

Patients with large numbers of colorectal liver metastases (CRLMs) are potential candidates for resection, but the benefit from surgery is unclear.

METHODS

Patients undergoing resection for CRLMs between 1998 and 2012 in two high-volume liver surgery centres were categorized according to the number of CRLMs: between one and seven (group 1) and eight or more (group 2). Overall (OS) and recurrence-free (RFS) survival were compared between the groups. Multivariable analysis was performed to identify adverse prognostic factors.

RESULTS

A total of 849 patients were analysed: 743 in group 1 and 106 in group 2. The perioperative mortality rate (90 days) was 0.4 per cent (all group 1). Median follow-up was 37.4 months. Group 1 had higher 5-year OS (44.2 versus 20.1 per cent; P < 0.001) and RFS (28.7 versus 13.6 per cent; P < 0.001) rates. OS and RFS in group 2 were similar for patients with eight to ten, 11-15 or more than 15 metastases (48, 40 and 18 patients respectively). In group 2, multivariable analysis identified three preoperative adverse prognostic factors: extrahepatic disease (P = 0.010), no response to chemotherapy (P = 0.023) and primary rectal cancer (P = 0.039). Patients with two or more risk factors had very poor outcomes (median OS and RFS 16.9 and 2.5 months; 5-year OS zero); patients in group 2 with no risk factors had similar survival to those in group 1 (5-year OS rate 44 versus 44.2 per cent).

CONCLUSION

Liver resection is safe in selected patients with eight or more metastases, and offers reasonable 5-year survival independent of the number of metastases. However, eight or more metastases combined with at least two adverse prognostic factors is associated with very poor survival, and surgery may not be beneficial.

A survival analysis of the liver-first reversed management of advanced simultaneous colorectal liver metastases: a LiverMetSurvey-based study

BACKGROUND

Liver-first reversed management (RM) for the treatment of patients with simultaneous colorectal liver metastases (CRLM) includes liver-directed chemotherapy, the resection of the CRLM, and the subsequent resection of the primary cancer. Retrospective data have shown that up to 80% of patients can successfully undergo a complete RM, whereas less than 30% of those undergoing classical management (CM) do so. This registry-based study compared the 2 approaches.

METHODS

The study was based on the LiverMetSurvey (January 1, 2000 to December 31, 2010) and included patients with 2 or more metastases. All patients had irinotecan and/or oxaliplatin-based chemotherapy before liver surgery. Patients undergoing simultaneous liver and colorectal surgery were excluded.

RESULTS

A total of 787 patients were included: 729 in the CM group and 58 in the RM group. Patients in the 2 groups had similar numbers of metastases (4.20 vs 4.80 for RM and CM, P = 0.231) and Fong scores of 3 or more (79% vs 87%, P = 0.164). Rectal cancer, neoadjuvant rectal radiotherapy, and the use of combined irinotecan/oxaliplatin chemotherapy were more frequent in the RM group (P < 0.001), whereas colorectal lymph node involvement was more frequent in the CM group (P < 0.001). Overall survival and disease-free survival were similar in the RM and CM groups (48% vs 46% at 5 years, P = 0.965 and 30% vs 26%, P = 0.992).

CONCLUSIONS

Classical and reversed managements of metastatic liver disease in colorectal cancer are associated with similar survival when successfully completed.

Treatment of colorectal liver metastases

Colorectal cancer (CRC) is the third most common cancer in the word. Liver metastasis is the most common site of colorectal metastases. The prognosis of resectable colorectal liver metastases (CRLM) was improved in the recent years with the consideration of chemotherapy and surgical resection as part of the multidisciplinary management of the disease; the current 5-year survival rates after resection of liver metastases are 25% to 40%. Resectable synchronous or metachronous liver metastases should be treated with perioperative chemotherapy based on three months of FOLFOX4 (5-fluorouracil [5FU], folinic acid [LV], and oxaliplatin) chemotherapy before surgery and three months after surgery. In the case of primary surgery, pseudo-adjuvant chemotherapy for 6 months, based on 5FU/LV, FOLFOX4, XELOX (capecitabine and oxaliplatin) or FOLFIRI (5FU/LV and irinotecan), should be indicated. In potentially resectable disease, primary chemotherapy based on more intensive regimens such as FOLFIRINOX (5FU/LV, irinotecan and oxaliplatin) should be considered to enhance the chance of cure. The palliative chemotherapy based on FOLFIRI, or FOLFOX4/XELOX with or without targeted therapies, is the mainstay treatment of unresectable disease. This review would provide additional insight into the problem of optimal integration of chemotherapy and surgery in the management of CRLM.

The timing of chemotherapy and surgery for the treatment of colorectal liver metastases

Combining surgery and chemotherapy in the treatment of patients with colorectal hepatic metastases is increasingly becoming the standard of care. However, controversy remains regarding the juxtapositioning of chemotherapy and surgery, the duration of chemotherapy, and particularly, the use of preoperative chemotherapy in the treatment of patients with initially resectable metastases. The arguments for and against the different approaches presented are based on the data published in the medical literature and on the data presented at the most recent major oncology meetings, coupled with the personal experience of the authors. For patients with liver metastases that are resectable at presentation, perioperative chemotherapy has become the standard treatment in many institutions, with the recommendation that surgery is performed after a maximum of 6 cycles of systemic therapy. In the case of patients with initially unresectable liver metastases receiving preoperative systemic therapy, patients should be carefully monitored and surgery performed as soon as the metastases become resectable. All patients should, where possible, be treated by a multidisciplinary team. Going forward, it needs to be established whether more intensive treatment (ie, perioperative versus postoperative systemic therapy) is merited for the treatment of patients with initially resectable disease, and what the precise contribution of new therapeutic agents in these settings is, based on new prospective randomized trial data.

[Hepatic lesions induced by systemic chemotherapy for digestive cancer]

The anticancerous chemotherapies are often responsible for toxic injury of the nontumoral liver. Two types of histological lesions were recently reported during the treatment of digestive cancers: the sinusoidal obstruction syndrome (SOS); or veno-occlusive disease associated with the use of oxaliplatine, and steatohepatitis associated with the use of irinotecan. The SOS is a cause of increased postoperative morbidity, particularly during major hepatectomy or when more than six cycles of chemotherapy are administered. Steatohepatitis increases the postoperative morbidity and mortality. The new targeted molecules do not seem to modify the postoperative course. Hepatic injury and postoperative complications associated with chemotherapies used in the treatment of digestive cancers are summarized in this review.

Sinusoidal obstruction syndrome

Sinusoidal obstruction syndrome (SOS), formerly named venoocclusive disease, is a well-known complication of hematopoietic stem cell transplantation and ingestion of food or drinks contaminated by pyrrolizidine alkaloids. Many other drugs and toxins have been associated with SOS, including several chemotherapeutic agents and immunosuppressors. SOS contributes to significant morbidity and mortality in all these settings. This review describes the histologic lesions of SOS, details its pathogenesis as it is understood today, specifies the recent data on its causes and how it may influence clinical management of colorectal liver metastases, and discusses the current knowledge on diagnosis and preventive options.

Advances in therapeutics for liver metastasis from colorectal cancer

The evolution of chemotherapeutic regimens that include targeted molecular agents has resulted in a breakthrough in the management of advanced colorectal liver metastasis (CLM), improving the progression-free survival after liver resection, and rendering initially unresectable liver tumors resectable, with reported resection rates ranging from 13% to 51%. In addition, the criteria used for selecting patients for hepatectomy have been expanding because of advances in surgical techniques and improvements in chemotherapy. However, the increasing use of chemotherapy has raised concern about potential hepatotoxicities such as steatosis, chemotherapy-associated steatohepatitis, and sinusoidal obstruction syndrome, and their deleterious effects on postoperative outcome. The present review focuses on the advantages and disadvantages of chemotherapy, strategies for the prevention and diagnosis of chemotherapy-associated liver injury, and the adoption of more aggressive surgical approaches, which have changed the traditional paradigm for CLM.

Role of surgery in colorectal liver metastases: Too early or too late?

As colorectal cancer and colorectal liver metastases become a serious public health problem, new treatment modalities are needed in order to achieve better results. In the last decade there has been very important progress in oncology, with new and more effective chemotherapeutic agents administered alone or in combination improving the resectability rate in up to 40% of patients with colorectal liver metastases. Advances in interventional radiology, in particular, with the use of portal vein embolization and radiofrequency thermal ablation are new strategies allowing major liver resections and treatment of small liver metastases or early recurrences. Surgery, however, remains the gold standard strategy with intention to treat. In this review article we will describe the advanced role of surgery in the multidisciplinary approach to colorectal liver metastases, and the clinical problems the liver surgeon has to deal with, such as the resectability of the metastases, the presence of bilobar liver lesions and extrahepatic disease, the impact of chemotherapy in already resectable liver metastases, the problem of vanishing metastases after chemotherapy and the dilemma of staged or combined liver and colon operations and which organ first in the clinical scenario of synchronous colorectal liver metastases.

The surgical treatment of hepatic metastases in colorectal carcinoma

BACKGROUND

Colorectal carcinoma with hepatic metastases was long considered an incurable disease. Recent advances in surgical treatment have substantially improved the affected patients' prognosis. At first, surgery was only performed in patients whose hepatic tumor burden was small (<4 nodes, <5 cm). Currently, however, the main issue is the feasibility of curative resection of all metastases.

METHOD

The PubMed literature database was selectively searched for articles with the keywords "colorectal liver metastases," "chemotherapy," and "surgery." Particular attention was devoted to studies of large groups of patients, randomized trials, the German guidelines, and an analysis of the authors' own patient population.

RESULTS

Only 10% to 20% of all patients are candidates for surgical therapy (hepatic resection), as the rest are disqualified either by extensive liver involvement or by extrahepatic neoplasia. A further 10% of patients have hepatic metastases that are primarily considered inoperable, yet later become amenable to surgery after interdisciplinary treatment involving preoperative chemotherapy, portal-vein embolization, two-stage hepatectomy, and/or locally ablative procedures. Chemotherapy is probably beneficial after hepatic resection, although the benefit has not yet been definitively demonstrated by clinical trials. Therefore, chemotherapy should only be given perioperatively in selected cases, when recommended by an interdisciplinary treatment team.

CONCLUSION

A multimodal approach to the treatment of hepatic metastases of colorectal carcinoma has led to an increase in the number of resections and to an improved long-term survival rate (currently more than 40% at 5 years).

Safety and efficacy of weekly 5-fluorouracil/folinic acid/oxaliplatin/irinotecan in the first-line treatment of gastrointestinal cancer

BACKGROUND

Standard chemotherapy for patients with metastatic colorectal cancer (mCRC) or gastric cancer (GC) consists of two-drug, usually fluoropyrimidine-based, combinations, with or without the addition of biological agents. Studies of triple-drug regimens combining 5-fluorouracil (5-FU)/folinic acid (FA) with both oxaliplatin and irinotecan have shown promising efficacy in studies of patients with mCRC or GC. However, improved efficacy has often been achieved at the expense of high rates of grade 3 or 4 toxicities such as neutropenia and diarrhoea, occasionally even resulting in toxic deaths.

OBJECTIVE/METHODS

We performed a phase II study of previously untreated patients with mCRC or GC to assess the safety and efficacy of our 5-fluorouracil/folinic acid/oxaliplatin/irinotecan (FUFOXIRI) regimen with weekly administration of irinotecan 70 mg/m(2), oxaliplatin 50 mg/m(2), FA 500 mg/m(2) and 5-FU 2000 mg/m(2) on days 1, 8, 15 and 22, repeated from day 36.

RESULTS

A total of 22 patients were enrolled, 11 each with mCRC and GC receiving a median of four cycles per patient. The FUFOXIRI regimen was generally well tolerated with no toxic deaths, neutropenic fever or grade 4 toxicities. Most common grade 3 side effects were diarrhoea and neutropenia each affecting 24% of patients. Dose reductions due to toxicity were performed in 48% of all and 60% of patients having received at least two cycles of FUFOXIRI. The overall response rate was 46% (all partial responses), 55% and 36% for patients with mCRC and GC, respectively. Median progression-free survival for all patients, mCRC and GC patients was 9.5, 10.0 and 8.0 months, respectively. The median overall survival for all patients was 16.5, 18.0 and 15.0 months for patients with mCRC and GC, respectively.

CONCLUSION

These data show excellent tolerance and efficacy of the FUFOXIRI regimen in both mCRC and GC. Therefore, FUFOXIRI is a promising backbone for future studies incorporating biologic 'targeted' agents for the treatment of gastrointestinal cancers.

Neoadjuvant chemotherapy in patients with stage IV colorectal cancer: a comparison of histological response in liver metastases, primary tumors, and regional lymph nodes

BACKGROUND

We report the histopathological results of a novel "inversed" strategy designed to manage patients with colorectal cancer (CRC) who have synchronous liver metastases by using chemotherapy first, liver surgery second, and resection of the primary tumor as a final step. This study was designed to compare the response to chemotherapy in liver metastases, primary tumors, and locoregional lymph nodes.

METHODS

Twenty-nine patients with stage IV CRC received a combination of oxaliplatin, irinotecan, 5-fluorouracil, and leucovorin (OCFL) for 3-4 months. Histological response to chemotherapy was assessed by using a tumor regression grading (TRG) score based on presence of residual tumor cells and extent of fibrosis.

RESULTS

Median age of patients was 56 (range, 37-69) years. Primary tumor location was right colon (n = 5), left colon (n = 7), and rectum (n = 17 patients). TRG scores correlated across disease sites (Spearman correlation coefficients for TRG in the primary tumor and lymph nodes was 0.59 [P = 0.005]; for the primary tumor and metastases 0.44 [P = 0.021]; and for lymph nodes and metastases 0.58 [P = 0.006]). Complete absence or poor tumor response (TRG4/5) was significantly more frequent in primary tumors (35.7%) and locoregional lymph nodes (38%) than in liver metastases (6.9%; McNemar test, P = 0.02). Two patients had a complete pathologic response (pT0N0M0).

CONCLUSIONS

In patients with stage IV colorectal cancer, liver metastases exhibit a better histological response than primary tumors to OCFL neoadjuvant chemotherapy.

Sinusoidal obstruction syndrome and nodular regenerative hyperplasia are frequent oxaliplatin-associated liver lesions and partially prevented by bevacizumab in patients with hepatic colorectal metastasis

AIMS

Because of its efficacy, oxaliplatin (OX) is increasingly used as a chemotherapeutic agent in the treatment of colorectal liver metastases (CRLM). Oxaliplatin-associated liver toxicity has been reported and can affect clinical practice, but studies on its prevalence and a full pathological description are lacking. The aims of this study were to fill this gap by providing, from a pathologist's perspective, a detailed assessment of the spectrum of hepatic lesions associated with OX, to suggest a scoring system to quantify them, and to investigate the protective effect of bevacizumab against OX-associated damage.

METHODS AND RESULTS

The spectrum of oxaliplatin-associated liver lesions was investigated in a multi-institutional series of surgically resected CRLM (n = 385). Among 274 patients treated by OX, 54% had moderate/severe sinusoidal obstruction syndrome (SOS). Peliosis, centrilobular perisinusoidal/venular fibrosis and nodular regenerative hyperplasia (NRH) developed in 10.6%, 47% and 24.5%, respectively. The 111 patients treated by surgery alone had no lesions. Hepatic lesions were less severe in patients treated with OX/bevacizumab (n = 70) compared with the group treated by OX alone (n = 204), with an incidence of moderate/severe SOS (31.4% versus 62.2%), peliosis (4.3% versus 14.6%), NRH (11.4% versus 28.9%, respectively) and centrilobular/venular fibrosis (31.4% versus 52%, respectively) (P < 0.001).

CONCLUSIONS

Pathologists should be aware of the distinctive lesions associated with OX and of their high prevalence. OX-related lesions are less frequent in patients treated with bevacizumab, suggesting that this drug has a preventive effect. Uniform criteria for diagnosis and grading of OX-associated lesions should help to include histological data in the optimal multidisciplinary management of CRLM.

A phase II study of irinotecan and capecitabine for patients with unresectable liver-only metastases from colorectal cancer

OBJECTIVE

To assess the resectability rate of patients with initially unresectable liver-only metastases from colorectal cancer (CRC) after treatment with irinotecan/capecitabine.

METHODS

Patients received irinotecan (240 mg/m(2)) as a 30 min intravenous infusion on day 1 and capecitabine (1000 mg/m(2)) orally bid for 14 days beginning on day 2. Treatment was repeated every 3 weeks. The protocol encouraged two to four cycles of irinotecan/capecitabine after recovery from surgery.

RESULTS

Between May 2004 and February 2007, 48 patients entered in the study. Forty-seven (97.9%) of the 48 patients were assessable for response. The overall response rate before surgery was 56.3% (95% CI, 42.3-70.3%) in the treated population, including 2 non-confirmed complete response (CR), 18 partial responses (PR) and 7 non-confirmed PR. Twenty-three (47.9%) of 29 patients with tumor shrinkage proceeded to surgical intervention. Twenty of the 23 patients had a complete resection (S-CR). With a median follow-up time of 32 months (range, 24-38 months), the overall median time to progression and overall survival for all patients were 16.7 months (95% CI, 10.0-23.4 months) and 27.5 months (95% CI, 23.6-31.4 months) for all patients. The 1- 2- and 3-year overall survival estimates were 79.2% (95% CI, 67.7-90.7%), 60.4% (95% CI, 46.6-74.3%) and 29.2% (95% CI, 16.3-42.0%), respectively. Grade 3 diarrhea occurred in eight (17.0%) patients. The most common Grade 3/4 hematological adverse event was neutropenia in 8.5% of the patients. There were no treatment-related deaths during this study.

CONCLUSIONS

Irinotecan/capecitabine appears to be a safe and very effective regimen in selected patients with unresectable liver metastases from CRC, but who are treated with a curative intent.

Liver resection for metastatic colorectal cancer in the presence of extrahepatic disease

Early studies of liver resection for colorectal cancer metastases identified patients with concomitant extrahepatic disease as a group with poor outcomes. These studies concluded that the presence of extrahepatic disease should be a contraindication to resection. This contraindication has more recently been challenged. In this paper, we review the published work on metastatic colorectal cancer, pertaining to the role of surgery in patients with liver metastases and concomitant extrahepatic disease. 5-year survival after resection is worse in patients with extrahepatic disease than in patients with liver-only disease, but is similar to that seen in patients who underwent resection in the era before the use of modern chemotherapy. Recurrence occurs in most patients. There is a role for surgery in highly selected patients with single sites of extrahepatic disease, although expectations should be different than those of patients with liver-only metastases. Further studies are necessary to define the patient group best suited for resection of hepatic metastases with extrahepatic disease.

Dangerous halo after neoadjuvant chemotherapy and two-step hepatectomy for colorectal liver metastases

BACKGROUND

Bilobar colorectal metastases are a therapeutic challenge and require a multidisciplinary approach. The aim of this study was to describe the clinical and histological outcomes of patients having neoadjuvant chemotherapy and two-step hepatectomy with right portal vein occlusion for advanced bilateral colorectal metastases.

METHODS

A series of 23 consecutive patients treated with curative intent according to a standardized multidisciplinary management protocol was reviewed.

RESULTS

Of 23 patients, 22 completed the programme. There was no mortality and no Clavien grade III morbidity. Median survival from the start of treatment was 45 months, and 1-, 3- and 5-year Kaplan-Meier estimates were 95, 73 and 27 per cent respectively. On histology at the first operation, ten patients had a dangerous halo of proliferating tumour cells infiltrating the surrounding liver parenchyma, of variable importance (six focal and four diffuse), regardless of the response to chemotherapy of the metastases. The dangerous halo increased in prevalence and importance (six focal and seven diffuse) between the first and second operation.

CONCLUSION

Neoadjuvant chemotherapy followed by two-step hepatectomy with right portal vein occlusion is feasible, safe and may be advantageous to the patient. The appearance of a dangerous halo around the liver metastases may require adaptation of the surgical technique to decrease the risk of local recurrence.

Resection of colorectal liver metastases: is a resection margin of 3 mm enough? : a multicenter analysis of the GAST Study Group

BACKGROUND

A safety margin of > or =10 mm is generally accepted in surgery for colorectal metastases. It is reasonable that modern methods of liver parenchyma dissection may allow for a reduction in this distance.

METHODS

A total of 333 patients were included in a multicenter trial after resection of colorectal liver metastases. Dissection of the liver had been performed with a CUSA, UltraCision, or water-jet dissector. The size of the resection margin was correlated with recurrence risk and survival.

RESULTS

The median hepatic recurrence-free survival reached 35 months for all patients; median recurrence-free survival was 24 months and overall survival was 41 months. Univariate analysis of different groups denoting the extent of resection margin (> or =10 mm, 6-9 mm, 3-5 mm, 1-2 mm, 0 mm (R1)) indicated that a margin of 1-2 mm leads to a significantly reduced median hepatic recurrence-free survival of 20 months (p = 0.004) and recurrence-free survival of 19 months (p = 0.011). Patients with R1 resection had the worst prognosis. Overall survival was not influenced by the size of the resection margin. Surgical margins were significantly reduced in simultaneous resections of four or more liver metastases and in cases in which metastatic infiltration of central liver segments was present. At multivariate analysis, resection margins of 1-2 mm and 0 mm were independent predictors of hepatic recurrence and overall recurrence.

CONCLUSION

The indication for resection of metastases can be safely extended to cases in which tumors sit closer than 1 cm to nonresectable structures.

Management of hepatic metastasis from colorectal cancers: an update

Approximately 50%-60% of patients with colorectal cancers will develop liver lesions in their life span. Despite the potential of surgical resection to provide long-term survival in this subset of patients, only 15%-20% are found to be resectable. The introduction of new neoadjuvant chemotherapeutic agents and the expanding criteria of resection have enhanced the overall 5-year survival from 30% to 60% in the past decade. The use of technical innovations such as staged resection; portal vein embolization, and repeat resection have allowed higher resection rates in patients with bilobar disease. Extrahepatic primary and liver-exclusive recurrent disease no longer represent an absolute contraindication to resection. The role of regional therapy using hepatic arterial infusion is being redefined for liver-exclusive unresectable disease. Adjuvant chemotherapy in combination with regional therapies is being looked at from fresh perspectives. Ablative approaches have gained a firm role both as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Overall, the management of hepatic metastasis from colorectal cancers requires a multimodal approach.

Treatment of the elderly colorectal cancer patient: SIOG expert recommendations

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Sinusoidal obstructive syndrome diagnosed with superparamagnetic iron oxide-enhanced magnetic resonance imaging in patients with chemotherapy-treated colorectal liver metastases

PURPOSE

To assess the predictive value of superparamagnetic iron oxide (SPIO) -enhanced T2-weighted gradient echo (GRE) imaging to determine the presence and severity of sinusoidal obstructive syndrome (SOS).

PATIENTS AND METHODS

Sixty hepatic resection patients with colorectal metastases treated with chemotherapy underwent unenhanced magnetic resonance imaging (MRI) followed by T2-weighted GRE sequences obtained after SPIO. The images were reviewed in consensus by two experienced observers who determined the presence and severity of linear and reticular hyperintensities, indicating SOS-type liver injury, using a 4-point ordinal scale. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% CIs for the detection of SOS were calculated.

RESULTS

Twenty-four of 60 patients had moderate to severe SOS on MRI. MRI achieved a sensitivity of 87% (95% CI, 66% to 97%), specificity of 89% (95% CI, 75% to 97%), PPV of 83% (95% CI, 63% to 95%), and NPV of 92% (95% CI, 77% to 98%). SOS was never found at surgery or histology in patients whose background liver parenchyma was normal on SPIO-enhanced MRI.

CONCLUSION

SOS is present in a significant proportion of patients with treated colorectal metastases and is effectively detected on SPIO-enhanced T2-weighted GRE images.

Urgent need for a new staging system in advanced colorectal cancer

Despite recent advances in the medical treatment of metastatic colorectal cancer (mCRC), which include irinotecan- and oxaliplatin-based first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the increasing use of targeted monoclonal antibodies, 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with CRC liver metastases, liver resection remains the only chance of cure, with 5-year survival rates ranging from 25% to 40%. However, 80% to 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. The rapid expansion in the use of improved combination chemotherapy regimens plus or minus biologics, to render initially unresectable metastases resectable has increased the percentage of patients eligible for potentially curative surgery. However, the current staging criteria for CRC patients with metastatic disease do not reflect these recent changes or the fact that there is also a large variation in the survival of patients with stage IV CRC. For example the survival for a patient with a solitary, resectable liver metastasis is better than that for a patient with stage III disease. A new staging system is therefore needed that acknowledges both the improvements that have been made in surgical techniques for resectable metastases and the impact of modern chemotherapy on rendering initially unresectable CRC liver metastases resectable, while at the same time distinguishing between patients with a chance of cure at presentation and those for whom only palliative treatment is possible.

Staging of advanced colorectal cancer

The management of advanced colorectal cancer has changed dramatically during the last decade. By redefining resectability, and with the use of modern chemotherapy, nearly 10% of unresectable patients are now alive 5 years after diagnosis, and, overall, 20% are alive at 5 years when the combined results of surgery and chemotherapy are considered. These achievements are not reflected in the current staging, which categorizes all disease spread beyond the lymph node basin of the primary tumor as unstratified stage 4. This article discusses the merits of a number of proposals for a new, meaningful staging system for advanced colorectal cancer.

Neoadjuvant treatment before resection of liver metastases

Surgical resection remains the only treatment of colorectal liver metastases that can ensure long-term survival and cure in some patient. However, only a minority of patients with liver metastases are amenable to surgery. Other patients can benefit from modern chemotherapy regimens, which achieve high response rates but are rarely sufficient for cure. In patients with unresectable metastases, neoadjuvant chemotherapy may increase the number of candidates for potentially curative resection, hence affording these patients the possibility of prolonged survival. For patients with resectable metastases, it is likely that the benefit of neoadjuvant chemotherapy before surgery will be demonstrated in the near future but is not yet validated. The integration of novel targeted agents will probably transform the therapeutic strategy for colorectal liver metastases.

Improved Long-Term Outcome of Surgery for Advanced Colorectal Liver Metastases: Reasons and Implications for Management on the Basis of a Severity Score

BACKGROUND

The outcome of liver resection for colorectal liver metastases (CRLM) appears to be improving despite the fact that surgery is offered to patients with more-severe disease. To quantify this assumption and to understand its causes we analyzed a series of patients on the basis of a standardized severity score and changes in management occurring over the years.

METHODS

Patients' characteristics, operative data, chemotherapies and follow-up were recorded. CRLM severity was quantified according to Fong's clinical risk score (CRS), modified to take into account the presence of bilateral liver metastases. Three periods were analyzed, in which different indications, surgical strategies and uses of chemotherapy were applied: 1984-1992, 1993-1998, and 1999-2005.

RESULTS

Between January 1984 and December 2005, 210 liver resections were performed in 180 patients (1984-1992, 43 patients; 1993-1998, 42 patients; 1999-2005, 95 patients). CRLM severity increased throughout the time periods, as did the use of neoadjuvant chemotherapies, repeat resections, and multistep procedures. While the disease-free survival did not improve over time, the 1-, 3- and 5-year overall survival rate increased from 85%, 30%, and 23% in the first period, to 88%, 60%, and 34% in the second period, and to 94%, 69%, and 46% in the third period.

CONCLUSIONS

Analysis according to the CRS showed that despite the fact that patients had more severe disease, the overall survival improved over the years, mainly thanks to more aggressive treatment of recurrent disease. Management of advanced CRLM should, from the start, take into account the likelihood of secondary procedures.

Tritherapy with fluorouracil/leucovorin, irinotecan and oxaliplatin (FOLFIRINOX): a phase II study in colorectal cancer patients with non-resectable liver metastases

PURPOSE

To assess the rate of R(0) resection of liver metastases achieved after chemotherapy with FOLFIRINOX.

PATIENTS AND METHODS

Patients with histologically proven primary colorectal cancer and bidimensionally measurable liver metastasis, not fully resectable based on technical inability to achieve R(0) resection, but potentially resectable after tumor reduction, were given FOLFIRINOX: oxaliplatin 85 mg/m(2), irinotecan 180 mg/m(2), leucovorin 400 mg/m(2), bolus fluorouracil 400 mg/m(2) and fluorouracil 46-h continuous IV infusion 2,400 mg/m(2), every 2 weeks for a maximum of 12 cycles.

RESULTS

Thirty-four patients were enrolled. Response rate before surgery was 70.6% (95%CI: 52.5-84.9). Twenty-eight patients (82.4%) underwent hepatic resection and nine achieved R(0) resection [26.5% (95% CI: 12.9-44.4%)]. The rate of clinical complete remission after surgery was 79.4%. Two-year overall survival was 83%. The most frequent grade 3 or 4 toxicities were neutropenia (64.8%), diarrhea (29.4%), fatigue (23.5%), abdominal cramps (14.7%), neuropathy and nausea (11.8% each), and AST/ALT elevation (14.7/11.8%). Only one patient experienced febrile neutropenia, four patients withdrew due to toxicity and no toxic death was observed.

CONCLUSION

FOLFIRINOX, with an acceptable toxicity profile, shows a high response rate in liver metastases from colorectal cancer. The rate of hepatic resection in patients initially not resectable, is attractive and warrants further assessment of this regimen in randomized studies compared to standard regimens.

Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group

Liver resection offers the only chance of cure for patients with advanced colorectal cancer (CRC). Typically, the 5-year survival rates following liver resection range from 25% to 40%. Unfortunately, approximately 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. However, the rapid expansion in the use of improved combination therapy regimens has increased the percentage of patients eligible for potentially curative surgery. Despite this, the selection criteria for patients potentially suitable for resection are not well documented and patient management by multidisciplinary teams, although essential, is still evolving. The goal of the European Colorectal Metastases Treatment Group is to establish pan-European guidelines for the treatment of patients with CRC liver metastases that can be adopted more widely by established treatment centres and to develop more accurate staging systems and evaluation criteria.

Phase II trial of oxaliplatin/irinotecan/5-fluorouracil/leucovorin for metastatic colorectal cancer

BACKGROUND

Individually, oxaliplatin and irinotecan have substantial activity in metastatic colorectal cancer (CRC) in combination with 5-fluorouracil/leucovorin. A combination regimen using all 4 agents could potentially increase response rates in CRC.

PATIENTS AND METHODS

A multicenter phase II trial of oxaliplatin 85 mg/m(2) on day 1, irinotecan 175 mg/m(2) on day 1, 5-fluorouracil 240 mg/m(2) by 90-minute infusion on days 2-5, and leucovorin 20 mg/m(2) on days 2-5 of a 21-day cycle was undertaken in patients with CRC through the North Central Cancer Treatment Group. The primary endpoint was response rate, with secondary endpoints of toxicity and quality of life.

RESULTS

Of 14 patients enrolled (13 evaluable), 3 partial responses were seen (23%; 95% confidence interval, 5%-54%), and 9 patients had stable disease (69%). Toxicity was significant, with 1 (8%) grade 5 event (diarrhea and dehydration) and 3 (23%) grade 4 events (leukopenia and diarrhea). The study was closed to further enrollment because of toxicity.

CONCLUSION

The 4-drug regimen was extremely toxic. Future studies incorporating irinotecan- and oxaliplatin-based therapy should consider alternative schedules.

Clinical Risk Score predicts yield of staging laparoscopy in patients with colorectal liver metastases

Background

Resection offers the only realistic chance of cure for hepatic colorectal metastases. The aim of this study was to examine the potential of laparoscopy and laparoscopic intraoperative ultrasonography (IOUS) for detecting incurable disease, and to determine whether the Clinical Risk Score (CRS) is useful in selecting patients for laparoscopy before hepatic resection.

Methods

All patients with potentially curable colorectal liver metastases who underwent staging laparoscopy and laparoscopic IOUS before planned hepatic resection between January 2000 and December 2004 were included. A preoperative CRS was determined for each patient and correlated with curability.

Results

Two hundred patients were identified, of whom 133 were found to have resectable disease at laparotomy. Laparoscopy detected 39 (58 per cent) of 67 patients with incurable disease, changing the management in 19·5 per cent of the 200 patients. The CRS correlated with the likelihood of detecting incurable disease; incurable disease was present in two of 31 patients with a CRS of 0–1, 35 of 129 with a score of 2–3 and 30 of 40 with a score of 4–5. The potential benefit of laparoscopy increased progressively with increasing CRS, changing management in none of 31 patients with a CRS of 0–1, 18 of 129 with a score of 2–3 and 21 of 40 with a score of 4–5.

Conclusion

Staging laparoscopy and IOUS detected more than half of the incurable disease in this cohort. Laparoscopy had a low diagnostic yield in patients with a CRS of 0–1 and its routine use in this group of patients is therefore not recommended.

Multiple-target Chemotherapy (Lv-modulated 5-FU Bolus and Continuous Infusion, Oxaliplatin, CPT-11) in Advanced 5-Fu-refractory Colorectal Cancer: Mtd Definition and Efficacy Evaluation. A Phase I-II Study

Aims and Background

To identify the maximum tolerated doses and to define the activity of a regimen incorporating leucovorin (LV)-modulated 5-fluorouracil (5-FU) bolus and continuous infusion, oxaliplatin (I-OHP) and irinotecan (CPT-11) in patients with advanced, 5-FU-refractory colorectal cancer (CRC).

Patients and Methods

Starting doses: LV 100 mg/m2 as a 2-hour infusion followed by 5-FU 300 mg/m2 bolus administration followed by 5-FU 500 mg/m2 as a 22-hour infusion on days 1 and 2; I-OHP 65 mg/m2 as a 2-hour infusion concomitantly with LV on day 1; CPT-11 90 mg/m2 concomitantly with LV on day 2. Planned cycle interval: 2 weeks.

Results

Two hundred twenty-six cycles were administered to 27 patients. Recommended doses were 5-FU bolus 300 mg/m2, 5-FU protracted infusion 500 mg/m2, l-OHP 75 mg/m2, and CPT-11 150 mg/m2. Among 25 patients evaluable for response we observed 13 disease stabilizations (52%; 95% CI: 33-71%), 6 instances of disease progression and 6 responses (24%; 95% CI: 7-41%). Median time to progression and overall survival were 24 and 60 weeks, respectively. A cycle delay >3 days was observed in 134/199 cycles (67%).

Conclusions

This study confirms the feasibility of triplet chemotherapy in patients with advanced 5-FU-refractory CRC.

Metastatic colorectal cancer

Metastatic colorectal cancer remains a public-health issue on a global scale. With development of a new generation of cytotoxic agents, survival has improved for patients with metastatic disease. How to maximize the benefit of chemotherapy with acceptable toxicity remains incompletely answered. Hepatic resection can provide a significant hope for long term survival, and a subset of patients might benefit from perioperative approaches. More recently, specific molecular processes have been targeted for therapeutic interventions, and encouraging results have been achieved using inhibitors of the Epidermal Growth Factor Receptor and the Vascular Endothelial Growth Factor.

Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary

BACKGROUND

In many patients with advanced synchronous liver metastases from colorectal tumours, the metastases progress during treatment of the primary, precluding curative treatment. The authors have investigated a management strategy that involves high-impact chemotherapy first, resection of liver metastases second and finally removal of the primary tumour in patients with adverse prognostic factors.

METHODS

Twenty consecutive patients with non-obstructive colonic (nine patients) or rectal (11 patients) cancer and advanced synchronous liver metastases were treated according to this strategy. Median age was 56 years. Patients received between two and six cycles of 5-fluorouracil, oxaliplatin and irinotecan-based chemotherapy. Data were collected prospectively.

RESULTS

Overall survival rates at 1, 2, 3 and 4 years after the start of treatment were 85, 79, 71 and 56 per cent respectively, with a median survival of 46 months. Sixteen of the 20 patients had complete removal of liver metastases and colorectal tumours (resectability rate 80 per cent).

CONCLUSION

This new strategy produced resectability and survival rates better than those expected from the published data on patients with disease of similar severity. It allows initial control and downstaging 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.

Neoadjuvant treatment of unresectable liver metastases from colorectal cancer

There has been increasing interest in the use of neoadjuvant treatment for downstaging and downsizing disease in patients with initially unresectable liver metastases from colorectal cancer with a view to potentially curative surgery. This has been increasingly feasible with the more active treatment combinations presently available based on oxaliplatin or irinotecan. This article reviews the evidence supporting the use of this treatment strategy and discusses the implications of advances in treatment in other metastatic disease settings for these patients and the issues of patient selection and prognostic factors.

Irinotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer

Out of every 17-18 individuals in the US, one develops colorectal cancer (CRC) in their lifetime. Of individuals diagnosed with CRC, > 50% present or develop metastatic disease, which, if untreated, is associated with 6-9 months median survival. Although surgical resection is the primary treatment modality for CRC, chemotherapy is the mainstay of treatment for metastatic or unresectable disease. For nearly three decades, 5-fluorouracil (5-FU) has been the chemotherapy of choice for treatment of CRC. However, the response rates to single 5-FU therapy have been suboptimal with an objective tumour response of 10-20%. Attempts have been made to improve the efficacy of 5-FU by either schedule alteration (protracted infusion versus intravenous push) or biochemical modulation with leucovorin (LV). Continuous infusion induced more tumour regression and prolonged the time-to-disease progression with some significant impact on survival (11.3 versus 12.1 months; p < 0.04). 5-FU/LV resulted in a significant increase in overall response rates and in the prolongation of disease-free survival in the adjuvant setting, although severe toxicities represent a major clinical problem. The last 10 years have seen the addition of several new agents such as irinotecan, oxaliplatin, raltitrexed, bevacizumab and cetuximab. The prognosis has significantly improved with the addition of these agents, with median survivals now > 20 months. This review paper focuses on irinotecan, oxaliplatin and raltitrexed when used alone and in combination.