Surgical resection after downsizing of colorectal liver metastasis in the era of bevacizumab

Five-year complete remission of super-giant hepatocellular carcinoma with hepatectomy followed by sorafenib plus camrelizumab: A case report

BACKGROUND

Cirrhotic patients with super-giant hepatocellular carcinoma (HCC) and portal vein invasion generally have a poor prognosis. This paper presents a patient with super-giant HCC and portal vein invasion, who underwent hepatectomy followed by a combination of sorafenib and camrelizumab, resulting in complete remission (CR) for 5 years.

CASE SUMMARY

A 40-year-old male with compensated hepatitis B-related cirrhosis was diagnosed with HCC, Barcelona Clinic Liver Cancer stage C. Enhanced computed tomography imaging revealed a 152 mm × 171 mm tumor in the right liver, invading the portal vein and hepatic vein. Liver function was normal. The patient successfully underwent hepatectomy on July 18, 2019. However, by December 2019, HCC recurrence with lung metastases and portal vein invasion were detected. He started treatment with sorafenib (200 mg twice daily) and camrelizumab (200 mg every 3 weeks). By May 12, 2020, the patient was confirmed to have CR. Camrelizumab was adjusted to 200 mg every 12 weeks from June 16, 2021, with the last infusion on March 29, 2024. Although no further tumor recurrence was observed, he experienced two episodes of gastrointestinal bleeding due to esophagogastric varices, which were managed with endoscopic therapy. To date, the patient has remained in CR for 5 years.

CONCLUSION

The combination of hepatectomy with sorafenib and camrelizumab can achieve durable CR in patients with super-giant HCC and portal vein invasion. Further research is necessary to address these challenges and improve patient outcomes.

Reduced-Dose or Discontinuation of Bevacizumab Might Be Considered after Variceal Bleeding in Patients with Hepatocellular Carcinoma Receiving Atezolizumab/Bevacizumab: Case Reports

Background and Objectives: Variceal bleeding (VB) is the most concerning condition that is difficult to treat after atezolizumab/bevacizumab in patients with advanced hepatocellular carcinoma (HCC). Materials and Methods: We would like to introduce the cases of two patients who underwent bevacizumab reduction or discontinuation when VB occurred after atezolizumab/bevacizumab. Results: VB occurred in two patients who showed good tumor response after atezolizumab/bevacizumab treatment, and all VBs were successfully treated with endoscopic variceal ligations. In the first patient, VB did not occur as the tumor response decreased after a 50% reduction in bevacizumab. In the second patient, VB occurred again after a 50% bevacizumab reduction, so bevacizumab was discontinued and treatment with atezolizumab alone has been successfully maintained. Conclusions: Accordingly, we would like to suggest that considering bevacizumab dose reduction instead of changing to tyrosine kinase inhibitor may be a good clinical choice in atezolizumab/bevacizumab patients who develop VB.

Percutaneous image-guided ablation for hepatic metastases

The presence of hepatic metastases indicates advanced disease and is associated with significant morbidity and mortality, especially when the hepatic disease is not amenable to locoregional treatments. The primary tumour of origin, the distribution and extent of metastatic disease, the underlying liver reserve, the patient performance status and the presence of comorbidities are factors that determine whether a patient will benefit from hepatectomy or local curative-intent treatments. For patients with metastatic colorectal cancer, the most common primary cancer that spreads to the liver, several studies have demonstrated a survival benefit for patients who can be treated with hepatectomy and/or percutaneous ablation, compared to those treated with chemotherapy alone. Despite advances in surgical techniques increasing the percentage of patients eligible for surgery, most patients have unresectable disease or are poor surgical candidates. Percutaneous ablation can be used to provide local disease control and prolong survival for both surgical and non-surgical candidates. This is typically offered to patients with small hepatic metastases that can be ablated with optimal (≥10 mm) or at least adequate minimum ablation margins (≥5 mm), as high local tumour control rates can be achieved for these patients which are comparable to surgical resection. This review summarizes available evidence and outcomes following percutaneous ablation of the most frequently encountered types of hepatic metastases in the clinical practice of interventional oncology. Patient selection, technical considerations, follow-up protocols and oncologic outcomes are presented and discussed.

Impact of neoadjuvant chemotherapy on post-hepatectomy regeneration for patients with colorectal cancer liver metastasis - Systematic review and meta-analysis

BACKGROUND

Today, there is still debate on the impact of neoadjuvant chemotherapy (NeoChem) on liver regeneration (LivReg). The objectives of this study were to assess the impact of NeoChem and its characteristics (addition of bevacizumab, number of cycles and time from end of NeoChem) on post-hepatectomy LivReg.

MATERIAL & METHODS

Studies reporting LivReg in patients submitted to liver resection were included. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases were searched. Only studies comparing NeoChem vs no chemotherapy or comparing chemotherapy characteristics from 1990 to present were included. Two researchers individually screened the identified records registered in a predesigned database. Primary outcome was future liver remnant regeneration rate (FLR3). Bias of the studies was evaluated with the ROBINS-I tool, and quality of evidence with the GRADE system. Data was presented as mean difference or standard mean difference.

RESULTS

Eight studies with a total of 681 patients were selected. Seven were retrospective and one prospective comparative cohort studies. In patients submitted to major hepatectomy, NeoChem did not have an impact on LivReg (MD 3.12, 95% CI -2,12-8.36, p 0,24). Adding bevacizumab to standard NeoChem was associated with better FLR3 (SMD 0.45, 95% CI 0.19-0.71, p 0.0006).

DISCUSSION

The main drawback of this review is the retrospective nature of the available studies. NeoChem does not have a negative impact on postoperative LivReg in patients submitted to liver resection. Regimens with bevacizumab seem to be associated with better postoperative LivReg rates when compared to standard NeoChem.

Gastrointestinal Surgical Emergencies in the Neutropenic Immunocompromised Patient

Surgeons encounter neutropenic patients through elective or emergency consultation with increasing regularity. As medical management continues to extend the lives of patients with benign hematologic diseases, hematologic malignancies, solid malignancies, or iatrogenic neutropenia, more patients are presenting with infectious complications caused and/or complicated by their neutropenia. This leaves surgeons in the difficult position of managing medically fragile patients with unusual presentations of common disease processes. These patients often fall outside of classical guidelines and treatment pathways. Many studies addressing these issues are retrospective and non-randomized. Here, we review common emergency gastrointestinal surgery scenarios and their management in the setting of a neutropenic patient. While biliary disease, appendicitis, anorectal disease, and perforations will be covered in detail, an extensive appreciation of a patient's medical or oncologic disease course and appropriate utilization of consultants such as interventional radiology, gastroenterology, and hematology is often necessary.

Issues to be considered to address the future liver remnant prior to major hepatectomy

An accurate preoperative evaluation of the hepatic function and application of portal vein embolization in selected patients have helped improve the safety of major hepatectomy. In planning major hepatectomy, however, several issues remain to be addressed. The first is which cut-off values for serum total bilirubin level and prothrombin time should be used to define post-hepatectomy liver failure. Other issues include what minimum future liver remnant (FLR) volume is required; whether the total liver volume measured using computed tomography or the standard liver volume calculated based on the body surface area should be used to assess the adequacy of the FLR volume; whether there is a discrepancy between the FLR volume and function during the recovery period after portal vein embolization or hepatectomy; and how best the function of a specific FLR can be assessed. Various studies concerning these issues have been reported with controversial results. We should also be aware that different strategies and management are required for different types of liver damage, such as cirrhosis in hepatocellular carcinoma, cholangitis in biliary tract cancer, and chemotherapy-induced hepatic injury.

Disappearing colorectal liver metastases: Strategies for the management of patients achieving a radiographic complete response after systemic chemotherapy

The mainstays of treatment for colorectal liver metastases (CRLMs) are surgery and chemotherapy. Chemotherapeutic benefits of tumor shrinkage and systemic control of micrometastases are in part counterbalanced by chemotoxicity that can modify the liver parenchyma, jeopardizing the detection of CRLM. This review addresses the clinical decision-making process in the context of radiographic and pathologic responses, the preoperative imaging workup, and the approaches to the liver for CRLM, which disappear after systemic chemotherapy.

Phase 2 study of perioperative chemotherapy with SOX and surgery for stage III colorectal cancer (SOS3 study)

This phase 2 study evaluated the safety and efficacy of perioperative chemotherapy with S-1 plus oxaliplatin (SOX) for stage III colorectal cancer (CRC). Patients with stage III CRC received surgery after neoadjuvant chemotherapy (NAC; SOX 4 cycles) and adjuvant chemotherapy (AC; SOX 4 cycles). The primary endpoints were response rate and safety. We enrolled 30 patients. Their median age was 62 years (range: 43-87 years); 53% were women. They received a median of 4 cycles (range: 1-4) of NAC and a median 4 cycles (range: 0-4) of AC. Five patients interrupted NAC treatment because of toxicity (grade 3 diarrhoea [n = 1], grade 3 ileus [n = 1], and grade 3-4 thrombocytopenia [n = 3]). Patients' responses were complete responses: n = 2 (6.6%), partial responses: n = 21 (70%), stable disease: n = 6 (20.0%), and progressive disease: n = 1 (3.3%; response rate: 73.3%). Curative resection was performed in 29 patients. No patients showed anastomotic leakage. Five-year overall survival and disease-free survival were 83.3% and 76.7%, respectively (median follow-up time: 48 months). NAC using SOX regimen is safe and effective, and may lead to reduced local recurrence and distant metastasis. Long-term outcomes are awaited to evaluate further the efficacy of this strategy (UMIN000006790).

Decrease in VEGF-Induced Pericardial Adhesion Formation Using Bevacizumab After Surgery

OBJECTIVES

Some degrees of postoperative cardiac adhesions occur in response to the first cardiac surgery in patients that may limit surgeons for subsequent operations and increase the risk of heart injury. In this article, we established a model of postoperative pericardial adhesions, and because vascular endothelial growth factor (VEGF) seems to initiate adhesion formation through inflammatory responses, we used an anti-VEGF antibody, that is, bevacizumab, to examine its effects on postoperative adhesion formation.

METHODS

Twenty Wistar rats were divided in 2 groups: control and bevacizumab. After chest opening, pericardial sac was opened and the heart was fully exposed. In the bevacizumab group, bevacizumab (2.5 mg/kg) was applied locally on the heart and then the chest was closed. The control group received saline solution as placebo. After 42 days, high-sensitivity C-reactive protein in peripheral blood was measured, and re-sternotomy was performed to measure severity of pericardial adhesions. Then, the hearts were collected from all rats to evaluate percentage of CD-31-positive cells (as a marker of angiogenesis) using immunohistochemical staining.

RESULTS

When the bevacizumab group was compared with the control group, we found that the mean score of adhesion (0.89 ± 0.38 vs 2.56 ± 0.41) and CD-31 expression (27.45 ± 3.75% vs 56.26 ± 1.98%) was decreased significantly after bevacizumab administration. However, we did not find any difference in high-sensitivity C-reactive protein levels of control and bevacizumab animals.

CONCLUSION

In the current study, bevacizumab administration could effectively reduce adhesion formation after first sternotomy by preventing VEGF-induced angiogenesis through CD-31 downregulation.

Effect of bevacizumab plus XELOX (CapeOX) chemotherapy on liver natural killer cell activity in colorectal cancer with resectable liver metastasis

AIM

We investigated the chemotherapy effect of resectable colorectal cancer with liver metastasis (CRLM) on the function of intrahepatic immune cells.

METHODS

We classified patients into adjuvant chemotherapy (bevacizumab+CapeOX) after hepatectomy group (group A) and neoadjuvant chemotherapy followed by hepatectomy group (group B), and collected peripheral blood mononuclear cells (PBMC) and liver mononuclear cells (LMNC) to ascertain phenotypic and functional differences.

RESULTS

There were no significant differences in lymphocyte fractions of either PBMC or LMNC between groups, except for the significantly lower percentage of natural killer (NK) cells in LMNC in group B than in group A. Significantly higher percentage of natural-killer group 2, member D (NKG2D)- positive NK cells in PBMC and percentage of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-, NKp30-, and signal regulatory protein β (SIRPβ)-positive NK cells in LMNC were found in group B. Furthermore, significantly higher expressions of NKG2D and SIRPβ in peripheral blood NK cells and of NKp46 and CD122 in liver NK cells were found in group B. When LMNC were incubated with interleukin (IL)-2 in vitro, no difference was observed in the expression of these molecules in NK cells between groups. Consistently, there was no difference in the cytotoxic activity of those LMNC against a colon adenocarcinoma cell line between groups.

CONCLUSION

Colorectal cancer with liver metastasis patients treated with neoadjuvant chemotherapy showed enhanced expression of activation markers on peripheral blood and liver NK cells in comparison with patients who did not receive therapy; however, the difference in those function remains unclear. These results suggest that neoadjuvant chemotherapy does not have a negative impact on intrahepatic immune cells in resectable CRLM patients.

18FDG-PET Evaluation Correlates Better than CT with Pathological Response in a Metastatic Colon Cancer Patient Treated with Bevacizumab-Based Therapy

Around 20–30% of patients with hepatic metastasis from colorectal cancer can undergo liver resection, but the increased response rate obtained with the addition of monoclonal antibodies to chemotherapy regimens could result in a higher rate of liver surgery. In this report we describe the case of a patient who underwent a liver resection after neoadjuvant treatment with capecitabine, oxaliplatin and bevacizumab and who achieved a complete pathological response of the liver metastasis. A preoperative CT scan demonstrated a partial response to the treatment while 18FDG-PET scan correctly evaluated the complete pathological response in the liver and detected an active interaortocaval lymph node metastasis. New specific studies are required to evaluate the imaging response in metastatic colorectal cancer patients especially after treatment with new, targeted agents.

Gene therapy for colorectal cancer using adenovirus-mediated full-length antibody, cetuximab

Cetuximab is a chimeric monoclonal antibody, approved to treat patients with metastatic colorectal cancer (mCRC), head and neck squamous cell carcinoma (HNSCC), non-small-cell lung cancer (NSCLC) for years. It functions by blocking the epidermal growth factor receptor (EGFR) from receiving signals or interacting with other proteins. Although the demand for cetuximab for the treatment of cancer patients in clinics is increasing, the complicated techniques involved and its high cost limit its wide applications. Here, a new, cheaper form of cetuximab was generated for cancer gene therapy. This was achieved by cloning the full-length cetuximab antibody into two serotypes of adenoviral vectors, termed as AdC68-CTB and Hu5-CTB. In vivo studies showed that a single dose of AdC68-CTB or Hu5-CTB induced sustained cetuximab expression and dramatically suppressed tumor growth in NCI-H508– or DiFi-inoculated nude mice. In conclusion, gene therapy using adenovirus expressing full-length cetuximab could be a novel alternative method for the effective treatment of colorectal cancer.

Liver surgery for metastatic colorectal cancer: the surgical oncologist perspective

Neoadjuvant/conversion chemotherapy has emerged as an indispensable tool to achieve resectability of initially unresectable metastatic colorectal cancer and improves oncological outcomes. In parallel, surgical strategy has adopted a more aggressive treatment approach to achieve complete tumor clearance. However, chemotherapy affects liver function and combined with extensive liver resection, morbidity has increased, thereby compromising oncological outcome. There is an imperative need for careful patient selection to optimize patient management. In this review, we discuss available evidence and indications for neoadjuvant treatment in the management of colorectal cancer liver metastases, on preoperative patient selection and identification of high-risk patients, potential treatment strategies to promote postoperative liver regeneration to avoid postoperative morbidity and potentially deleterious side effects of these therapies on tumor growth.

Bevacizumab with preoperative chemotherapy versus preoperative chemotherapy alone for colorectal cancer liver metastases: a retrospective cohort study

This study aimed to assess the efficacy and safety of bevacizumab plus preoperative chemotherapy as first-line treatment for liver-only metastatic colorectal cancer in Chinese patients compared with those of preoperative chemotherapy alone.Patients with histologically confirmed liver-only metastatic colorectal cancer were sequentially reviewed, and received either preoperative chemotherapy plus bevacizumab (bevacizumab group, n = 32) or preoperative chemotherapy alone (chemotherapy group, n = 57). Progression-free survival, response rate, liver resection rate, conversion rate, and safety were analyzed.With median follow-up of 28.7 months, progression-free survival was 10.9 months (95% confidence interval: 8.7-13.1 months) in bevacizumab group and 9.9 months (95% confidence interval: 6.8-13.1 months) in chemotherapy group (P = 0.472). Response rates were 59.4% in bevacizumab group and 38.6% in chemotherapy group (P = 0.059). Overall liver resection (R0, R1, and R2) rate was 68.8% in bevacizumab group and 54.4% in chemotherapy group (P = 0.185). Conversion rate was 51.9% in bevacizumab group and 40.4% in chemotherapy group (P = 0.341). No postoperative complication was observed in all patients.Bevacizumab plus preoperative chemotherapy as first-line treatment for liver-only metastatic colorectal cancer tends to achieve better clinical benefit with controllable safety in Chinese patients.

Neoadjuvant chemotherapy does not impair liver regeneration following hepatectomy or portal vein embolization for colorectal cancer liver metastases

BACKGROUND AND OBJECTIVES

Treatment strategies for colorectal cancer liver metastasis (CRCLM) such as major hepatectomy and portal vein embolization (PVE) rely on liver regeneration. We aim to investigate the effect of neoadjuvant chemotherapy on liver regeneration occurring after PVE and after major hepatectomy.

METHODS

CRCLM patients undergoing PVE or major resection were identified retrospectively from our database. Liver regeneration data (expressed as future liver remnant [FLR] and percentage of liver regeneration [%LR]), total liver volume (TLV) and clinical characteristics were collected.

RESULTS

Between 2003 and 2013, 226 patients were included (85 major resection, 141 PVE). The median chemotherapy cycles was six in both groups. The median time interval between the last chemotherapy and the intervention was 51 days in the PVE group and 79 days in the hepatectomy group. In the PVE group, chemotherapy was not associated with altered liver regeneration (number of cycles [P = 0.435], timing [P = 0.563], or chemotherapy agent [P = 0.116]). Similarly in the major hepatectomy group, preoperative chemotherapy (number of cycles [P = 0.114]; agent [P = 0.061], timing [P = 0.126]) were not significantly associated with differences in liver regeneration (P = 0.592). In both groups, the predicted FLR% was inversely correlated with the %LR (P < 0.001).

CONCLUSION

Chemotherapy does not affect liver regeneration following PVE or major resection. J. Surg. Oncol. 2016;113:449-455. © 2016 Wiley Periodicals, Inc.

Population pharmacokinetics of bevacizumab in children with osteosarcoma: implications for dosing

PURPOSE

To describe sources of interindividual variability in bevacizumab disposition in pediatric patients and explore associations among bevacizumab pharmacokinetics and clinical wound healing outcomes.

EXPERIMENTAL DESIGN

Before tumor resection, three doses of bevacizumab (15 mg/kg) were administered to patients (median age, 12.2 years) enrolled in a multi-institutional osteosarcoma trial. Serial sampling for bevacizumab pharmacokinetics was obtained from 27 patients. A population pharmacokinetic model was fit to the data, and patient demographics and clinical chemistry values were systematically tested as predictive covariates on model parameters. Associations between bevacizumab exposure and wound healing status were evaluated by logistic regression.

RESULTS

Bevacizumab concentration-time data were adequately described by a two-compartment model. Pharmacokinetic parameter estimates were similar to those previously reported in adults, with a long median (range) terminal half-life of 12.2 days (8.6 to 32.4 days) and a volume of distribution indicating confinement primarily to the vascular space, 49.1 mL/kg (27.1 to 68.3 mL/kg). Body composition was a key determinant of bevacizumab exposure, as body mass index percentile was significantly (P < 0.05) correlated to body-weight normalized clearance and volume of distribution. Furthermore, bevacizumab exposure before primary tumor resection was associated with increased risk of major wound healing complications after surgery (P < 0.05).

CONCLUSION

A population pharmacokinetic model for bevacizumab was developed, which demonstrated that variability in bevacizumab exposure using weight-based dosing is related to body composition. Bevacizumab dosage scaling using ideal body weight would provide an improved dosing approach in children by minimizing pharmacokinetic variability and reducing likelihood of major wound healing complications.

Management of a patient with metastatic colorectal cancer and liver metastases

Liver metastases are commonly encountered in patients presenting with metastatic colorectal cancer (mCRC); resection is the treatment of choice. A number of systemic treatment options are currently available for such patients, including the use of 5-fluorouracil-based chemotherapies and oxaliplatin (e.g., FOLFOX) in combination with biologic agents that target angiogenesis (e.g., bevacizumab). For patients with progression following first-line treatment, current second-line options include a change in chemotherapy with bevacizumab (for patients who did or did not receive prior bevacizumab) or FOLFIRI in combination with aflibercept, a more recently approved antiangiogenesis therapy. Neurotoxicity is a well-established adverse event of oxaliplatin-based therapy. The current case details an mCRC patient with liver metastases who was treated with a capecitabine and oxaliplatin regimen (XELOX), and experienced two episodes of transient cortical blindness possibly related to oxaliplatin. After disease progression, the patient was switched to a regimen of FOLFIRI and aflibercept and did well on this second-line regimen.

Neoadjuvant capecitabine and oxaliplatin (XELOX) combined with bevacizumab for high-risk localized rectal cancer

PURPOSE

Chemoradiotherapy followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. Although this approach decreases the risk of local recurrence, pelvic radiation is associated with long-term morbidity and delays systemic treatment. We conducted this study to evaluate the feasibility of neoadjuvant capecitabine and oxaliplatin (XELOX) plus bevacizumab as a treatment for high-risk localized rectal cancer.

METHODS

Patients with T4 or lymph node-positive rectal cancer were treated with three cycles of XELOX plus bevacizumab and one additional cycle of XELOX. This was followed by TME performed 3-8 weeks after the last chemotherapy session.

RESULTS

Twenty-five patients were recruited between December 2009 and November 2011. In seven of the patients (28.0 %), grade 3-4 adverse events occurred. After preoperative chemotherapy, the frequency of tumor (T) downstaging was 69.6 %, and that of lymph node (N) downstaging was 78.9 %. Seven patients discontinued the treatment after 2-3 cycles of XELOX plus bevacizumab. The frequency of subsequent surgery was 92 %, and all patients underwent R0 resections. Postoperative complications occurred in six patients (26.1 %). One patient achieved a pathological complete response (pCR) for the primary tumor and lymph nodes, whereas an additional four patients achieved near-pCR. After a median follow-up of 31 months, five patients displayed metastatic progression, including one who suffered local recurrence.

CONCLUSIONS

XELOX plus bevacizumab followed by TME is feasible for high-risk localized rectal cancer, as it achieves good tumor regression and causes manageable toxicity.

Conversion therapy for colorectal cancer patients with potentially resectable liver metastases

Conversion therapy brings hope of a cure for colorectal cancer patients with potentially resectable liver metastases. Recent studies demonstrated that conversion therapy could achieve shrinkage of liver metastases and thus render some for resection and offer the chance of long-term survival. Besides preoperative systemic chemotherapy, oncosurgical modalities are also available, primarily including liver resection following portal vein ligation/embolization and two-stage liver resection. In this article, we will review recent advances in conversion therapy for these patients.

Targeting Neovascularization in Ischemic Retinopathy: Recent Advances

Pathological retinal neovascularization (RNV) is a common micro-vascular complication in several retinal diseases including retinopathy of prematurity, diabetic retinopathy, age-related macular degeneration and central vein occlusion. The current therapeutic modalities of RNV are invasive and although they may slow or halt the progression of the disease they are unlikely to restore normal acuity. Therefore, there is an urgent need to develop treatment modalities, which are less invasive and therefore associated with fewer procedural complications and systemic side effects. This review article summarizes our understanding of the pathophysiology and current treatment of RNV in ischemic retinopathies; lists potential therapeutic targets; and provides a framework for the development of future treatment modalities.

Chemotherapy-associated liver injury and its influence on outcome after resection of colorectal liver metastases

BACKGROUND

Advances in neoadjuvant therapy enabled novel strategies for treating resectable and initially unresectable colorectal cancer liver metastases. Although it is well known that chemotherapeutic agents cause certain types of liver parenchymal injury, the actual contribution of chemotherapy-associated hepatotoxicity to postoperative morbidity remains poorly defined. The aim of this study was to define all kinds of chemotherapy-associated liver injury and to examine its impact on postoperative morbidity.

PATIENTS AND METHODS

We included 119 patients who were treated between 2002 and 2010. Chemotherapy-associated changes of the liver were subclassified in 11 different categories and correlated with postoperative morbidity with the ultimate aim of generating a liver injury risk score.

RESULTS

On univariate analysis severity (P = .004) and localization of parenchymal inflammation (P = .04) were associated with morbidity. Steatosis did not correlate with postoperative outcome (P = .69), whereas steatohepatitis (as assessed by the nonalcoholic fatty liver disease activity score score) was related with morbidity (P = .03). On multivariate analysis, the severity of inflammation (95% confidence interval, 1.008-6.526; odds ratio, 2.56; P = .04) was significantly correlated with postoperative morbidity. The newly developed liver injury risk score was highly associated with postoperative complications (P = .006).

CONCLUSION

In this study, the induction of inflammation by conventional chemotherapy and its relevance for the development of clinical complications could be demonstrated. The proposed risk score for liver injury-related morbidity might help to better select patients eligible for an operation.

The aspartate aminotransferase to platelet ratio before chemotherapy predicts adverse events for FOLFOX and XELOX regimens including bevacizumab as the first-line therapy for stage IV, recurrent and metastatic colorectal cancer

BACKGROUND

Oxaliplatin-based chemotherapy for colorectal liver metastasis can induce hepatotoxicity, which increases the risk of liver resection. We previously reported that the aspartate aminotransferase to platelet ratio (APR) before chemotherapy can indicate oxaliplatin-induced splenomegaly and also predict the occurrence of adverse events during chemotherapy. Bevacizumab (BEV) was recently reported to reduce oxaliplatin-induced splenomegaly. Therefore, the aim of the present study was to investigate whether the APR before chemotherapy can predict the splenomegaly and adverse events associated with FOLFOX/BEV or XELOX/BEV in patients with stage IV or recurrent colorectal cancer.

METHODS

We performed CT volumetry of the spleen before and 12 weeks after FOLFOX/BEV and XELOX/BEV in 63 patients. The incidence of adverse events, haematological parameters, and biochemistry and urinalysis results were assessed during treatment.

RESULTS

An increase in the splenic volume was not observed in the FOLFOX/BEV group, but was significant in the XELOX/BEV group (+5.0% vs. +18.8%, P=0.01). The APR before chemotherapy did not indicate the presence of splenomegaly in the 63 patients, however, it did significantly predict the development of grade 2 or higher adverse events during chemotherapy.

CONCLUSIONS

An APR of 0.15 or higher before chemotherapy did not indicate the presence of splenomegaly, but could predict the development of adverse events due to FOLFOX/BEV and XELOX/BEV treatment.

Neoadjuvant FOLFIRI+bevacizumab in patients with resectable liver metastases from colorectal cancer: a phase 2 trial

Background:

Preoperative treatment of resectable liver metastases from colorectal cancer (CRC) is a matter of debate. The aim of this study was to assess the feasibility and activity of bevacizumab plus FOLFIRI in this setting.

Methods:

Patients aged 18–75 years, PS 0–1, with resectable liver-confined metastases from CRC were eligible. They received bevacizumab 5 mg kg⁻¹ followed by irinotecan 180 mg m⁻², leucovorin 200 mg m⁻², 5-fluorouracil 400 mg m⁻² bolus and 5-fluorouracil 2400 mg m⁻² 46-h infusion, biweekly, for 7 cycles. Bevacizumab was stopped at cycle 6. A single-stage, single-arm phase 2 study design was applied with 1-year progression-free rate as the primary end point, and 39 patients required.

Results:

From October 2007 to December 2009, 39 patients were enrolled in a single institution. Objective response rate was 66.7% (95% exact CI: 49.8–80.9). Of these, 37 patients (94.9%) underwent surgery, with a R0 rate of 84.6%. Five patients had a pathological complete remission (14%). Out of 37 patients, 16 (43.2%) had at least one surgical complication (most frequently biloma). At 1 year of follow-up, 24 patients were alive and free from disease progression (61.6%, 95% CI: 44.6–76.6). Median PFS and OS were 14 (95% CI: 11–24) and 38 (95% CI: 28–NA) months, respectively.

Conclusion:

Preoperative treatment of patients with resectable liver metastases from CRC with bevacizumab plus FOLFIRI is feasible, but further studies are needed to define its clinical relevance.

Prognostic importance of some clinical and therapeutic factors for the effect of portal vein embolization in patients with primarily inoperable colorectal liver metastases

INTRODUCTION

Portal vein embolization (PVE) may increase the resectability of liver metastases. However, the problem of PVE is insufficient growth of the liver or tumor progression in some patients. The aim of this study was to evaluate the significance of commonly available clinical factors for the result of PVE.

MATERIAL AND METHODS

Portal vein embolization was performed in 38 patients with colorectal liver metastases. Effects of age, gender, time between PVE and liver resection, oncological therapy after PVE, indocyanine green retention rate test, synchronous, metachronous and extrahepatic metastases, liver volume before and after PVE, increase of liver volume after PVE and the quality of liver parenchyma before PVE on the result of PVE were evaluated.

RESULTS

Liver resection was performed in 23 (62.2%) patients within 1.3 ±0.4 months after PVE. Tumor progression occurred in 9 (23.7%) patients and 6 (15.8%) patients had insufficient liver hypertrophy. Significant clinical factors of PVE failure were number of liver metastases (cut-off - 4; odds ratio - 4.7; p < 0.03), liver volume after PVE (cut-off 1000 cm(3); odds ratio - 5.1; p < 0.02), growth of liver volume after PVE (cut-off 150 cm(3); odds ratio - 18.7; p < 0.002), oncological therapy administered concomitantly with PVE (p < 0.003).

CONCLUSIONS

Negative clinical factors of resectability of colorectal cancer liver metastases after PVE included more than four liver metastases, liver volume after PVE < 1000 cm(3), growth of the contralateral lobe by less than 150 cm(3) and concurrent oncological therapy.

Bevacizumab treatment before resection of colorectal liver metastases: safety, recovery of liver function, pathologic assessment

Patients with metastatic colorectal cancer receive chemotherapy prior liver resection more and more frequently. This preoperative treatment has many effects which have to be analysed, like the safety of liver resection, toxicity, tissue regeneration, radiological and pathological response and survival data. The aim of the study was to evaluate the safety of bevacizumab containing preoperative chemotherapy and functional recovery of the liver after resection for colorectal liver metastases (CLM) and to analyse radiological and pathological data. Data of three groups of 120 consecutive patients-(1) CTX + BV: cytotoxic chemotherapy + bevacizumab, (2) CTX: cytotoxic chemotherapy, (3) NC: no treatment before liver resection-were analysed. Postoperative liver function and complications were compared, clinical, radiological and pathological data were evaluated. Between 01.12.2006 and 31.12.2010 41 resections was performed after chemotherapy + bevacizumab (CTX + BV) and 27 resections was performed after preoperative chemotherapy without bevacizumab (CTX). There were 60 hepatic resections in this period without neoadjuvant treatment (NC). 8 patients had repeated resections. The postoperative complication rate was 40 % but there was no statistical difference between the groups (P = 0.72). Only the type of resection was associated with a significantly higher complication rate (p = 0.03). The subgroup of patients, who received irinotecan had a higher complication rate in the CTX group than in the BV + CTX group (55 % vs 41 %). Preoperative administration of bevacizumab was associated with higher peak postoperative AST, ALT levels but did not affect functional recovery of the liver. The RECIST system was not able to predict the outcome after chemotherapy in every patient and in many cases this system overestimated the effect of chemotherapy. On histopathological examination the presence of necrosis was not associated with chemotherapy or pathological response. Use of chemotherapy before hepatic resection of CLM was not associated with a significant increase in complication rates. The functional recovery of the liver was not affected by the preoperative administration of chemotherapy. The use of combined neoadjuvant chemotherapy is safe before hepatic resection.

The effect of intravitreal bevacizumab and ranibizumab on cutaneous tensile strength during wound healing

Purpose

To investigate the effect of intravitreal bevacizumab and ranibizumab on wound tension and by histopathology during cutaneous wound healing in a rabbit model and to compare this effect to placebo intravitreal saline controls 1 and 2 weeks following intravitreal injection.

Methods

A total of 120 New Zealand white rabbits were randomly assigned to one of three treatment groups each consisting of 40 rabbits. Each group received intravitreal injections of bevacizumab, ranibizumab, or normal saline. Immediately afterwards, each rabbit underwent four 6 mm full-thickness dermatologic punch biopsies. Twenty rabbits from each agent group underwent wound harvesting on day 7 or day 14. The skin samples were stained for CD34 for vascular endothelial cells on day 7, and maximal wound tensile load was measured on days 7 and 14. Quantitative assessment of mean neovascularization (MNV) scores was obtained from 10 contiguous biopsy margin 400× fields of CD34-stained sections by two independent observers.

Results

Wound tension reading means (N) with standard error and adjusted P-values on day 7 were: saline placebos, 7.46 ± 0.87; bevacizumab, 4.50 ± 0.88 (P = 0.041); and ranibizumab, 4.67 ± 0.84 (P = 0.025). On day 14 these were: saline placebos, 7.34 ± 0.55; bevacizumab, 6.05 ± 0.54 (P = 0.18); and ranibizumab 7.99 ± 0.54 (P = 0.40). MNV scores in CD34 stained sections were: saline controls, 18.31 ± 0.43; bevacizumab, 11.02 ± 0.45 (P < 0.0001); and ranibizumab, 13.55 ± 0.43 (P < 0.0001). The interobserver correlation coefficient was 0.928.

Conclusion

At day 7, both anti–vascular endothelial growth factor (anti-VEGF) agents had significantly suppressed MNV scores and exerted a significant reduction of cutaneous wound tensile strength compared with saline controls. At day 14, neither agent produced a significant effect on tensile wound strength. Since angiogenesis is an integral component of the proliferative phase of wound healing, we encourage clinicians to be aware of their patients’ recent surgical history during intravitreal anti-VEGF therapy and to consider refraining from their use during the perioperative period.

Bevacizumab in older patients with advanced colorectal or breast cancer

The incidence of colorectal and breast cancer is growing among the 550 million living people aged 65 or older. Bevacizumab was the first anti-angiogenic agent approved for the treatment of the advanced phase of these cancers. Although older chronological age still hampers the use of modern treatments, there is a widespread awareness that chronological and physiological (i.e. functional) ages may largely differ, and that seniority itself should not be a stringent limit for the introduction of anti-angiogenics. However, the use of bevacizumab in the general older population is questionable. There is limited evidence of a favorable risk-to-benefit ratio, with efficacy data deriving from clinical trials that selected only elderly patients in rather good health. While summarizing the recent advances, this review highlights specific clinical features characterizing those older patients who may benefit the most from receiving bevacizumab.

A reversal in the vascularity of metastatic liver tumors from colorectal cancer after the cessation of chemotherapy plus bevacizumab: contrast-enhanced ultrasonography and histological examination

OBJECTIVE

To assess the effect of chemotherapy plus bevacizumab on tumor vessels, as well as the reversibility of this effect, using contrast-enhanced ultrasonography (CEUS) and histology in patients with metastatic liver tumors derived from colorectal cancer.

METHODS

The study included 12 patients who received chemotherapy plus bevacizumab, experienced a reduction in tumor vascularity as demonstrated by CEUS and consequently underwent liver resection. CEUS was performed before and after four courses of chemotherapy and before surgery. The numbers of microvessels highlighted by anti-CD34 antibodies in the viable tumor tissue were counted to quantify the microvessel density (MVD). As a control, 12 surgical specimens from 12 patients who had not received chemotherapy were examined.

RESULTS

A reversal of tumor vascularity was observed in 10 of 12 patients. In two patients, the vascularity remained reduced. The MVD in the treatment group was significantly lower than that observed in the group without treatment.

CONCLUSION

The data suggest that the tumor vessels regenerated substantially, although the effect of chemotherapy plus bevacizumab remained weak for approximately 6 weeks after the cessation of treatment. Therefore, future research must determine whether bevacizumab should be used prior to surgery.

Neoadjuvant bevacizumab persistently inactivates VEGF at the time of surgery despite preoperative cessation

BACKGROUND

When anti-VEGF (vascular endothelial growth factor) antibody bevacizumab is applied in neoadjuvant treatment of colorectal cancer patients with liver metastasis, 5-6 weeks between last bevacizumab dose and liver resection are currently recommended to avoid complications in wound and liver regeneration. In this context, we aimed to determine whether VEGF is inactivated by bevacizumab at the time of surgery.

METHODS

Fifty colorectal cancer patients with liver metastases received neoadjuvant chemotherapy ± bevacizumab supplementation. The last dose of bevacizumab was administered 6 weeks before surgery. Plasma, subcutaneous and intraabdominal wound fluid were analysed for VEGF content before and after liver resection (day 1-3). Immunoprecipitation was applied to determine the amount of bevacizumab-bound VEGF.

RESULTS

Bevacizumab-treated individuals showed no increase in perioperative complications. During the entire monitoring period, plasma VEGF was inactivated by bevacizumab. In wound fluid, VEGF was also completely bound by bevacizumab and was remarkably low compared with the control chemotherapy group.

CONCLUSION

These data document that following a cessation time of 6 weeks, bevacizumab is fully active and blocks circulating and local VEGF at the time of liver resection. However, despite effective VEGF inactivation no increase in perioperative morbidity is recorded suggesting that VEGF activity is not essential in the immediate postoperative recovery period.

The effect of intravitreal anti-VEGF agents on peripheral wound healing in a rabbit model

Purpose

To investigate the effect of intravitreal pegaptanib, bevacizumab, and ranibizumab on blood-vessel formation during cutaneous wound healing in a rabbit model and to compare this effect to placebo controls.

Methods

Forty New Zealand albino rabbits underwent full thickness cutaneous wounds using 6-mm dermatologic punch biopsies. The rabbits were assigned to four groups of ten, each receiving intravitreal injections of pegaptanib, bevacizumab, ranibizumab, or no injection (untreated controls). Five rabbits from each group underwent wound harvesting on day 7 and five from each group on day 14. The skin samples were stained with hematoxylin and eosin (HE), Masson’s trichrome (MT), and CD34 for vascular endothelial cells. Semiquantitative evaluation of HE- and MT-stained slides was performed by one pathologist. Quantitative assessment of mean neovascularization (MNV) scores was obtained from five contiguous biopsy margin 400× fields of CD34-stained sections by four independent observers.

Results

Week 1 MNV scores in CD-34 stained sections were: untreated controls: 11.51 ± 4.36; bevacizumab: 7.41 ± 2.82 (P = 0.013); ranibizumab: 8.71 ± 4.08 (P = 0.071); and pegaptanib: 10.15 ± 5.59 (P = 0.378). Week 2 MNV data were: untreated controls: 6.14 ± 2.25; bevacizumab: 7.25 ± 2.75 (P = 0.471); ranibizumab: 4.53 ± 3.12 (P = 0.297); and, pegaptanib: 6.35 ± 3.09 (P = 0.892). Interobserver variability using intraclass correlation coefficient was 0.961.

Conclusions

At week 1, all three anti-VEGF agents had suppressed MNV scores compared to controls. Although not statistically significant, there was an inhibitory trend, particularly with bevacizumab and ranibizumab. These effects were diminished at 2 weeks, reflecting a transition between the proliferative and remodeling phases of wound healing.

Treatment of colorectal liver metastases

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

Comorbid Conditions in Patients With Metastatic Colorectal Cancer

Background

Patients with metastatic colorectal cancer (mCRC) often have other medical conditions that may impact treatment decisions, prognoses and quality of care. We aimed to assess co-existing medical conditions in the mCRC patient population. This retrospective cohort study used linked medical and pharmacy claims data from two US-based Medstat MarketScan claims databases and identified patients with newly diagnosed mCRC between January 2005 and June 2008.

Methods

Patient data were analyzed for comorbid conditions and medication use in the year prior to diagnosis of mCRC. Univariate analyses were conducted to compare the comorbid conditions between patients aged ≥ 65 and < 65 years old. In total, 12 648 patients aged ≥ 18 years were identified. The study was evenly populated by gender and age above and below 65, and most patients had a primary diagnosis of colon cancer (70.1%).

Results

The most prevalent comorbidity was cardiovascular disease (CVD) (55.7% of patients) including hypertension (40.8%), cardiac dysrhythmia (14.2%), coronary artery disease (13.5%), congestive heart failure (7.2%) and arterial and venous thromboembolism (6.2% and 4.6%, respectively). Most comorbidities were significantly more prevalent in patients ≥ 65 years of age, particularly with respect to CVD (67.9% versus 42.5%, respectively; P < 0.0001). Additionally, nearly half (49.7%) of the patients received antihypertensive agents and many patients were prescribed more than one class of medications prior to mCRC diagnosis.

Conclusions

Comorbid medical conditions, particularly CVDs, are common in patients with mCRC, which could increase the complexity of patient management. This should be a consideration integral to the selection of the most appropriate treatment for individual patients.

Two-photon fluorescence vascular bioimaging with new bioconjugate probes selective toward the vascular endothelial growth factor receptor 2

We report the synthesis and characterization of two amine reactive fluorescent dyes with efficient two-photon absorption (2PA) properties and high fluorescence quantum yields. Bioconjugation of these dyes with the DC-101 antibody proved to be useful for selectively imaging the vascular endothelial growth factor receptor 2 (VEGFR-2) in cells expressing this receptor in vitro and in "whole" mounted excised tumors (ex vivo) by two-photon fluorescence microscopy (2PFM). The penetration depths reached within the tumors by 2PFM was over 800 μm. In addition, the concentration of dye required for incubation of these bioconjugates was in the picomolar domain, the probes possessed very good photostability, and the 2PFM setup did not require any additional means of increasing the collection efficiencies of fluorescent photons to achieve the relatively deep tissue imaging that was realized, due, in large part, to the favorable photophysical properties of the new probes.

Mechanisms regulating colorectal cancer cell metastasis into liver (Review)

The metastatic spread of tumor cells is one of the most common causes of mortality in cancer patients. The elucidation of the molecular mechanisms that underlie the formation of metastatic colonies has been one of the major objectives of cancer research. Organ-specific colonization of cancer cells is a significant and noteworthy feature of metastasis. Colorectal cancer (CRC) is one of the most common causes of cancer-related mortality. The liver is commonly the sole site of metastasis for CRC and represents a major cause of mortality in CRC patients. However, what regulates CRC cell metastasis into liver and the reasons for the liver-specific metastasis of CRC have yet to be adequately elucidated. Recent progress provides indications and a conceptual framework with which to investigate this issue. This review evaluated experimental and clinical evidence to support a mechanistic role for circulation patterns and microvessels in liver, metastasis-related genes, chemokines and their receptors, and cellular adhesion molecules in the process of CRC liver metastasis.

Clinical guidance on the perioperative use of targeted agents in solid tumor oncology

The use of targeted anti-cancer agents is increasing. It is common to utilize a multi-modal treatment approach towards solid tumors, often including surgical resection, and it has become apparent that some targeted agents can impair wound healing or cause an increased risk of perioperative complications. This article reviews targeted agents used in solid tumor oncology with an emphasis on clinically relevant details. Overall, the evidence of targeted agents causing surgical complications is limited. The greatest amount of evidence exists for bevacizumab causing perioperative complications, possibly due to its extended half-life. There are limited data for cetuximab, sorafenib and sunitinib and very little for other solid tumor targeted agents. Our findings suggest that there should be heightened pharmacovigilence around targeted agents with respect to perioperative complications and increased post-surgical support for patients to aid early detection of postoperative complications until definitive data become available.

Review: incidence and clinical significance of Bevacizumab-related non-surgical and surgical serious adverse events in metastatic colorectal cancer

OBJECTIVE AND BACKGROUND

This review describes the extent, frequency and clinical importance of Bevacizumab(BV)-related serious adverse events (SAE) after surgery, during or after chemotherapy with BV in patients with metastatic colorectal cancer (mCRC).

METHODS

Detailed PubMed search in November 2009.

RESULTS

Addition of BV to first- or second-line chemotherapy in patients with mCRC results in a statistically significant benefit in OS, PFS and RR. Addition of BV to chemotherapy causes no clinically relevant aggravation of SAE and seems safe with the primary tumor still in situ. The risk of emergency surgery due to BV-related SAE is estimated 2.0%. SAE rate is low if a time to surgery of 5-6 weeks is respected. The majority of SAE are wound healing complications. Bleeding and GI perforation occur infrequently, even following major surgery after BV-treatment. Major surgery during the course of BV-treatment results in an SAE rate of 1.3-2.7%. Postoperatively, a period of minimally 28 days should be respected before starting BV.

CONCLUSION

Reported rates of BV-related SAE in relationship to surgery are low.

Treatment recommendations for metastatic colorectal cancer

Metastatic colorectal cancer (CRC) represents an important health problem in which several biological predictive and prognostic factors have been identified, including clinical features and molecular markers that might influence the response to treatment. Actually, certain prognostic factors are considered key elements, along with disease extent, for deciding the therapeutic approach. However, a distinction between resectable/potentially resectable and unresectable patients must be made in order to establish an adequate therapeutic strategy. Different drugs and chemotherapy regimens are currently available, and their administration depends on patient characteristics, disease-related factors and the treatment objective. Moreover, special situations such as peritoneal carcinomatosis and local treatment of CRC in the setting of metastatic disease should be considered when deciding the most appropriate treatment strategy. This article reviews all the previously mentioned issues involved in the management of metastatic CRC and suggests some general recommendations for its treatment.

The timing of surgery for resectable metachronous liver metastases from colorectal cancer: Better sooner than later? A retrospective analysis

BACKGROUND

The benefit of preoperative chemotherapy in patients with initially resectable liver metastases from colorectal cancer is still a matter of debate.

AIMS

We aim to evaluate the role of neoadjuvant chemotherapy on the outcome of patients with colorectal cancer metachronous liver metastases undergoing potentially curative liver resection.

METHODS

One-hundred four patients were available for analysis. Tested variables included age, sex, primary tumour TNM stage, location and grading, the number of liver metastases, monolobar or bilobar location, interval time between liver metastases diagnosis and liver resection, Fong Clinical Risk Score (CRS). Neoadjuvant chemotherapy was administered according to the FOLFOX4 regimen.

RESULTS

Forty-four patients underwent liver resection without receiving neoadjuvant chemotherapy (group A); 60 patients received neoadjuvant chemotherapy (group B). At univariate analysis, only the time of liver resection seemed to affect overall survival: patients in group A showed a median survival time significantly superior to that of patients in group B (48 vs. 31 months; p=0.0358).

CONCLUSIONS

Our findings suggest that, when feasible, resection of liver metastases should be considered as an initial approach in this setting. Further studies are needed to better delineate innovative therapeutic strategies that may lead to an improved outcome for colorectal cancer patients with surgically resectable liver metastases.

Biologic modulation of chemotherapy in patients with hepatic colorectal metastases: the role of anti-VEGF and anti-EGFR antibodies

In the treatment of metastatic colorectal cancer, the subset of patients with liver-only metastases shows the greatest promise for prolonged survival and cure. Advances in surgery and medical treatment have encouraged multimodality treatment strategies and therefore require a true multidisciplinary approach. The current standard of care includes peri-operative chemotherapy and surgery. The new era of biologically targeted therapy requires an in-depth look at the possible efficacy and risks of adding these agents to the treatment protocol.

Portal vein embolization (prior to major hepatectomy) effects on regeneration, resectability, and outcome

Portal vein embolization (PVE) is used to increase the volume and function of the liver that will remain after extensive liver resection. Operative outcomes are improved in properly selected patients who undergo PVE and experience adequate future liver remnant (FLR) hypertrophy. Absolute volume and volume change of the FLR after PVE (interpreted in context of liver disease) predict adequate liver function postresection. Oncologic outcomes following resection in patients with appropriately applied PVE are excellent.

[Managing side-effects of targeted therapies in renal cancer:surgical complications]

The principal surgical complication feared in a patient under anti-angiogenic targeted therapy is gastrointestinal perforation. It is therefore important to be alert to situations "potentially at risk" of perforation: diverticulitis, carcinomatosis, intra-abdominal abscess, history of external radiotherapy, colonoscopy in the 4 weeks preceding the treatment, inflammatory disease and gastrointestinal mucosal ulceration, colonic stent, NSAID. It is essential to make an early diagnosis, and for treatment to be conservative if possible, with nasogastric aspiration without surgery. Surgical treatment is only offered in the event of worsening or failure of medical treatment. The time periods between surgery and the initiation of anti-angiogenic treatment vary according to the medication. With bevacizumab: major surgery: 4 weeks; 6 weeks if the patient has comorbidities. Minor surgery (e.g. dental extraction): wait for the wound to heal. With insertion of a PAC, bevacizumab can be administered the day after the insertion if necessary. With TKI: it is recommended to wait for the scar to heal in cases of major surgery. There is no specific recommendation for mTOR inhibitors. The time periods between termination of an anti-angiogenic treatment and scheduling of surgery also vary depending on the medication. With bevacizumab: 6 to 8 weeks for scheduled surgery. In the event of emergency surgery, the surgeon must be aware of an increased risk of post-operative complications. With TKI, 2 days for sorafenib, and 4 days for sunitinib. There is no specific recommendation for mTOR inhibitors.

Colorectal liver metastases

BACKGROUND

Despite major advances in therapies for liver metastases, colorectal cancer remains one of the commonest causes of cancer-related deaths in the UK.

SOURCES OF DATA

The international literature on the management of colorectal liver metastases (CLM) was reviewed.

AREAS OF AGREEMENT

Due to a combination of highly active systemic agents and low perioperative mortality achieved by high-volume centres, a growing number of patients are being offered liver resection with curative intent. Patients with bilobar and/or extrahepatic disease who would previously have received palliative treatment only, are undergoing major surgery with good results. This review focuses on preoperative evaluation, surgical planning and the role of adjuvant therapies in the management of patients with CLM.

AREAS OF CONTROVERSY

Can ablative therapies match the outcomes of surgical resection? How can even more patients be rendered resectable?

GROWING POINTS

The use of other therapies, such as radiofrequency ablation and selective internal radiation therapy.

AREAS TIMELY FOR DEVELOPING RESEARCH

New chemotherapy regimens for neo-adjuvant therapy and the development of new modalities of liver tumour ablation.

Impact of bevacizumab on functional recovery and histology of the liver after resection of colorectal metastases

BACKGROUND

The impact of bevacizumab on functional recovery and histology of the liver was evaluated in patients undergoing hepatic resection for colorectal liver metastases (CLM) following bevacizumab treatment.

METHODS

Consecutive patients who had resection of CLM between July 2005 and July 2009 following preoperative chemotherapy were identified retrospectively from a prospectively collected database. Patients who had received bevacizumab before the last chemotherapy line were excluded. Postoperative liver function and histology were compared between patients with and without bevacizumab treatment. Recorded parameters included serum prothrombin time, total bilirubin concentration, and levels of aspartate and alanine aminotransferase and γ-glutamyltransferase.

RESULTS

Of 208 patients identified, 67 had received last-line bevacizumab, 44 were excluded and 97 had not received bevacizumab. Most patients in the bevacizumab group (66 per cent) received a single line of chemotherapy. Bevacizumab was most often combined with 5-flurouracil/leucovorin and irinotecan (68 per cent). The median number of bevacizumab cycles was 8·6 (range 1-34). Bevacizumab administration was stopped a median of 8 (range 3-19) weeks before surgery. There were no deaths. Postoperative morbidity occurred in 43 and 36 per cent of patients in the bevacizumab and no-bevacizumab groups respectively (P = 0·353). The mean(s.d.) degree of tumour necrosis was significantly higher in the bevacizumab group (55(27) versus 32(29) per cent; P = 0·001). Complete pathological response rates were comparable (3 versus 8 per cent; P = 0·307). Postoperative changes in functional parameters and objective signs of hepatic toxicity were similar in both groups.

CONCLUSION

Preoperative administration of bevacizumab does not seem to affect functional recovery of the liver after resection of CLM. Tumour necrosis is increased following bevacizumab treatment.