An Increasingly Common Challenge: Management of the Complete Responder With Multi-Focal Metastatic Colorectal Cancer

Very large hidden genetic diversity in one single tumor: evidence for tumors-in-tumor

Despite the concern of within-tumor genetic diversity, this diversity is in fact limited by the kinship among cells in the tumor. Indeed, genomic studies have amply supported the 'Nowell dogma' whereby cells of the same tumor descend from a single progenitor cell. In parallel, genomic data also suggest that the diversity could be >10-fold larger if tumor cells are of multiple origins. We develop an evolutionary hypothesis that a single tumor may often harbor multiple cell clones of independent origins, but only one would be large enough to be detected. To test the hypothesis, we search for independent tumors within a larger one (or tumors-in-tumor). Very high density sampling was done on two cases of colon tumors. Case 1 indeed has 13 independent clones of disparate sizes, many having heavy mutation burdens and potentially highly tumorigenic. In Case 2, despite a very intensive search, only two small independent clones could be found. The two cases show very similar movements and metastasis of the dominant clone. Cells initially move actively in the expanding tumor but become nearly immobile in late stages. In conclusion, tumors-in-tumor are plausible but could be very demanding to find. Despite their small sizes, they can enhance the within-tumor diversity by orders of magnitude. Such increases may contribute to the missing genetic diversity associated with the resistance to cancer therapy.

Surgical strategy of colorectal liver metastases treatment depending on clinical and pathological response to neoadjuvant chemo- and target therapy

Napjainkban az előrehaladott colorectalis carcinoma mindennapos onkológiai kihívásként jelenik meg a kezelőorvos számára. Az utóbbi években bevezetett protokolloknak köszönhetően jelentős terápiás előrelépésnek lehetünk tanúi. A neoadjuváns kemoterápia biológiai válaszmódosítókkal történt kiegészítése nagymértékben növelte a terápiára adott klinikai választ a májmetasztázisos betegek körében. Az ezredfordulót követően egyre gyakrabban találkozunk a májáttétek teljes eltűnésének jelenségével. A májáttétek sebészetével foglalkozó irodalom egyértelmű és világos különbséget tesz a klinikai és patológiai válasz között, ugyanakkor a két válasz között lévő összefüggés pontos kritériumait is rögzítette. A colorectalis carcinoma májmetasztázisainak komplex kezelésében a teljes patológiai válasz jelenti a végső célt.Célok és módszerek:Jelen kutatás 2009. január 1.–2010 augusztus 31. közötti időszakban, 39 betegben vizsgálta a klinikai és patológiai választ. A májreszekciós műtétet neoadjuváns kemo- és targetterápia előzte meg.Eredmények:Teljes patológiai válasz két betegben (5,71%), major patológiai válasz (necrosis >50%) 12 betegben, minor patológiai válasz (necrosis <50%) 22 betegben alakult ki, míg 3 betegben egyáltalán nem volt necrosis.Következtetések:A colorectalis carcinoma májmetasztázisainak neoadjuváns és célzott terápiás kezelése során a patológiai válasz elérésére kell törekedni. Jelenleg a patológiai választ tartjuk a legfontosabb prognosztikus faktornak, amely az R0 reszekciót követő hosszú távú túlélést döntően és alapvetően határozza meg. Ellentmondásos a májmetasztázisok teljes eltűnésének megítélése, mivel műtéttechnikailag ez igen nehéz helyzet elé állítja az operatőrt. Ebben az értelemben az áttétek teljes eltűnése nemkívánatos mellékhatás, amely miatt a stratégia azt kívánja, hogy májmetasztázisos beteg ne legyen „túlkezelve”, amíg az áttét/áttétek teljesen eltűnnek, hanem a multidiszciplináris onkoteam hozza meg időben a döntést a májműtét indikációját illetően a még lokalizálható metasztázis/metasztázisok eltávolítására. Orv. Hetil., 2010,47,1956–1960.

Surgical management of locally advanced and locally recurrent colon cancer

Locally advanced and locally recurrent colon cancers pose a surgical challenge with tumors extending into surrounding structures and organs. Anticipation of the need for an extended surgical resection, often with multivisceral en bloc organ removal, is critical for surgical planning. For both primary and recurrent tumors, postsurgical long-term survival is achievable but only after complete resection. The role of neoadjuvant and adjuvant therapy continues to be redefined in this era of biologic chemotherapeutics, and multimodality therapy holds promise in aiding resection and improving postsalvage survival.

Inoperable colorectal liver metastases: a declining entity?

BACKGROUND

Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation.

METHODS

Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease.

RESULTS

Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection).

CONCLUSION

A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.

Urgent need for a new staging system in advanced colorectal cancer

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

Staging of advanced colorectal cancer

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

Contemporary Imaging for Colorectal Cancer

With improvements in therapy for colorectal cancer, accurate imaging has taken on an increased significance. Preoperative diagnosis of metastatic disease helps identify patients who could undergo combined resection or might benefit from systemic therapy before surgery. Accurate imaging of rectal cancer is critical in evaluating locally advanced disease treatable by combined modality therapy, including chemoradiation and surgery. Postoperative imaging enhances identification of recurrent disease that might be amenable to salvage surgery.

Surgery for colorectal and sarcomatous pulmonary metastases: history, current management, and future directions

This article provides a historical review of metastasectomy, reviews current surgical management approaches, and proposes what direction future research must take to determine whether there is a survival advantage associated with pulmonary metastasectomy and how best to integrate metastasectomy with medical therapies, primarily induction, and adjuvant chemotherapy.