Time to halt perioperative chemotherapy for resectable colorectal liver metastasis?

Evaluating combined bevacizumab and XELOX in advanced colorectal cancer: Serum markers carcinoembryonic antigen, carbohydrate antigen 125, carbohydrate antigen 199 analysis

BACKGROUND

Colorectal cancer ranks third and second among common and fatal cancers. The treatment of metastatic colorectal cancer (mCRC) is generally based on XELOX in clinical practice, which includes capecitabine (CAP) and oxaliplatin. Serum tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 125 and CA199 are prognostic factors for various tumors.

AIM

To investigate evaluating combined bevacizumab (BEV) and XELOX in advanced colorectal cancer: Serum markers CEA, CA125, CA199 analysis.

METHODS

In this retrospective study, a total of 94 elderly patients diagnosed with mCRC were recruited and subsequently categorized into two groups based on the distinct treatment modalities they received. The control group was treated with XELOX plus CAP (n = 47), while the observation group was treated with XELOX plus CAP and BEV (n = 47). Several indexes were assessed in both groups, including disease control rate (DCR), incidence of adverse effects, serum marker levels (CEA, CA125, and CA19) and progression-free survival (PFS).

RESULTS

After 9 wk of treatment, the serum levels of CEA, CA199 and CA125 in the observation group were significantly lower than those in the control group (P < 0.05). Moreover, the PFS of the observation group (9.12 ± 0.90 mo) was significantly longer than that of the control group (6.49 ± 0.64 mo). Meanwhile, there was no statistically significant difference in the incidence of adverse reactions and DCR between the two groups during maintenance therapy (P > 0.05).

CONCLUSION

On the basis of XELOX treatment, the combination of BEV and CAP can reduce serum tumor marker levels and prolong PFS in patients with mCRC.

Posthepatectomy but not prehepatectomy chemotherapy was associated with a longer time to recurrence in patients with resectable colorectal liver metastases: Inverse probability of treatment weighting analysis

BACKGROUND

Patients with resectable colorectal liver metastases (CLM) are treated with surgery alone, surgery and posthepatectomy chemotherapy, or prehepatectomy chemotherapy and surgery. The optimal approach in terms of survival is unclear. We compared survival in the three treatment groups using inverse probability of treatment weighting (IPTW) analysis.

METHODS

Data from patients undergoing initial CLM resection in 2005-2018 were obtained from a prospectively maintained database. Our group treated resectable CLM with surgery alone but gradually adopted post- and prehepatectomy chemotherapy for patients with CLM number ≥5 after 2015. IPTW analysis was employed to adjust the characteristics of the three groups.

RESULTS

Of the 439 patients meeting the inclusion criteria, 175 underwent surgery alone, 135 underwent surgery and posthepatectomy chemotherapy, and 129 underwent prehepatectomy chemotherapy and surgery. After the IPTW adjustment, the demographic and clinicopathological characteristics were well balanced. The IPTW analysis revealed that the recurrence-free survival was better in patients undergoing surgery and posthepatectomy chemotherapy than in patients undergoing surgery alone (median recurrence-free survival, 1.3 years vs 0.7 years; P = .018). Overall survival was not significantly different between the three treatment approaches.

CONCLUSION

Posthepatectomy but not prehepatectomy chemotherapy prolongs the time to recurrence after curative-intent resection of CLM.

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.

Real-time administration of indocyanine green in combination with computer vision and artificial intelligence for the identification and delineation of colorectal liver metastases

Introduction

Fluorescence guided surgery for the identification of colorectal liver metastases (CRLM) can be better with low specificity and antecedent dosing impracticalities limiting indocyanine green (ICG) usefulness currently. We investigated the application of artificial intelligence methods (AIM) to demonstrate and characterise CLRMs based on dynamic signalling immediately following intraoperative ICG administration.

Methods

Twenty-five patients with liver surface lesions (24 CRLM and 1 benign cyst) undergoing open/laparoscopic/robotic procedures were studied. ICG (0.05 mg/kg) was administered with near-infrared recording of fluorescence perfusion. User-selected region-of-interest (ROI) perfusion profiles were generated, milestones relating to ICG inflow/outflow extracted and used to train a machine learning (ML) classifier. 2D heatmaps were constructed in a subset using AIM to depict whole screen imaging based on dynamic tissue-ICG interaction. Fluorescence appearances were also assessed microscopically (using H&E and fresh-frozen preparations) to provide tissue-level explainability of such methods.

Results

The ML algorithm correctly classified 97.2 % of CRLM ROIs (n = 132) and all benign lesion ROIs (n = 6) within 90-s of ICG administration following initial mathematical curve analysis identifying ICG inflow/outflow differentials between healthy liver and CRLMs. Time-fluorescence plots extracted for each pixel in 10 lesions enabled creation of 2D characterising heatmaps using flow parameters and through unsupervised ML. Microscopy confirmed statistically less CLRM fluorescence vs adjacent liver (mean ± std deviation signal/area 2.46 ± 9.56 vs 507.43 ± 160.82 respectively p < 0.001) with H&E diminishing ICG signal (n = 4).

Conclusion

ML accurately identifies CRLMs from surrounding liver tissue enabling representative 2D mapping of such lesions from their fluorescence perfusion patterns using AIM. This may assist in reducing positive margin rates at metastatectomy and in identifying unexpected/occult malignancies.

Parenchymsparende Operationen oder anatomische Resektionen bei Lebermetastasen des kolorektalen Karzinoms?

Darmkrebs ist eine der häufigsten Todesursachen in der westlichen Welt. Die Hälfte der Patienten entwickelt kolorektale Lebermetastasen (CRLM), dabei weisen weniger als 30% der Patienten zum Zeitpunkt der Diagnose eine chirurgisch resektable Metastasierung auf. Im Falle einer Resektabilität bietet die klassische anatomische (Major-)Hepatektomie eine hohe R0-Resektionsrate, allerdings bei gleichzeitig erhöhter Morbidität und Mortalität. In den letzten 2 Jahrzehnten wurden die potenziellen Vorteile der parenchymsparenden Hepatektomie (PSH) in Bezug auf die onkologischen Gesamtergebnisse, das Überleben und die Re-Resektion im Falle eines Rezidivs („Salvageability“) nachgewiesen. Der Beitrag fasst die aktuellen Erkenntnisse zur PSH als chirurgische Therapieoption zusammen und diskutiert den aktuellen „state of the art“ in verschiedenen Szenarien.