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Aquina CT, Brown ZJ, Beane JD, Ejaz A, Cloyd JM, Tsung A, Adam MO, Pawlik TM, Kim AC. Disparities in Care Access to Liver-Directed Therapy Among Medicare Beneficiaries with Colorectal Cancer Liver Metastasis. Ann Surg Oncol 2023; 30:335-344. [PMID: 36149611 PMCID: PMC9510323 DOI: 10.1245/s10434-022-12513-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver-directed therapies (LDT) are important components of the multidisciplinary care of patients with colorectal cancer liver metastases (CRCLM) that contribute to improved long-term outcomes. Factors associated with receipt of LDT are poorly understood. PATIENTS AND METHODS Patients > 65 years old diagnosed with CRCLM were identified within the Medicare Standard Analytic File (2013-2017). Patients with extrahepatic metastatic disease were excluded. Mixed-effects analyses were used to assess patient factors associated with the primary outcome of LDT, defined as hepatectomy, ablation, and/or hepatic artery infusion chemotherapy (HAIC), as well as the secondary outcome of hepatectomy. RESULTS Among 23,484 patients with isolated CRCLM, only 2004 (8.5%) received LDT, although resectability status could not be determined for the entire cohort. Among patients who received LDT, 61.7% underwent hepatectomy alone, 28.1% received ablation alone, 8.5% underwent hepatectomy and ablation, and 1.8% received HAIC either alone (0.8%) or in combination with hepatectomy and/or ablation (0.9%). Patient factors independently associated with lower odds of LDT included older age, female sex, Black race, greater comorbidity burden, higher social vulnerability index, primary rectal cancer, synchronous liver metastasis, and further distance from a high-volume liver surgery center (p < 0.05). Results were similar for receipt of hepatectomy. CONCLUSIONS Despite the well-accepted role of LDT for CRCLM, only a small proportion of Medicare beneficiaries with CRCLM receive LDT. Increasing access to specialized centers with expertise in LDT, particularly for Black patients, female patients, and those with higher levels of social vulnerability or long travel distances, may improve outcomes for patients with CRCLM.
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Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Surgical Health Outcomes Consortium (SHOC), Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, FL, USA.
| | - Zachary J Brown
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joal D Beane
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mohamed O Adam
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alex C Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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2
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Predictive Factors for Local Recurrence after Intraoperative Microwave Ablation for Colorectal Liver Metastases. Cancers (Basel) 2022; 15:cancers15010122. [PMID: 36612119 PMCID: PMC9817841 DOI: 10.3390/cancers15010122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
This study aimed to clarify local recurrence (LR) predictive factors following intraoperative microwave ablation (MWA) for colorectal liver metastases. The data from 195 patients with 1392 CRLM lesions, who were preoperatively diagnosed by gadolinium-enhanced MRI with diffusion-weighted imaging and dynamic CT and treated with intraoperative MWA (2450 MHz) with or without hepatectomy, from January 2005 to December 2019, were retrospectively reviewed and analyzed using logistic regression. In addition, the margins were measured on contrast-enhanced CT 6 weeks post-ablation. Overall, 1066 lesions were ablated. The LRs occurred in 44 lesions (4.1%) among 39 patients (20.0%). The multivariate analysis per patient showed that tumor size > 20 mm and ablation margin < 5 mm were significant predictors for LR. Furthermore, multivariate analysis per lesion revealed that segments 1, 7, and 8 and tumor size > 15 mm, ablation margin < 5 mm, tumor size > 20 mm, and proximity to the Glisson were significant LR predictors. Finally, the outcome of this study may help determine indications for MWA.
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3
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Zhu S, Li Z, Zheng D, Yu Y, Xiang J, Ma X, Xu D, Qiu J, Yang Z, Wang Z, Li J, Sun H, Chen W, Meng X, Lu Y, Ren Q. A cancer cell membrane coated, doxorubicin and microRNA co-encapsulated nanoplatform for colorectal cancer theranostics. Mol Ther Oncolytics 2022; 28:182-196. [PMID: 36820302 PMCID: PMC9937835 DOI: 10.1016/j.omto.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Endogenous microRNAs (miRNA) in tumors are currently under exhaustive investigation as potential therapeutic agents for cancer treatment. Nevertheless, RNase degradation, inefficient and untargeted delivery, limited biological effect, and currently unclear side effects remain unsettled issues that frustrate clinical application. To address this, a versatile targeted delivery system for multiple therapeutic and diagnostic agents should be adapted for miRNA. In this study, we developed membrane-coated PLGA-b-PEG DC-chol nanoparticles (m-PPDCNPs) co-encapsulating doxorubicin (Dox) and miRNA-190-Cy7. Such a system showed low biotoxicity, high loading efficiency, and superior targeting ability. Systematic delivery of m-PPDCNPs in mouse models showed exceptionally specific tumor accumulation. Sustained release of miR-190 inhibited tumor angiogenesis, tumor growth, and migration by regulating a large group of angiogenic effectors. Moreover, m-PPDCNPs also enhanced the sensitivity of Dox by suppressing TGF-β signal in colorectal cancer cell lines and mouse models. Together, our results demonstrate a stimulating and promising m-PPDCNPs nanoplatform for colorectal cancer theranostics.
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Affiliation(s)
- Sihao Zhu
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,Institute of Medical Technology, Peking University Health Science Center, Peking University, Beijing 100191, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen 5181071, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Ziyuan Li
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,Institute of Medical Technology, Peking University Health Science Center, Peking University, Beijing 100191, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen 5181071, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Dongye Zheng
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,Institute of Medical Technology, Peking University Health Science Center, Peking University, Beijing 100191, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen 5181071, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Yue Yu
- Beijing National Laboratory for Molecular Sciences (BNLMS), Key Laboratory of Bioorganic Chemistry and Molecular Engineering of Ministry of Education, College of Chemistry and Molecular Engineering, Peking University, Beijing 100871, China
| | - Jing Xiang
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,Institute of Medical Technology, Peking University Health Science Center, Peking University, Beijing 100191, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen 5181071, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Xiao Ma
- Research Group Signal Transduction, Department of Psychiatry, Ludwig Maximilian University of Munich, Nussbaumstr.7, 80336 Munich, Germany
| | - Dongqing Xu
- Department of Pediatric Hematology/Oncology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Jiajun Qiu
- Department of Otolaryngology Head and Neck Surgery, the Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Ziyu Yang
- College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen 518060, China
| | - Zhiyi Wang
- School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China
| | - Jun Li
- Laboratory Animal Center, Peking University, Beijing 100871, China
| | - Hongfang Sun
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China
| | - Weiqiang Chen
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou 730000, Gansu Province, China,Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Lanzhou 730000, Gansu Province, China
| | - Xiangxi Meng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Nuclear Medicine, Peking University Cancer Hospital & Institute, Beijing 100142, China,NMPA Key Laboratory for Research and Evaluation of Radiopharmaceuticals, Beijing 100142, China,Corresponding author.
| | - Yanye Lu
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,Institute of Medical Technology, Peking University Health Science Center, Peking University, Beijing 100191, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China,Corresponding author.
| | - Qiushi Ren
- Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing 100871, China,National Biomedical Imaging Center, Peking University, Beijing 100871, China,Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen 5181071, China,Institute of Biomedical Engineering, Peking University Shenzhen Graduate School, Shenzhen 518055, China,Corresponding author.
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4
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Hellingman T, Galjart B, Henneman JJ, Görgec B, Bijlstra OD, Meijerink MR, Vahrmeijer AL, Grünhagen DJ, van der Vliet HJ, Swijnenburg RJ, Verhoef C, Kazemier G. Limited Effect of Perioperative Systemic Therapy in Patients Selected for Repeat Local Treatment of Recurrent Colorectal Cancer Liver Metastases. ANNALS OF SURGERY OPEN 2022; 3:e164. [PMID: 37601612 PMCID: PMC10431462 DOI: 10.1097/as9.0000000000000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/12/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives The aim of this study was to determine the potential benefit of perioperative systemic therapy on overall and progression-free survival after repeat local treatment in patients suffering from recurrent colorectal cancer liver metastasis (CRLM). Background The optimal treatment strategy in patients with recurrent CRLM needs to be clarified, in particular for those suffering from early recurrence of CRLM. Methods In this multicenter observational cohort study, consecutive patients diagnosed with recurrent CRLM between 2009 and 2019 were retrospectively identified in 4 academic liver surgery centers. Disease-free interval after initial local treatment of CRLM was categorized into recurrence within 6, between 6 and 12, and after 12 months. Perioperative systemic therapy consisted of induction, (neo)adjuvant, or combined regimens. Overall and progression-free survival after repeat local treatment of CRLM were analyzed by multivariable Cox regression analyses, resulting in adjusted hazard ratios (aHRs). Results Out of 303 patients included for analysis, 90 patients received perioperative systemic therapy for recurrent CRLM. Favorable overall (aHR, 0.45; 95% confidence interval [CI], 0.26-0.75) and progression-free (aHR, 0.53; 95% CI, 0.35-0.78) survival were observed in patients with a disease-free interval of more than 12 months. No significant difference in overall and progression-free survival was observed in patients receiving perioperative systemic therapy at repeat local treatment of CRLM, stratified for disease-free interval, previous exposure to chemotherapy, and RAS mutation status. Conclusions No benefit of perioperative systemic therapy was observed in overall and progression-free survival after repeat local treatment of recurrent CRLM.
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Affiliation(s)
- Tessa Hellingman
- From the Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Boris Galjart
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Julia J. Henneman
- From the Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Burak Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Dirk J. Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hans J. van der Vliet
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Lava Therapeutics, Utrecht, The Netherlands
| | - Rutger-Jan Swijnenburg
- From the Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Geert Kazemier
- From the Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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5
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Vogl TJ, Dosch MP, Haas Y. MR elastography is a good response parameter for microwave ablation liver tumors. Eur J Radiol 2022; 152:110360. [PMID: 35597071 DOI: 10.1016/j.ejrad.2022.110360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the response of hepatic tissue to percutaneous microwave ablation (MWA) of liver tumors via MR elastography in a clinical setting using MRI and MR elastography. METHODS 51 Patients (28 m, 23f) underwent MWA of liver tumors (HCC: 20, metastasis: 31) and received MRI and MR elastography immediately before and 24 h after MWA. Retrospective analysis included pre- and post-ablative tumor extent, T1/T2 mapping and stiffness values as well as the duration and energy dose of the MWA session. RESULTS Total liver stiffness increased by 4.3% from 3.31 kPa to 3.45 kPa (p = 0.036). Total liver stiffness post-MWA significantly correlated with the duration of the MWA session (r = 0.369, p = 0.008). The higher the baseline tumor stiffness was, the more energy had to be applied in MWA (r = 0.391, p < 0.001) and the longer the duration of the session (r = 0.391, p = 0.007). Healthy parenchyma stiffness increased by 3.5% from 3.55 kPa to 3.68 kPa (p = 0.142) and was strongly influenced by the cumulative energy (r = 0.436, p < 0.001), the duration (r = 0.458, p < 0.001) and the energy intensity (r = 0.458, p < 0.001) of MWA. 43 patients had a technically successful ablation result (margin ≥ 5 mm). Those with successful ablation had increased ablation margin stiffness (5.3 kPa vs. 4.6 kPa, p = 0.26) and had received higher ablation intensity than those with unsuccessful ablation (5.73 kJ/min vs. 5.03 kJ/min, p = 0.002). CONCLUSION Additional MRE may be used before and after MWA to assess treatment response and collateral tissue damage after MWA. Baseline tumor stiffness helps finding the appropriate MWA parameters.
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Affiliation(s)
- Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Max P Dosch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Yannick Haas
- Department of Trauma Surgery, Klinikum Rechts der Isar, Munich, Germany
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6
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Aquina CT, Eskander MF, Pawlik TM. Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature. Front Oncol 2022; 12:832405. [PMID: 35174097 PMCID: PMC8841620 DOI: 10.3389/fonc.2022.832405] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/11/2022] [Indexed: 01/27/2023] Open
Abstract
Recurrence following curative-intent hepatectomy for colorectal cancer liver metastasis, hepatocellular carcinoma, or cholangiocarcinoma is unfortunately common with a reported incidence as high as 75%. Various treatment modalities can improve survival following disease recurrence. A review of the literature was performed using PubMed. In addition to systemic therapy, liver-directed treatment options for recurrent liver disease include repeat hepatectomy, salvage liver transplantation, radiofrequency or microwave ablation, intra-arterial therapy, and stereotactic body radiation therapy. Repeat resection can be consider for patients with limited recurrent disease that meets resection criteria, as this therapeutic approach can provide a survival benefit and is potentially curative in a subset of patients. Salvage liver transplantation for recurrent hepatocellular carcinoma is another option, which has been associated with a 5-year survival of 50%. Salvage transplantation may be an option in particular for patients who are not candidates for resection due to underlying liver dysfunction but meet criteria for transplantation. Ablation is another modality to treat patients who recur with smaller tumors and are not surgical candidates due to comorbidity, liver dysfunction, or tumor location. For patients with inoperable disease, transarterial chemoembolization, or radioembolization with Yttrium-90 are liver-directed intra-arterial therapy modalities with relatively low risks that can be utilized. Stereotactic body radiation therapy is another palliative treatment option that can provide a response and local tumor control for smaller tumors.
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Affiliation(s)
- Christopher T. Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, FL, United States
| | - Mariam F. Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Division of Surgical Oncology, Department of Surgery, Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- *Correspondence: Timothy M. Pawlik,
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7
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Dixon M, Cruz J, Sarwani N, Gusani N. The Future Liver Remnant : Definition, Evaluation, and Management. Am Surg 2020; 87:276-286. [PMID: 32931301 DOI: 10.1177/0003134820951451] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
When considering patients for a major hepatectomy, one must carefully consider the volume of liver to be left behind and if additional procedures are necessary to augment its volume. This review considers the optimal volume of the future liver remnant (FLR) and analyzes the techniques of augmenting this volume, the various growth parameters to assess adequate growth of the FLR, as well as further management when there has been inadequate growth of the FLR.
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Affiliation(s)
- Matthew Dixon
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Jeffrey Cruz
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Nabeel Sarwani
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Niraj Gusani
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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8
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Filip S, Vymetalkova V, Petera J, Vodickova L, Kubecek O, John S, Cecka F, Krupova M, Manethova M, Cervena K, Vodicka P. Distant Metastasis in Colorectal Cancer Patients-Do We Have New Predicting Clinicopathological and Molecular Biomarkers? A Comprehensive Review. Int J Mol Sci 2020; 21:E5255. [PMID: 32722130 PMCID: PMC7432613 DOI: 10.3390/ijms21155255] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) remains a serious health problem worldwide. Approximately half of patients will develop distant metastasis after CRC resection, usually with very poor prognosis afterwards. Because patient performance after distant metastasis surgery remains very heterogeneous, ranging from death within 2 years to a long-term cure, there is a clinical need for a precise risk stratification of patients to aid pre- and post-operative decisions. Furthermore, around 20% of identified CRC cases are at IV stage disease, known as a metastatic CRC (mCRC). In this review, we overview possible molecular and clinicopathological biomarkers that may provide prognostic and predictive information for patients with distant metastasis. These may comprise sidedness of the tumor, molecular profile and epigenetic characteristics of the primary tumor and arising metastatic CRC, and early markers reflecting cancer cell resistance in mCRC and biomarkers identified from transcriptome. This review discusses current stage in employment of these biomarkers in clinical practice as well as summarizes current experience in identifying predictive biomarkers in mCRC treatment.
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Affiliation(s)
- Stanislav Filip
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove, Šimkova 870, 50001 Hradec Králové, Czech Republic; (J.P.); (O.K.); (S.J.)
| | - Veronika Vymetalkova
- Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 14220 Prague, Czech Republic; (V.V.); (L.V.); (K.C.)
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655, 32300 Pilsen, Czech Republic
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University, Albertov 4, 12800 Prague, Czech Republic
| | - Jiri Petera
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove, Šimkova 870, 50001 Hradec Králové, Czech Republic; (J.P.); (O.K.); (S.J.)
| | - Ludmila Vodickova
- Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 14220 Prague, Czech Republic; (V.V.); (L.V.); (K.C.)
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655, 32300 Pilsen, Czech Republic
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University, Albertov 4, 12800 Prague, Czech Republic
| | - Ondrej Kubecek
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove, Šimkova 870, 50001 Hradec Králové, Czech Republic; (J.P.); (O.K.); (S.J.)
| | - Stanislav John
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove, Šimkova 870, 50001 Hradec Králové, Czech Republic; (J.P.); (O.K.); (S.J.)
| | - Filip Cecka
- Department of Surgery, University Hospital in Hradec Kralove, Sokolská 581, 50005 Hradec Králové, Czech Republic;
| | - Marketa Krupova
- The Fingerland Department of Pathology, University Hospital in Hradec Kralove, Sokolská 581, 50005 Hradec Králové, Czech Republic; (M.K.); (M.M.)
| | - Monika Manethova
- The Fingerland Department of Pathology, University Hospital in Hradec Kralove, Sokolská 581, 50005 Hradec Králové, Czech Republic; (M.K.); (M.M.)
| | - Klara Cervena
- Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 14220 Prague, Czech Republic; (V.V.); (L.V.); (K.C.)
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University, Albertov 4, 12800 Prague, Czech Republic
| | - Pavel Vodicka
- Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 14220 Prague, Czech Republic; (V.V.); (L.V.); (K.C.)
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655, 32300 Pilsen, Czech Republic
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University, Albertov 4, 12800 Prague, Czech Republic
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9
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Kim WJ, Lim TW, Kang SH, Park PJ, Choi SB, Lee SI, Min BW, Kim WB. Development and validation of novel scoring system for the prediction of disease recurrence following resection of colorectal liver metastasis. Asian J Surg 2019; 43:438-446. [PMID: 31439461 DOI: 10.1016/j.asjsur.2019.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/27/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The aim of this study was to identify predictive factors for the recurrence of colorectal cancer liver metastasis (CRLM) and then to develop a corresponding novel scoring system that should improve the sensitivity of predicting recurrence in patients with CRLM. METHODS A total of 295 consecutive CRLM patients were enrolled in our institution between January 2002 and December 2015. Multivariate analyses were performed to identify the variables associated with disease recurrence and established the novel scoring system based on it. RESULTS The scoring system considered seven variables: synchronosity, CA19-9 level, number of liver metastasis, largest size of liver metastasis, resection margin of hepatic lesion, neutrophil-to-lymphocyte ratio and prognostic nutritional index. The area under the curve of ROC was 0.824 (95% confidence interval 0.767-0.882); the sensitivity of our scoring system was 87.9%, specificity was 66.7%, positive predictive value was 20.6%, and negative predictive value was 20.9%. CONCLUSION For patients with CRLM undergoing curative hepatic resection, our novel scoring system would improve the sensitivity for prediction of disease recurrence in Case of CRLM patients.
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Affiliation(s)
- Wan-Joon Kim
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Tae-Wan Lim
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sang-Hee Kang
- Division of Colorectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Pyoung-Jae Park
- Division of Transplantation Vascular Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sae-Byeol Choi
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sun-Il Lee
- Division of Colorectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Byung-Wook Min
- Division of Colorectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Wan-Bae Kim
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.
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10
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Ou S, Xu R, Li K, Chen Y, Kong Y, Liu H, Li J, Ouyang Y, Yu X. Radiofrequency ablation with systemic chemotherapy in the treatment of colorectal cancer liver metastasis: a 10-year single-center study. Cancer Manag Res 2018; 10:5227-5237. [PMID: 30464620 PMCID: PMC6217171 DOI: 10.2147/cmar.s170160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To retrospectively evaluate the long-term efficacy and safety of radiofrequency ablation (RFA) with systemic chemotherapy (CT) in treatment of solitary liver metastasis after surgery for colorectal cancer (CRC). Methods This single-center study was conducted at the Hunan Provincial Cancer Hospital from June 2006 to December 2015 with median follow-up time of 26 months. Percutaneous ultrasound-guided RFA was carried out on eligible patients with solitary liver metastasis after surgery for CRC. After a week, ablation status was confirmed by MRI. Post MRI, all patients received systemic CT with or without molecular-targeted therapy. Survival rate was evaluated and survival curve was constructed with Kaplan-Meier analysis. Log-rank test and Cox regression model were used for univariate and multivariate analysis, respectively, to determine the independent prognostic factors for survival rate. Results A total of 109 eligible patients (mean age, 53.84±11.71; mean tumor mass diameter, 3.4+2.01 cm) were enrolled in this 10-year study. After RFA, 95 patients achieved complete ablation, and 14 patients achieved partial ablation, with median ablation time of 26 minutes (range: 12-120 minutes). The median survival time required for achieving complete and partial ablation was 56.0 and 19.0 months, respectively (P<.01). After RFA and adjuvant systemic CT, the 1-, 3-, and 5-year survival rates were 92.3%, 50.7%, and 41.6%, respectively, with the median (mean) survival time of 39.0 (56.5) months. Age was the only significant independent prognostic factor with better survival rate observed in patients aged ≥50 years than those aged <50 years (P<0.05). The incidence of complications was minimal (1.8%) with only two cases: one biliary fistula and one liver hemorrhage. Conclusion RFA combination with systemic CT was safe; it showed long-term efficacy in patients with solitary liver metastasis after surgery for CRC and can be a preferred treatment.
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Affiliation(s)
- Shuangyan Ou
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Ruocai Xu
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Ke Li
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Yong Chen
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Yi Kong
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Hanchun Liu
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Jianliang Li
- Department of Hepatobiliary and Pancreatic Medicine, Hunan Cancer Hospital, Changsha City, Hunan Province, China,
| | - Yongzhong Ouyang
- Department of Gastroduodenal Surgery, Hunan Provincial Cancer Hospital, Changsha City, Hunan Province, China
| | - Xiaoping Yu
- Department of Radiology, Hunan Cancer Hospital, Changsha City, Hunan Province, China
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Griggs RKL, Pathak S, Poston G. An Overview of the Current Management of Bilobar Colorectal Liver Metastases. Indian J Surg Oncol 2017; 8:600-606. [PMID: 29203994 DOI: 10.1007/s13193-017-0686-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 08/01/2017] [Indexed: 10/19/2022] Open
Abstract
Bilobar colorectal liver metastases (BCRLM) present a challenging scenario for liver surgeons globally. The following article aims to provide an overview of the different strategies which may be utilised in order to successfully manage advanced BCRLM.
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Affiliation(s)
- Rebecca K L Griggs
- Department of Hepatobiliary Surgery, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW UK
| | - Samir Pathak
- Department of Hepatobiliary Surgery, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW UK
| | - Graeme Poston
- Department of Hepatobiliary Surgery, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL UK
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12
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Wang Y, Zheng J, Chen H, Hu C, Sun B, Wang H, Shi Q, Long J, Zhang H, Li W. A prognostic nomogram for colorectal cancer liver metastases after percutaneous thermal ablation. Int J Hyperthermia 2017; 34:853-862. [PMID: 28826279 DOI: 10.1080/02656736.2017.1368095] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To assess the efficacy of percutaneous thermal ablation in treating colorectal cancer liver metastases (CRCLM), and to propose a prognostic nomogram for overall survival (OS). MATERIALS AND METHODS Seventy-one patients with CRCLM undergoing thermal ablation at our institute from 2009 to 2013 were identified and analysed to formulate a prognostic nomogram. The concordance index (C-index) and calibration curve were calculated to evaluate the predictive accuracy of the nomogram. The nomogram was compared with two current prognostic nomograms for patients with CRCLM who had undergone hepatectomy (Kattan) and selective internal radiation therapy (Fendler). Predictive validity was assessed in the validation cohort of 25 patients who had undergone thermal ablation from 2014 to 2016. RESULTS The median OS in the primary cohort was 26.4 months, whereas the 1-, 3- and 5-year OS rates were 72.2%, 37.2% and 17%, respectively. The median progression-free survival was 4.2 months. After univariate and multivariate analysis, a prognostic nomogram was formulated based on four predictors, including the number of tumours, maximum diameter of the tumour, CA19-9 level and ablation margin. The C-index of the nomogram was 0.815. Based on the patients of this study, the C-index was significantly higher than that of the Fendler nomogram (C-index, 0.698) and Kattan nomogram (C-index, 0.514, p < 0.001). Predictive accuracy of the proposed nomogram was also satisfactory in the validation cohort, with a C-index of 0.884. CONCLUSIONS Thermal ablation was an effective therapy for CRCLM. Moreover, the nomogram was effective and simple for CRCLM patients undergoing thermal ablation.
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Affiliation(s)
- Yang Wang
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Jiasheng Zheng
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Hui Chen
- b School of Biomedical Engineering , Capital Medical University , Beijing , P.R. China
| | - Caixia Hu
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Bin Sun
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Haiyan Wang
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Qinsheng Shi
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Jiang Long
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Honghai Zhang
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
| | - Wei Li
- a Center of Interventional Oncology and Liver Diseases , Beijing You'an Hospital, Capital Medical University , Beijing , P.R. China
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13
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Al Bandar MH, Kim NK. Current status and future perspectives on treatment of liver metastasis in colorectal cancer (Review). Oncol Rep 2017; 37:2553-2564. [PMID: 28350137 DOI: 10.3892/or.2017.5531] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/13/2017] [Indexed: 12/29/2022] Open
Abstract
Liver metastasis is the most common site of colorectal cancer (CRC) metastasis. Approximately half of all colorectal cancer patients will develop liver metastases. Although radical surgery is the standard treatment modality, only 10-20% of patients are deemed eligible for resection. Despite advances in survival with chemotherapy, surgical resection is still considered the only curative option for patients with liver metastases. Much effort has been expended to address patients with metastatic liver disease. The majority of evidence stated a significant survival benefit with surgical resection to reach an overall 5-year survival rate of 35-55% after hepatic resection. However, still majority of patients will experience disease recurrence even after a successful resection. In this review, we describe current status and controversies related to treatment options for CRC liver metastases and its potential for enhancing oncologic outcomes and improving quality of life.
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Affiliation(s)
- Mahdi Hussain Al Bandar
- Department of Surgery, Yonsei University, College of Medicine, Seoul 120-752, Republic of Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University, College of Medicine, Seoul 120-752, Republic of Korea
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14
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[Surgery of colorectal lung metastases : Results of a survey in Germany]. Chirurg 2016; 88:512-517. [PMID: 27928604 DOI: 10.1007/s00104-016-0334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no evidence from randomized trials on the prognostic significance of pulmonary metastasectomy of colorectal cancer. The objective of this study was to assess the current criteria for indications, preoperative diagnostics and preferred operative techniques of pulmonary metastasectomy in Germany. METHODS An anonymous survey was carried out in 239 German centers performing thoracic surgery in October 2015. RESULTS Chest computed tomography (CT, 98%), liver CT (62%), pelvis CT (39%) and fluorodeoxyglucose positron emission tomography (FDG-PET, 37%) were used by the respondents (65% of participants) for preoperative staging. Pulmonary metastasectomy was most commonly performed for solitary lung metastasis without extrathoracic disease (96%), >1 ipsilateral lung metastases without extrathoracic disease (94.8%), solitary lung metastasis with resectable hepatic metastases (92%) and resectable bilateral lung metastases without extrathoracic disease (91%). Of the respondents 95% performed open lung metastasectomy, 82% video-assisted thoracic surgery, 18% radiofrequency ablation, 53% used laser-assisted open resection and 46% indicated that there was no scientific consensus on pulmonary metastasectomy. CONCLUSION The majority of respondents performed pulmonary metastasectomy for solitary and multiple, unilateral and bilateral lung metastases without extrathoracic disease and/or local recurrence of primary tumors. The coexistence of resectable liver metastases was not an absolute contraindication for surgery. Of the respondents 46% expressed the need for prospective randomized studies to improve the evidence on pulmonary metastasectomy for colorectal cancer.
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15
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Kim MJ, Kim SJ, Park SC, Kim DY, Park JW, Ryoo SB, Jeong SY, Park KJ, Oh HK, Kim DW, Kang SB, Joo JN, Oh JH. Adjuvant radiotherapy for the treatment of stage IV rectal cancer after curative resection: A propensity score-matched analysis and meta-analysis. Medicine (Baltimore) 2016; 95:e4925. [PMID: 27893653 PMCID: PMC5134846 DOI: 10.1097/md.0000000000004925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of pelvic radiotherapy (RT) in stage IV rectal cancer with total mesorectal excision (TME) has not been defined. We evaluated the impact of RT on oncologic outcomes among patients with stage IV rectal cancer who underwent TME and performed a meta-analysis of published studies.The records of stage IV rectal cancer patients who underwent TME between August 2001 and December 2011 were reviewed. Patients who received pelvic RT (RT group) and those who did not (non-RT group) were matched using a propensity score. Oncologic outcomes were compared between the groups. A systematic literature search and meta-analysis was conducted.One hundred seventy-six patients were matched with propensity score matching, resulting in 39 patients in each group. The local recurrence-free survival (LRFS) of the RT group was significantly higher than that of the non-RT group (2-year LRFS: 100% vs 83.6%, respectively, P = 0.038). The overall survival, disease-free survival, and systemic recurrence were not significantly different between the groups. In the meta-analysis, the RT group had a reduced risk for loco-regional recurrence than the non-RT group (RR: 0.48, 95% confidence interval: 0.29-0.79).Pelvic RT might have benefits for loco-regional control in patients with stage IV rectal cancer who undergo TME.
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Affiliation(s)
- Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang
| | - Sang Jin Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang
| | - Sung-Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine
- Cancer Research Institute, Seoul National University
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine
- Cancer Research Institute, Seoul National University
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul
| | - Heung Kwon Oh
- Department of Surgery, Seoul National University College of Medicine
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam
| | - Jung Nam Joo
- Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang
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16
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Abstract
Until recently, hepatic arterial therapies (HAT) had been used for colorectal liver metastases after failure of first-, second-, and third-line chemotherapies. HAT has gained greater acceptance in patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The current data demonstrate that HAT is a safe and effective option for preoperative downsizing, optimizing the time to surgery, limiting non-tumor-bearing liver toxicity, and improving overall survival after surgery in patients with colorectal liver-only metastases. The aim of this review is to present the current data for HAT in liver-only and liver-dominant colorectal liver metastases.
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Affiliation(s)
- Neal Bhutiani
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA; Division of Surgical Oncology, Upper Gastrointestinal and Hepato-Pancreatico-Biliary Clinic, 315 East Broadway, #311, Louisville, KY 40202, USA.
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17
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Hallet J, Sa Cunha A, Adam R, Goéré D, Bachellier P, Azoulay D, Ayav A, Grégoire E, Navarro F, Pessaux P. Factors influencing recurrence following initial hepatectomy for colorectal liver metastases. Br J Surg 2016; 103:1366-76. [PMID: 27306949 DOI: 10.1002/bjs.10191] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/11/2016] [Accepted: 03/09/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Data on recurrence patterns following hepatectomy for colorectal liver metastases (CRLMs) and their impact on long-term outcomes are limited in the setting of modern multimodal management. This study sought to characterize the patterns of, factors associated with, and survival impact of recurrence following initial hepatectomy for CRLMs. METHODS A retrospective cohort study of patients undergoing initial hepatectomy for CRLMs at 39 institutions (2006-2013) was conducted. Kaplan-Meier methods were used for survival analyses. Overall survival landmark analysis at 12 months after hepatectomy was performed to compare groups based on recurrence. Multivariable Cox and regression models were used to determine factors associated with recurrence. RESULTS Among 2320 patients, tumours recurred in 47·4 per cent at median of 10·1 (range 0-88) months; 89·1 per cent of recurrences developed within 3 years. Recurrence was intrahepatic in 46·2 per cent, extrahepatic in 31·8 per cent and combined intra/extrahepatic in 22·0 per cent. The 5-year overall survival rate decreased from 74·3 (95 per cent c.i. 72·2 to 76·4) per cent without recurrence to 57·5 (55·0 to 60·0) per cent with recurrence (adjusted hazard ratio (HR) 3·08, 95 per cent c.i. 2·31 to 4·09). After adjusting for clinicopathological variables, prehepatectomy factors associated with increased risk of recurrence were node-positive primary tumour (HR 1·27, 1·09 to 1·49), more than three liver metastases (HR 1·27, 1·06 to 1·52) and largest metastasis greater than 4 cm (HR 1·19; 1·01 to 1·43). CONCLUSION Recurrence after CRLM resection remains common. Although overall survival is inferior with recurrence, excellent survival rates can still be achieved.
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Affiliation(s)
- J Hallet
- Institut Hospitalo-Universitaire, Institute for Minimally Hybrid Invasive Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,Division of General Surgery, Sunnybrook Health Sciences Center - Odette Cancer Center, Toronto, Ontario, Canada
| | - A Sa Cunha
- Department of Surgery, Hôpital Paul Brousse, Villejuif, France
| | - R Adam
- Department of Surgery, Hôpital Paul Brousse, Villejuif, France
| | - D Goéré
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - P Bachellier
- Department of Surgery, Hôpital Hautepierre, Strasbourg, France
| | - D Azoulay
- Department of Surgery, Hôpital Henri Mondor, Créteil, France
| | - A Ayav
- Department of Surgery, Hôpital de Brabois, Centre Régional Hospitalier Universitaire de Nancy, Nancy, France
| | - E Grégoire
- Department of Surgery, Hôpital de la Timone, Marseilles, France
| | - F Navarro
- Department of Surgery, Université de Montpellier, Hôpital Saint-Eloi, Montpellier, France
| | - P Pessaux
- Institut Hospitalo-Universitaire, Institute for Minimally Hybrid Invasive Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,General Digestive and Endocrine Surgery, Nouvel Hôpital Civil, Strasbourg, France
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18
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Pagès PB, Le Pimpec-Barthes F, Bernard A. [Surgery for pulmonary metastases from colorectal cancer: Predictive factors for survival]. Rev Mal Respir 2016; 33:838-852. [PMID: 27133381 DOI: 10.1016/j.rmr.2016.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/11/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Colorectal cancer is the 3rd commonest cause of death from cancer: 5% of patients will develop lung metastases. The management of oligometastatic disease is based on the objective of optimal local control. STATE OF THE ART To date, no results from randomized control trials support the resection of pulmonary metastases in oligometastastic colorectal cancer patients. However, numerous series, mainly retrospective, report long-term survival for highly selected patients, with 5-year survival ranging from 45 to 65% in the most recent series. The consensual predictive factors of a good prognosis are: a disease free-interval>36 months, a number of metastases≤3, a normal level of carcino-embryonic antigen and the absence of hilar or mediastinal lymph node involvement. PERSPECTIVES Around 20 to 40% of patients will develop recurrence, probably linked to the presence of undetectable micrometastases. Therefore, experimental work is being undertaken to develop new treatment techniques such as isolated lung perfusion, radiofrequency ablation and stereotactic radiation therapy. CONCLUSION Highly selected patients suffering from colorectal cancer lung metastases could benefit from resection with improved survival and disease-control.
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Affiliation(s)
- P-B Pagès
- Service de chirurgie cardiovasculaire et thoracique, CHU Bocage central, université de Bourgogne, 14, rue Gaffarel, BP 77908, 21079 Dijon cedex, France.
| | - F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Paris-Descartes, 75015 Paris, France
| | - A Bernard
- Service de chirurgie cardiovasculaire et thoracique, CHU Bocage central, université de Bourgogne, 14, rue Gaffarel, BP 77908, 21079 Dijon cedex, France
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Subramanian M, Choti MA, Yopp AC. Hepatic Arterial Infusion Pump Chemotherapy for Colorectal Liver Metastases: Making a Comeback? CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Transarterial chemoembolization (TACE) for colorectal liver metastases--current status and critical review. Langenbecks Arch Surg 2015; 400:641-59. [PMID: 26088872 DOI: 10.1007/s00423-015-1308-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/24/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transarterial liver-directed therapies are currently not recommended as a standard treatment for colorectal liver metastases. Transarterial chemoembolization (TACE), however, is increasingly used for patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The limited available data potentially reveals TACE as a valuable option for pre- and post-operative downsizing, minimizing time-to-surgery, and prolongation of overall survival after surgery in patients with colorectal liver only metastases. PURPOSE In this overview, the current status of TACE for the treatment of liver-dominant colorectal liver metastases is presented. Critical comments on its rationale, technical success, complications, toxicity, and side effects as well as oncologic outcomes are discussed. The role of TACE as a valuable adjunct to surgery is addressed regarding pre- and post-operative downsizing, conversion to resectability as well as improvement of the recurrence rate after potentially curative liver resection. Additionally, the concept of TACE for liver-dominant metastatic disease with a focus on new embolization technologies is outlined. CONCLUSIONS There is encouraging data with regard to technical success, safety, and oncologic efficacy of TACE for colorectal liver metastases. The majority of studies are non-randomized single-center series mostly after failure of systemic therapies in the 2nd line and beyond. Emerging techniques including embolization with calibrated microspheres, with or without additional cytotoxic drugs, degradable starch microspheres, and technical innovations, e.g., cone-beam computed tomography (CT) allow a new highly standardized TACE procedure. The real efficacy of TACE for colorectal liver metastases in a neoadjuvant, adjuvant, and palliative setting has now to be evaluated in prospective randomized controlled trials.
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Skipenko OG, Bedzhanyan AL, Polishchuk LO. The role of prognostic models in metastatic colorectal liver cancer surgery. Khirurgiia (Mosk) 2015:56-71. [PMID: 26978765 DOI: 10.17116/hirurgia20151256-71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patients with metastatic colorectal liver cancer differ from each other by some characteristics which affect on the prognosis of disease. Long-term results and, consequently, the prognosis depend on not one but group of factors which may be incorporated into mathematical models allowing to classify patients according to their risk of recurrence or prognosis of survival. AIM To calculate survival in patients with metastatic colorectal liver cancer and to evaluate the most popular models of 3- and 5-year survival rate prognosis after liver resection. MATERIAL AND METHODS We analyzed the results of treatment of 342 patients with metastatic colorectal cancer who underwent different resections since 1991 to 2014. The effectiveness of prognostic models was estimated according to the most popular scales that were developed based on groups of more than 200 patients. RESULTS Long-term results were followed in 312 (91.2%) patients. Median life in the total group of patients was 24 months in 3-, 5- and 10-year survival of 56.3%, 36.1% and 18.1% respectively. The most accurate stratification of patients into groups was obtained using preoperative Rees scale for 5-year and 3-year survival (C-statistics - 0.73 and 0.69, respectively). Analysis of Iwatsuki and Fong scales for 5-year survival prediction (C-statistics - 0.68 and 0.62) and postoperative Rees scale for 3-year survival (C-statistics - 0.63) also showed relatively good results. None of models showed C-statistics level over 0.8. CONCLUSION Stratification of patients according to prognostic scales should not affect on monitoring of patients with high risk of recurrence and poor prognosis of survival.
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Affiliation(s)
- O G Skipenko
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | - A L Bedzhanyan
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | - L O Polishchuk
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
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Eng OS, Tsang AT, Moore D, Chen C, Narayanan S, Gannon CJ, August DA, Carpizo DR, Melstrom LG. Outcomes of microwave ablation for colorectal cancer liver metastases: a single center experience. J Surg Oncol 2014; 111:410-3. [PMID: 25557924 DOI: 10.1002/jso.23849] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/27/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgical management of colorectal cancer liver metastases continues to evolve to optimize oncologic outcomes while maximizing parenchymal preservation. Long-term data after intraoperative microwave ablation are limited. This study investigates outcomes and patterns of recurrence in patients who underwent intraoperative microwave ablation. METHODS A retrospective analysis of 33 patients who underwent intraoperative microwave ablation of colorectal cancer liver metastases from 2009 to 2013 at our institution was performed. Perioperative and long-term data were reviewed to determine outcomes and patterns of recurrence. RESULTS A total of 49 tumors were treated, ranging 0.5-5.5 cm in size. Median Clavien-Dindo classification was one. Median follow-up was 531 days, with 13 (39.4%) patients presenting with a recurrence. Median time to first recurrence was 364 days. In those patients, 1 (7.8%) presented with an isolated local recurrence in the liver. Only 1 of 7 ablated tumors greater than 3 cm recurred (14.3%). Overall survival was 35.2% at 4 years, with a 19.3% disease-free survival at 3.5 years. No perioperative variables predicted systemic or local recurrence. CONCLUSION Intraoperative microwave ablation is a safe and effective modality for use in the treatment of colorectal cancer liver metastases in tumors as large as 5.5 cm in size.
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Affiliation(s)
- Oliver S Eng
- Department of Surgery, Division of Surgical Oncology, Rutgers-Robert Wood Johnson Medical School/Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Hwang M, Jayakrishnan TT, Green DE, George B, Thomas JP, Groeschl RT, Erickson B, Pappas SG, Gamblin TC, Turaga KK. Systematic review of outcomes of patients undergoing resection for colorectal liver metastases in the setting of extra hepatic disease. Eur J Cancer 2014; 50:1747-1757. [PMID: 24767470 DOI: 10.1016/j.ejca.2014.03.277] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/08/2014] [Accepted: 03/18/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical resection for patients with colorectal liver metastases (CRLM) can offer patients a significant survival benefit. We hypothesised that patients with CRLM and extra hepatic disease (EHD) undergoing metastasectomy had comparable survival and describe outcomes based on the distribution of metastatic disease. METHODS A systematic search using a predefined registered protocol was undertaken between January 2003 and June 2012. Primary exposure was hepatic resection for CRLM and primary outcome measure was overall survival. Meta-regression techniques were used to analyse differences between patients with and without extra hepatic disease. FINDINGS From a pool of 4996 articles, 50 were retained for data extraction (3481 CRLM patients with EHD). The median survival (MS) was 30.5 (range, 9-98) months which was achieved with an operative mortality rate of 0-4.2%. The 3-year and 5-year overall survival (OS) were 42.4% (range, 20.6-77%) and 28% (range, 0-61%) respectively. Patients with EHD of the lungs had a MS of 45 (range, 39-98) months versus lymph nodes (portal and para-aortic) 26 (range, 21-48) months versus peritoneum 29 (range, 18-32) months. The MS also varied by the amount of liver disease - 42.2months (<two lesions) versus 39.6months (two lesions) versus 28months (⩾three lesions). INTERPRETATION In the evolving landscape of multimodality therapy, selective hepatic resection for CRLM patients with EHD is feasible with potential impact on survival. Patients with minimal liver disease and EHD in the lung achieve the best outcome.
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Affiliation(s)
- Michael Hwang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Thejus T Jayakrishnan
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Danielle E Green
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ben George
- Division of Medical Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - James P Thomas
- Division of Medical Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ryan T Groeschl
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sam G Pappas
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, IL, United States
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Kiran K Turaga
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.
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Blackham AU, Russell GB, Stewart JH, Votanopoulos K, Levine EA, Shen P. Metastatic colorectal cancer: survival comparison of hepatic resection versus cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2014; 21:2667-74. [PMID: 24615177 DOI: 10.1245/s10434-014-3563-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver resection has long been considered the standard of care for resectable colorectal hepatic metastases (HM). Patients with colorectal peritoneal surface disease (PSD) are now also being treated with aggressive therapy in the form of cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS A retrospective comparison of optimally-treated colorectal cancer patients with HM or PSD obtained from prospectively maintained databases (1991-2010). RESULTS Liver resection was performed on 179 patients with HM, while 93 PSD patients received a complete cytoreduction followed by HIPEC. Patients differed in terms of age, performance status, site of primary cancer, T stage, and the use of perioperative chemotherapy. Five-year overall survival for HM patients was 36 %, with a median survival of 46 months, compared with 26 % and 34 months in patients with PSD (p = 0.024). When stratified by resection status, R0 HM (n = 170) and R0 PSD (n = 48) patients had similar median survival (49 vs. 41 months; p = 0.39). Median survival following R1 resection was also similar among HM (n = 9) and PSD (n = 45) patients (28 vs. 23 months; p = 0.68). Multivariate analysis identified distinctly different independent prognostic factors between HM and PSD patients. Major morbidity was 21 and 23 % (p = 0.88), while mortality was 3.9 versus 5.4 % (p = 0.55) in the HM and PSD patients, respectively. CONCLUSION Colorectal HM and PSD are distinct biologic diseases with different presentations and unique prognostic factors. However, long-term survival following CS/HIPEC is comparable to liver resection when stratified by completeness of resection. Furthermore, perioperative morbidity and mortality are similar.
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Affiliation(s)
- Aaron U Blackham
- Department of General Surgery, Surgical Oncology Section, Wake Forest School of Medicine, Winston-Salem, NC, USA,
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Tan MCB, Butte JM, Gonen M, Kemeny N, Fong Y, Allen PJ, Kingham TP, DeMatteo RP, Jarnagin WR, D'Angelica MI. Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis. HPB (Oxford) 2013; 15:803-13. [PMID: 23782400 PMCID: PMC3791120 DOI: 10.1111/hpb.12136] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/29/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model. METHODS Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution. RESULTS In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0-2) or high (3-5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance. DISCUSSION After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.
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Affiliation(s)
- Marcus CB Tan
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Nancy Kemeny
- Department of Medicine, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
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Wicherts DA, de Haas RJ, Salloum C, Andreani P, Pascal G, Sotirov D, Adam R, Castaing D, Azoulay D. Repeat hepatectomy for recurrent colorectal metastases. Br J Surg 2013; 100:808-18. [PMID: 23494765 DOI: 10.1002/bjs.9088] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The oncological benefit of repeat hepatectomy for patients with recurrent colorectal metastases is not yet proven. This study assessed the value of repeat hepatectomy for these patients within current multidisciplinary treatment. METHODS Consecutive patients treated by repeat hepatectomy for colorectal metastases between January 1990 and January 2010 were included. Patients undergoing two-stage hepatectomy were excluded. Postoperative outcome was analysed and compared with that of patients who had only a single hepatectomy. RESULTS A total of 1036 patients underwent 1454 hepatectomies for colorectal metastases. Of these, 288 patients had 362 repeat hepatectomies for recurrent metastases. Some 225 patients (78·1 per cent) had two hepatectomies, 52 (18·1 per cent) had three hepatectomies, and 11 patients (3·8 per cent) had a fourth hepatectomy. Postoperative morbidity following repeat hepatectomy was similar to that after initial liver resection (27·1 per cent after first, 34·4 per cent after second and 33·3 per cent after third hepatectomy) (P = 0·069). The postoperative mortality rate was 3·1 per cent after repeat hepatectomy versus 1·6 per cent after first hepatectomy. Three- and 5-year overall survival rates following first hepatectomy in patients who underwent repeat hepatectomy were 76 and 54 per cent respectively, compared with 58 and 45 per cent in patients who had only one hepatectomy (P = 0·003). In multivariable analysis, repeat hepatectomy performed between 2000 and 2010 was the sole independent factor associated with longer overall survival. CONCLUSION Repeat hepatectomy for recurrent colorectal metastases offers long-term survival in selected patients.
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Affiliation(s)
- D A Wicherts
- Department of Surgery, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Blackham AU, Swett K, Levine EA, Shen P. Surgical management of colorectal cancer metastases to the liver: multimodality approach and a single institutional experience. COLORECTAL CANCER 2013; 2:73-88. [PMID: 25110522 DOI: 10.2217/crc.12.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past 30 years, the treatment of metastatic colorectal cancer to the liver has undergone major changes. Once considered terminal and incurable, the prognosis of patients with colorectal hepatic metastases has seen dramatic improvements using modern multimodality therapy and now long-term survival and even cure are possible in some patients. Despite the advances seen in systemic therapy, hepatic resection offers the longest survival potential and remains the only curative option. Based on long-term outcomes and the improved safety of hepatic resection using modern operative techniques and critical care support, an aggressive locoregional approach to colorectal hepatic metastasis has become the standard of care. This article focuses on the management of colorectal hepatic metastases and highlights the importance of multimodality therapy. We also report our 18-year experience treating patients with hepatic resection for colorectal metastases.
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Affiliation(s)
- Aaron U Blackham
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Katrina Swett
- Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Edward A Levine
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Perry Shen
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Lee JH, Jo IY, Lee JH, Yoon SC, Kim YS, Choi BO, Kim JG, Oh ST, Lee MA, Jang HS. The role of postoperative pelvic radiation in stage IV rectal cancer after resection of primary tumor. Radiat Oncol J 2012; 30:205-12. [PMID: 23346540 PMCID: PMC3546289 DOI: 10.3857/roj.2012.30.4.205] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 10/17/2012] [Accepted: 10/23/2012] [Indexed: 12/19/2022] Open
Abstract
Purpose To evaluate the effect of pelvic radiotherapy (RT) in patients with stage IV rectal cancer treated with resection of primary tumor with or without metastasectomy. Materials and Methods Medical records of 112 patients with stage IV rectal cancer treated with resection of primary tumor between 1990 and 2011 were retrospectively reviewed. Fifty-nine patients received synchronous or staged metastasectomy whereas fifty-three patients did not. Twenty-six patients received pelvic radiotherapy. Results Median overall survival (OS), locoregional recurrence-free survival (LRFS), and progression-free survival (PFS) of all patients was 27, 70, and 11 months, respectively. Pathologic T (pT), N (pN) classification and complete metastasectomy were statistically significant factors in OS (p = 0.040, 0.020, and 0.002, respectively). RT did not improve OS or LRFS. There were no significant factors in LRFS. pT and pN classification were also significant prognostic factors in PFS (p = 0.010 and p = 0.033, respectively). In the subgroup analysis, RT improved LRFS in patients with pT4 disease (p = 0.026). The locoregional failure rate of the RT group and the non-RT group were 23.1% and 33.7%, showing no difference in the failure pattern of both groups (p = 0.260). Conclusion Postoperative pelvic RT did not improve LRFS of all metastatic rectal cancer patients; however, it can be recommended to patients with pT4 disease. A complete resection of metastatic masses should be performed if possible.
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Affiliation(s)
- Joo Hwan Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Yamazaki S, Takayama T, Okada S, Iwama A, Midorikawa Y, Moriguchi M, Nakayama H, Higaki T, Sugutani M. Good Candidates for a Third Liver Resection of Colorectal Metastasis. World J Surg 2012; 37:847-53. [DOI: 10.1007/s00268-012-1887-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Colorectal cancer is the third most common malignancy and cause of cancer-related deaths worldwide. Approximately half of the patients diagnosed with colorectal cancer ultimately die of the condition. Death from colorectal cancer can be prevented by early detection, but unfortunately presentation is often late, with a worse prognosis. Screening by fecal occult blood testing reduces disease-specific mortality, but there is a need for sensitive and specific noninvasive biomarkers to facilitate detecting the disease, staging it, and predicting the best therapeutic options. MicroRNAs (miRNAs) are short noncoding RNA sequences that have a crucial role in the regulation of gene expression. They have significant regulatory functions in basic cellular processes, such as cell differentiation, proliferation, and apoptosis. Evidence suggests that miRNAs may function as both tumor suppressors and oncogenes. The main mechanism for changes in the function of miRNAs in cancer cells is due to aberrant gene expression. Accurate discrimination of miRNA profiles between tumor and normal mucosa in colorectal cancer allows definition of specific expression patterns of miRNAs, giving good potential as diagnostic and therapeutic targets. MiRNAs expressed in colorectal cancers are also abundantly present and stable in stool and plasma samples. Their extraction from these three sources is feasible and reproducible. The ease and reliability of determining miRNA profiles in plasma or stool makes them potential molecular markers for colorectal cancer screening. This review summarizes the role miRNAs have in colorectal cancer, highlighting particularly the potential diagnostic, prognostic, and therapeutic implications in the future treatment of the disease.
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Ablation of perivascular hepatic malignant tumors with irreversible electroporation. J Am Coll Surg 2012; 215:379-87. [PMID: 22704820 DOI: 10.1016/j.jamcollsurg.2012.04.029] [Citation(s) in RCA: 210] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 04/10/2012] [Accepted: 04/11/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ablation is increasingly used to treat primary and secondary liver cancer. Ablation near portal pedicles and hepatic veins is challenging. Irreversible electroporation (IRE) is a new ablation technique that does not rely on heat and, in animals, appears to be safe and effective when applied near hepatic veins and portal pedicles. This study evaluated the safety and short-term outcomes of IRE to ablate perivascular malignant liver tumors. STUDY DESIGN A retrospective review of patients treated with IRE between January 1, 2011 and November 2, 2011 was performed. Patients were selected for IRE when resection or thermal ablation was not indicated due to tumor location. Treatment outcomes were classified by local, regional, and systemic recurrence and complications. Local failure was defined as abnormal enhancement at the periphery of an ablation defect on post-procedure contrast imaging. RESULTS Twenty-eight patients had 65 tumors treated. Twenty-two patients (79%) were treated via an open approach and 6 (21%) were treated percutaneously. Median tumor size was 1 cm (range 0.5 to 5 cm). Twenty-five tumors were <1 cm from a major hepatic vein; 16 were <1 cm from a major portal pedicle. Complications included 1 intraoperative arrhythmia and 1 postoperative portal vein thrombosis. Overall morbidity was 3%. There were no treatment-associated mortalities. At median follow-up of 6 months, there was 1 tumor with persistent disease (1.9%) and 3 tumors recurred locally (5.7%). CONCLUSIONS This early analysis of IRE treatment of perivascular malignant hepatic tumors demonstrates safety for treating liver malignancies. Larger studies and longer follow-up are necessary to determine long-term efficacy.
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The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: A systematic review. Surgery 2012; 151:860-70. [DOI: 10.1016/j.surg.2011.12.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 12/22/2011] [Indexed: 12/14/2022]
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Min BS, Kim NK, Jeong HC, Chung HC. High levels of serum VEGF and TIMP-1 are correlated with colon cancer liver metastasis and intrahepatic recurrence after liver resection. Oncol Lett 2012; 4:123-130. [PMID: 22807974 DOI: 10.3892/ol.2012.691] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 03/30/2012] [Indexed: 01/13/2023] Open
Abstract
The purpose of this study was to develop predictive/prognostic markers for liver metastasis and recurrence following liver resection, investigating not only clinical parameters but also molecular markers that are known to be involved in the process of liver metastasis. Seventy colon cancer patients with either no distant metastasis (group A) or with resectable synchronous liver metastasis only (group B) were prospectively enrolled. All 70 patients received curative resection of the primary tumor. Group B patients underwent additional liver resection. Clinical parameters as well as serum levels of molecular markers [carcinoembryonic antigen (CEA), osteopontin, matrix metalloproteinase-7 (MMP-7), tissue inhibitor of metalloproteinase-1 (TIMP-1), hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF) and E-selectin] from both tumor drainage (DV) and peripheral veins (PV) were analyzed. Results showed the clinical parameters were not significantly different between groups A and B. Nonetheless, the levels of VEGF and TIMP-1 from both DV and PV were significantly higher in group B compared to group A. In group A, 10 out of 33 (27.0%) patients developed metachronous liver metastasis. High levels of VEGF and TIMP-1 from DV were found to be significantly correlated with metachronous liver metastasis. In group B, 20 out of 33 (60.6%) patients had intrahepatic recurrence following resection of synchronous liver metastasis. The levels of VEGF from DV and the levels of TIMP-1 both from PV and DV were found to be significantly correlated with intrahepatic recurrence. Forty patients (7 from group A and 33 from group B) had liver resection and their 5-year disease-free survival rate was 15.9%. Univariate and multivariate analyses of prognostic factors revealed that the levels of VEGF and TIMP-1 from DV as well as the presence of lymph node metastasis from the primary tumor, synchronous metastasis and R1 resection were significantly associated with worse prognosis. The colon cancer patients with high levels of VEGF and TIMP-1 detected from the DV at the time of their initial surgery were found to have a high risk of metachronous liver metastasis and hepatic recurrence following the resection of synchronous liver metastasis. The high levels of VEGF and TIMP-1 were found to be significant predictive factors for poor prognosis following liver resection. These results require validation but pave the way for future transitional or clinical studies that may provide a greater understanding of colon cancer liver metastasis.
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Affiliation(s)
- Byung Soh Min
- Department of Surgery, Yonsei University Health System, Seoul, Republic of Korea
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Kingham TP, Tanoue M, Eaton A, Rocha FG, Do R, Allen P, De Matteo RP, D'Angelica M, Fong Y, Jarnagin WR. Patterns of recurrence after ablation of colorectal cancer liver metastases. Ann Surg Oncol 2012; 19:834-41. [PMID: 21879262 DOI: 10.1245/s10434-011-2048-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine the local recurrence rate and factors associated with recurrence after intraoperative ablation of colorectal cancer liver metastases. METHODS A retrospective analysis of a prospectively maintained database was performed for patients who underwent ablation of a hepatic colorectal cancer metastasis in the operating room from April 1996 to March 2010. Kaplan-Meier survival curves and Cox models were used to determine recurrence rates and assess significance. RESULTS Ablation was performed in 10% (n = 158 patients) of all cases during the study period. Seventy-eight percent were performed in conjunction with a liver resection. Of the 315 tumors ablated, most tumors were ≤ 1 cm in maximum diameter (53%). Radiofrequency ablation was used to treat most of the tumors (70%). Thirty-six tumors (11%) had local recurrence as part of their recurrence pattern. Disease recurred in the liver or systemically after 212 tumors (67%) were ablated. On univariate analysis, tumor size greater than 1 cm was associated with a significantly increased risk of local recurrence (hazard ratio 2.3, 95% confidence interval 1.2-4.5, P = 0.013). The 2 year ablation zone recurrence-free survival was 92% for tumors ≤ 1 cm compared to 81% for tumors >1 cm. On multivariate analysis, tumor size of >1 cm, lack of postoperative chemotherapy, and use of cryotherapy were significantly associated with a higher local recurrence rate. CONCLUSIONS Intraoperative ablation appears to be highly effective treatment for hepatic colorectal tumors ≤ 1 cm.
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Affiliation(s)
- T Peter Kingham
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Chan KM, Chiang JM, Lee CF, Yu MC, Lee WC, Chen JS, Wang JY. Outcomes of resection for colorectal cancer hepatic metastases stratified by evolving eras of treatment. World J Surg Oncol 2011; 9:174. [PMID: 22208884 PMCID: PMC3278383 DOI: 10.1186/1477-7819-9-174] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 12/30/2011] [Indexed: 12/30/2022] Open
Abstract
Background and purpose The outcomes and management of colorectal cancer (CRC) hepatic metastasis have undergone many evolutionary changes. In this study, we aimed to analyze the outcomes of patients with CRC hepatic metastasis in terms of the era of treatment. Methods We conducted a retrospective review of 279 patients who underwent liver resection (LR) for CRC hepatic metastases. The prognoses of patients treated pre-2003 (era 1) and post-2003 (era 2) were examined. Results Of the patients included in the study, 210 (75.3%) had CRC recurrence after LR. There was a significant difference in the ratio of CRC recurrence between the 2 eras (82.0% in era 1 vs. 69.5% in era 2; p = 0.008). Analysis of recurrence-free and overall survival rates also showed that the patient outcome was significantly better in the post-2003 era than in the pre-2003 era. Further analysis showed that a significantly higher percentage of patients in era 2 had received modern chemotherapeutic regimens including irinotecan and oxaliplatin, while patients in era 1 were mainly administered fluorouracil and leucovorin for adjuvant chemotherapy. Among patients with CRC recurrence, a significant ratio of those in era 2 underwent surgical resection for recurrent lesions, and these patients had a better survival curve than did patients without resection (34.1% vs. 2.2% for 5-year survival; p < 0.0001). Conclusion The incidence of CRC recurrence after LR for hepatic metastasis remains very high. However, the management and outcomes of patients with CRC hepatic metastasis have greatly improved with time, suggesting that the current use of aggressive multimodality treatments including surgical resection combined with modern chemotherapeutic regimens effectively prolongs the life expectancy of these patients.
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Affiliation(s)
- Kun-Ming Chan
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Chang CY, Kim HC, Park YS, Park JO, Choi DH, Park HC, Cho YB, Yun SH, Lee WY, Chun HK. The effect of postoperative pelvic irradiation after complete resection of metastatic rectal cancer. J Surg Oncol 2011; 105:244-8. [PMID: 21987401 DOI: 10.1002/jso.22109] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 09/13/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The 2010 NCCN clinical practice guidelines recommend radiation as a part of the standard adjuvant or neoadjuvant treatment for stage IV rectal cancer patients. This study evaluated the oncologic efficacy of postoperative radiotherapy (RTx) in loco-regional control after complete removal of primary and metastatic lesions in stage IV rectal cancer. METHODS Sixty-eight patients with metastatic rectal cancer were enrolled and analyzed. Twenty-eight of the enrolled patients received concurrent postoperative RTx with chemotherapy (RTx group) and the remaining 40 received only postoperative systemic chemotherapy (CTx) without RTx (non-RTx group). The eligibility criteria were as follows: a primary rectal tumor located in the low or mid-rectum, no postoperative macroscopic and microscopic evidence of residual tumor in primary and metastatic sites, and no history of prior CTx or pelvic RTx. RESULTS The recurrence rates were 75.0% in the RTx group and 72.5% in the non-RTx group. Local recurrence rates were 7.1% (RTx group) and 22.5% (non-RTx group) (P = 0.108). There were no differences in overall survival (OS), local recurrence-free survival, and disease-free survival between the two groups. The 2-year OS rates were 78.9% (RTx group) and 74.1% (non-RTx group) (P = 0.395). CONCLUSIONS Survival benefit of postoperative RTx in stage IV rectal cancer after complete removal of tumors was not apparent. RTx could be recommended for selected patients at high risk of local recurrence or for palliation of symptoms.
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Affiliation(s)
- Chul Young Chang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Misiakos EP, Karidis NP, Kouraklis G. Current treatment for colorectal liver metastases. World J Gastroenterol 2011; 17:4067-75. [PMID: 22039320 PMCID: PMC3203357 DOI: 10.3748/wjg.v17.i36.4067] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Revised: 11/30/2010] [Accepted: 12/07/2010] [Indexed: 02/06/2023] Open
Abstract
Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver, with five-year survival rates up to 58% in selected cases. However, only a minority are resectable at the time of diagnosis. Continuous research in this field aims at increasing the percentage of patients eligible for resection, refining the indications and contraindications for surgery, and improving overall survival. The use of surgical innovations, such as staged resection, portal vein embolization, and repeat resection has allowed higher resection rates in patients with bilobar disease. The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection. Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Current management of colorectal liver metastases requires a multidisciplinary approach, which should be individualized in each case.
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Hammill CW, Billingsley KG, Cassera MA, Wolf RF, Ujiki MB, Hansen PD. Outcome after laparoscopic radiofrequency ablation of technically resectable colorectal liver metastases. Ann Surg Oncol 2011; 18:1947-54. [PMID: 21399885 DOI: 10.1245/s10434-010-1535-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND There continues to be controversy surrounding the appropriate use of radiofrequency ablation (RFA) for the treatment of colorectal liver metastases (CRLM). This study analyzes outcomes data of CRLM patients who underwent laparoscopic RFA. Outcomes of patients determined to be technically resectable were compared to patients with unresectable disease. METHODS Data from all patients with CRLM who underwent laparoscopic RFA between 1996 and 2006 were retrospectively reviewed. A blinded independent hepatobiliary-trained surgical oncologist reviewed preoperative diagnostic imaging studies to determine resectability. Outcomes data for patients with disease deemed anatomically resectable and unresectable were analyzed and compared. Survival was calculated by the Kaplan-Meier method. The log rank test was performed to assess significance in survival. RESULTS A total of 113 patients who underwent laparoscopic RFA for CRLM were identified. Twelve patients who underwent concurrent hepatic resection were excluded. Of the remaining patients, 64 were determined to have disease that was be technically resectable and 37 unresectable as a result of tumor number and/or distribution. Median and 5-year survival of the potentially resectable group was 4.3years and 48.7%, compared to 2.2 years and 18.4% in the unresectable group (P = 0.002). Median disease-free survival in the resectable group was 15.0 months, compared to 16.4 months in the unresectable group (P = 0.796). No postoperative mortality was reported in the technically resectable group, and the rate of major complications was 3.1%. CONCLUSIONS Laparoscopic RFA of resectable CRLM can produce comparable long-term survival to hepatic resection in carefully selected patients, with favorable morbidity and mortality.
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Affiliation(s)
- Chet W Hammill
- Liver and Pancreas Surgery Program, Providence Portland Medical Center, Portland, OR, USA
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D'Angelica M, Kornprat P, Gonen M, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Effect on outcome of recurrence patterns after hepatectomy for colorectal metastases. Ann Surg Oncol 2010; 18:1096-103. [PMID: 21042942 DOI: 10.1245/s10434-010-1409-1] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite improvements in surgery and chemotherapy, most patients develop recurrence after hepatectomy for metastatic colorectal cancer. Data are lacking on the effect of these patterns on outcome. METHODS A retrospective review of a prospectively maintained hepatobiliary database was performed. Pattern and timing of recurrence and outcome after recurrence were analyzed. Univariate and multivariate analyses of factors associated with outcome after recurrence were carried out. RESULTS From January 1997 through May 2003, a total of 733 patients underwent hepatectomy for colorectal metastases. Of these, 637 patients (87%) were included in the analysis, and in 393 patients (62%), recurrence was documented at the time of last follow-up. Initial recurrence patterns included the following: liver only in 120 patients (31%), lung only in 107 (27%), other single sites in 49 (12%), and multiple sites in 117 (30%). Recurrence occurred within 2 years of hepatectomy in 75% of patients and after 3 years in 11%. Margins at hepatectomy, recurrence pattern, resected recurrence, and disease-free interval from time of colectomy to hepatic metastasis and from time of hepatectomy to recurrence were independently associated with survival as measured from the time of recurrence. Recurrence in the lung, resected recurrence, and time to recurrence after hepatectomy were associated with prolonged survival as measured from the time of hepatectomy and the time of recurrence. CONCLUSIONS The timing and pattern of recurrence after hepatic resection for metastatic colorectal cancer are important predictors of long-term survival.
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Affiliation(s)
- Michael D'Angelica
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Wicherts DA, de Haas RJ, Sebagh M, Ciacio O, Lévi F, Paule B, Giacchetti S, Guettier C, Azoulay D, Castaing D, Adam R. Regenerative nodular hyperplasia of the liver related to chemotherapy: impact on outcome of liver surgery for colorectal metastases. Ann Surg Oncol 2010; 18:659-69. [PMID: 20976564 PMCID: PMC3044234 DOI: 10.1245/s10434-010-1385-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Indexed: 12/15/2022]
Abstract
Background Regenerative nodular hyperplasia (RNH) represents the end-stage of vascular lesions of the liver induced by chemotherapy. The goal was to evaluate its incidence and impact on the outcome of patients resected for colorectal liver metastases (CLM). Methods Patients who underwent hepatectomy for CLM after six cycles or more of first-line chemotherapy, between January 1990 and November 2006, were included. Detailed histopathologic analysis of the nontumoral liver was performed according to a standard format. Results From a cohort of 856 resected patients at our institution, 771 (90%) received preoperative chemotherapy. Of these, 146 fulfilled the selection criteria and were included: 24 (16%) received 5-fluorouracil (5-FU) and leucovorin (LV) alone, 92 (63%) had 5-FU/LV and oxaliplatin, 18 (12%) had 5-FU/LV and irinotecan, and 12 (8%) were treated by 5-FU/LV, oxaliplatin, and irinotecan. RNH occurred in 22 of 146 patients (15%). Twenty of these patients (91%) received oxaliplatin, of whom six (30%) had chronomodulated therapy. Patients treated by oxaliplatin more often had RNH compared with oxaliplatin-naïve patients (22 vs. 4%). Although operative mortality was nil, the presence of RNH was associated with increased postoperative hepatic morbidity (50 vs. 29%). Elevated preoperative gamma-glutamyltransferase (GGT) (>80 U/L; >1N) and total bilirubin levels (>15 μmol/L; >1N) were independent predictors of RNH. Conclusions Patients with CLM who receive preoperative oxaliplatin have an increased risk of RNH and associated postoperative morbidity. Increased serum GGT and bilirubin are useful markers to predict the presence of RNH.
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Affiliation(s)
- Dennis A Wicherts
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Villejuif, France
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Kim JW, Kim YB, Kim NK, Min BS, Shin SJ, Ahn JB, Koom WS, Seong J, Keum KC. The role of adjuvant pelvic radiotherapy in rectal cancer with synchronous liver metastasis: a retrospective study. Radiat Oncol 2010; 5:75. [PMID: 20804559 PMCID: PMC2941492 DOI: 10.1186/1748-717x-5-75] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 08/31/2010] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Synchronous liver metastases are detected in approximately 25% of colorectal cancer patients at diagnosis. The rates of local failure and distant metastasis are substantial in these patients, even after undergoing aggressive treatments including resection of primary and metastatic liver tumors. The purpose of this study was to determine whether adjuvant pelvic radiotherapy is beneficial for pelvic control and overall survival in rectal cancer patients with synchronous liver metastasis after primary tumor resection. METHODS Among rectal cancer patients who received total mesorectal excision (TME) between 1997 and 2006 at Yonsei University Health System, eighty-nine patients diagnosed with synchronous liver metastasis were reviewed. Twenty-seven patients received adjuvant pelvic RT (group S + R), and sixty-two patients were managed without RT (group S). Thirty-six patients (58%) in group S and twenty patients (74%) in group S+R received local treatment for liver metastasis. Failure patterns and survival outcomes were analyzed. RESULTS Pelvic failure was observed in twenty-five patients; twenty-one patients in group S (34%), and four patients in group S+R (15%) (p = 0.066). The two-year pelvic failure-free survival rates (PFFS) of group S and group S+R were 64.8% and 80.8% (p = 0.028), respectively, and the two-year overall survival rates (OS) were 49.1% and 70.4% (p = 0.116), respectively. In a subgroup analysis of fifty-six patients who received local treatment for liver metastasis, the two-year PFFS were 64.9% and 82.9% (p = 0.05), respectively; the two-year OS were 74.1% and 80.0% (p = 0.616) in group S (n = 36) and group S+R (n = 20), respectively. CONCLUSIONS Adjuvant pelvic RT significantly reduced the pelvic failure rate but its influence on overall survival was unclear. Rectal cancer patients with synchronous liver metastasis may benefit from adjuvant pelvic RT through an increased pelvic control rate and improved quality of life.
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Affiliation(s)
- Jun Won Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Nam-Kyu Kim
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Byung-Soh Min
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Sang Joon Shin
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Yonsei University Health System, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
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Surgical treatment of hepatic colorectal metastasis: evolving role in the setting of improving systemic therapies and ablative treatments in the 21st century. Cancer J 2010; 16:103-10. [PMID: 20404606 DOI: 10.1097/ppo.0b013e3181d7e8e5] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Liver resection has clearly been established as the standard treatment for resectable colorectal liver metastases. This article will review the expanding role for hepatectomy in this disease. Faster and safer hepatectomies are allowing combined resections of the primary cancer and synchronous hepatic metastases. Effective neoadjuvant chemotherapy, as well as increasing data demonstrating effectiveness and safety of combined hepatectomy and ablative therapies, have further expanded the pool of patients now selected for resection. The end result is that increasing numbers of patients are undergoing acceptably aggressive surgical therapies with extension of life and possible cure. Successful multimodality therapies are also now allowing for long-term survival even in patients not cured of cancer. The prolonged survival of most patients treated by hepatectomy has allowed a long-term analysis of the patterns of recurrence, which emphasize the importance of controlling liver disease for prolongation of life. These improvements in treatments for hepatic metastases have come with a precipitous escalation of the costs of care. This will likely require that future clinical trials and algorithms of care not only be based on cancer outcome data but also on value analysis of treatment and follow-up regimens.
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Cohort Study of the Survival Benefit of Resection for Recurrent Hepatic and/or Pulmonary Metastases After Primary Hepatectomy for Colorectal Metastases. Ann Surg 2010; 251:902-9. [DOI: 10.1097/sla.0b013e3181c9868a] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Patterns of recurrence after curative-intent radiation for oligometastases confined to one organ. Am J Clin Oncol 2010; 33:157-63. [PMID: 19770627 DOI: 10.1097/coc.0b013e3181979238] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We sought to characterize and describe the patterns of distant recurrence in patients with macroscopic oligometastases, limited in number (<or=5) and confined to one organ, treated with curative-intent stereotactic body radiotherapy (SBRT). METHODS Seventy-seven patients enrolled on prospective studies of SBRT for oligometastases are included in the present analysis. All available radiography and records were retrospectively reviewed to determine the timing and location of recurrences. RESULTS New metastases occurred in 73% of patients. Among these patients, new metastases developed most frequently in the same organ (occurring in 82% of first new metastases after SBRT and 89% of cumulative new metastases). Metastases to other organs were common as well (occurring cumulatively in 79% of patients). In patients with liver oligometastases, common sites of further progression included the liver, other abdominal organs, and lungs. In patients with lung oligometastases, common sites of further progression included the lungs, thoracic lymph nodes, bones, liver, and brain. CONCLUSIONS Patients receiving SBRT for oligometastases confined to one organ are apt to develop new metastases, most frequently occurring in the initially involved organ, but also commonly in other organs. A subset of patients remains disease free after extended follow-up.
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Joo SH, Kim BS, Choi SI, Song JY, Lee KY, Kim YW, Kim GY, Lee SH, Lee SM, Hong SW. Cyclooxygenase (COX)-1, Cyclooxygenase (COX)-2 and E-cadherin Expression in Colorectal Cancer Patients with Hepatic Metastasis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.78.3.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sun Hyung Joo
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Bum Soo Kim
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Il Choi
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Jeong Yoon Song
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Kil Yeon Lee
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Yun Wha Kim
- Department of Pathology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Gyo Young Kim
- Department of Pathology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Suk Hwan Lee
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sang Mok Lee
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Wha Hong
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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de Jong MC, Mayo SC, Pulitano C, Lanella S, Ribero D, Strub J, Hubert C, Gigot JF, Schulick RD, Choti MA, Aldrighetti L, Mentha G, Capussotti L, Pawlik TM. Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis. J Gastrointest Surg 2009; 13:2141-51. [PMID: 19795176 DOI: 10.1007/s11605-009-1050-0] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/11/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients. METHODS Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed. RESULTS Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01). CONCLUSION Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.
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Affiliation(s)
- Mechteld C de Jong
- Department of Surgery, Johns Hopkins University School of Medicine, Harvey 611 600 N Wolfe Street, Baltimore, MD 21287, USA
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Rates and patterns of recurrence following curative intent surgery for colorectal liver metastasis: an international multi-institutional analysis of 1669 patients. Ann Surg 2009; 250:440-8. [PMID: 19730175 DOI: 10.1097/sla.0b013e3181b4539b] [Citation(s) in RCA: 555] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE(S) To investigate rates and patterns of recurrence in patients following curative intent surgery for colorectal liver metastasis. BACKGROUND Outcomes following surgical management of colorectal liver metastasis have largely focused on overall survival. Contemporary data on rates and patterns of recurrence following surgery for colorectal liver metastasis are limited. METHODS One thousand six hundred sixty-nine patients treated with surgery (resection +/- radiofrequency ablation [RFA]) for colorectal liver metastasis between 1982 and 2008 were identified from an international multi-institutional database. Clinicopathologic data, recurrence patterns, and recurrence-free survival (RFS) were analyzed. RESULTS At the time of the initial liver-directed surgery, surgical treatment was resection only (90.2%), resection plus RFA (8.0%), or RFA alone (1.8%). While 5-year overall survival was 47.3%, 947 (56.7%) patients recurred with a median RFS time of 16.3 months. First recurrence site was intrahepatic only (43.2%), extrahepatic only (35.8%), intra- and extrahepatic (21.0%). There was no difference in RFS based on site of recurrence (intrahepatic: 16.9 months; extrahepatic: 16.6 months; intra- and extrahepatic: 16.2 month; P > 0.05). Receipt of adjuvant chemotherapy was associated with overall recurrence risk (hazard ratio [HR] = 0.56), while history of RFA (HR = 2.39, P = 0.001) and R1 margin status (HR = 1.36) were predictive of intrahepatic recurrence. Pattern of recurrence and RFS remained similar following repeat surgery for recurrent disease. CONCLUSIONS While 5-year survival following surgery for colorectal liver metastasis approaches 50%, over one-half of patients develop recurrence within 2 years. The pattern of failure is distributed relatively equally among intrahepatic, extrahepatic, and intra- plus extrahepatic sites. Patients undergoing repeat surgery for recurrent metastasis have similar patterns of recurrence and RFS time.
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Adam R, Wicherts DA, de Haas RJ, Ciacio O, Lévi F, Paule B, Ducreux M, Azoulay D, Bismuth H, Castaing D. Patients With Initially Unresectable Colorectal Liver Metastases: Is There a Possibility of Cure? J Clin Oncol 2009; 27:1829-1835. [DOI: 10.1200/jco.2008.19.9273] [Citation(s) in RCA: 389] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Purpose Although oncosurgical strategies have demonstrated increased survival in patients with unresectable colorectal liver metastases (CLM), their potential for cure is still questioned. The aim of this study was to evaluate long-term outcome after combining downsizing chemotherapy and rescue surgery and to define prognostic factors of cure. Patients and Methods All patients with initially unresectable CLM who underwent rescue surgery and had a minimum follow-up of 5 years were included. Cure was defined as a disease-free interval ≥ 5 years from last hepatic or extrahepatic resection until last follow-up. Results Mean age of 184 patients who underwent resection (April 1988 through July 2002) was 56.9 years. Patients had a mean number of 5.3 metastases (bilobar in 76%), associated to extrahepatic disease in 27%. Surgery was possible after one (74%) or more (26%) lines of chemotherapy. Five- and 10-year overall survival rates were 33% and 27%, respectively. Of 148 patients with a follow-up ≥ 5 years, 24 patients (16%) were considered cured (mean follow-up, 118.6 months), six (25%) of whom were considered cured after repeat resection of recurrence. Twelve “cured” patients (50%) had a disease-free interval more than 10 years. Cured patients more often had three or fewer metastases less than 30 mm (P = .03) responding to first-line chemotherapy (P = .05). Multivariate analysis identified maximum size of metastases less than 30 mm at diagnosis, number of metastases at hepatectomy three or fewer, and complete pathologic response as independent predictors of cure. Conclusion Cure can be achieved overall in 16% of patients with initially unresectable CLM resected after downsizing chemotherapy. In addition to increased survival, this oncosurgical approach has real potential for disease eradication.
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Affiliation(s)
- René Adam
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dennis A. Wicherts
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robbert J. de Haas
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Oriana Ciacio
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Francis Lévi
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bernard Paule
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michel Ducreux
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel Azoulay
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Henri Bismuth
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Denis Castaing
- From the AP-HP Hopital Paul Brousse, Centre Hepato-Biliaire and Department of Medical Oncology; L'Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 785; INSERM, Laboratoire ‘Rythmes biologiques et cancers’ Unité 776; Université Paris-Sud, Villejuif, France; and Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Abstract
In the USA, cancers of the colon and rectum are the third most common site of new cancer cases and cancer deaths. With improved screening and adjuvant therapy, the survival of patients has increased substantially over the last decade. However, patients with metastatic disease often have limited survival. Hepatic metastasis is one of the most frequent sites of metastatic disease. In fact, 35-55% of patients with colorectal cancer will develop hepatic metastasis at some time during the course of their disease. Patients who are able to undergo complete resection of their hepatic metastases have the best chance of long-term survival. The goal of hepatic resection is to achieve complete resection of all metastases with microscopically negative surgical margins while preserving sufficient hepatic parenchyma. Survival following hepatic resection of colorectal metastasis now approaches 35-50%. However, approximately 65% of patients will have a recurrence at 5 years. Increasingly chemotherapeutic agents are being offered in the preoperative setting prior to operation. At the time of operation, patients with extensive hepatic disease can sometimes be offered ablative therapies combined with resection or staged approaches. Modern management of hepatic colorectal metastases necessitates a multidisciplinary approach to effectively treat these patients and increase the number of patients who will benefit from resection.
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Affiliation(s)
- Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins 600 North Wolfe Street, Halsted 614, Baltimore, MD 21287, USA
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Konopke R, Kersting S, Makowiec F, Gassmann P, Kuhlisch E, Senninger N, Hopt U, Saeger HD. Resection of colorectal liver metastases: is a resection margin of 3 mm enough? : a multicenter analysis of the GAST Study Group. World J Surg 2009; 32:2047-56. [PMID: 18521661 DOI: 10.1007/s00268-008-9629-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Ralf Konopke
- Department of General, Thoracic and Vascular Surgery, University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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