The significance of hepatic pedicle lymph nodes metastases in surgical management of colorectal liver metastases and of other liver malignancies

Shanghai international consensus on diagnosis and comprehensive treatment of colorectal liver metastases (version 2019)

The liver is the most common anatomical site for hematogenous metastases from colorectal cancer. Therefore effective treatment of liver metastases is one of the most challenging elements in the management of colorectal cancer. However, there is rare available clinical consensus or guideline only focusing on colorectal liver metastases. After six rounds of discussion by 195 clinical experts of the Shanghai International Consensus Expert Group on Colorectal Liver Metastases (SINCE) from 29 countries or regions, the Shanghai Consensus has been finally completed, based on current research and expert experience. The consensus emphasized the principle of multidisciplinary team, provided detailed diagnosis approaches, and guided precise local and systemic treatments. This Shanghai Consensus might be of great significance to standardized diagnosis and treatment of colorectal liver metastases all over the world.

Resection and chemotherapy is the optimal treatment approach for patients with clinically node positive intrahepatic cholangiocarcinoma

BACKGROUND

Clinically lymph node positive (cLNP) intrahepatic cholangiocarcinoma (ICC) carries a poor prognosis, without clear management guidelines for the practicing clinician. We sought to evaluate current practice patterns for cLNP ICC, including associations with survival.

METHODS

The National Cancer Database was queried for patients with cLNP ICC, without extrahepatic metastases.

RESULTS

We identified 1023 patients with cLNP ICC, 77%% (n = 784) of whom received chemotherapy alone. Resection was undertaken in 23% (n = 239) of patients and was most commonly utilized in combination with chemotherapy (n = 150). Median survival for all patients was 13.6 months. Patients undergoing resection in combination with chemotherapy were associated with an improved survival (22.5 months) as compared to those patients receiving chemotherapy alone (11.9 months) or resection alone (12.4 months) (p < 0.01). Finally, we compared the survival of patients with cLNP ICC with that of patients with pathologically proved lymph node positive (pLNP) ICC, all of whom were treated with resection with chemotherapy, and found no difference in survival (22.5 months-19.3 months, p = 0.99, respectively).

CONCLUSIONS

While the decision to pursue resection for ICC is multifactorial and patient specific, the presence of clinically positive LNs should not represent a contraindication.

The differential organogenesis and functionality of two liver-draining lymph nodes in mice

The liver is an immunological organ. However, fundamental knowledge concerning liver-draining lymph nodes (LNs), which have been newly identified in mice as the portal and celiac LNs, is still lacking. Here, we revealed that the portal LN and celiac LN drain liver lymph through different lymphatic vessels. Although both the portal LN and celiac LN possess typical structures, they have different cell compositions. Interestingly, these two LNs form at different times during fetal development. Moreover, the organogenesis of the celiac LN, but not the portal LN, is controlled by the transcription factor NFIL3. Furthermore, the portal LN and celiac LN also perform different functions. The celiac LN is the predominant site of liver antiviral immune responses, whereas the portal LN functions in the in situ induction of dietary antigen-specific regulatory T cells. In conclusion, the portal LN and celiac LN are two independent liver-draining LNs with different organogenesis histories and separate functions in maintaining immune homeostasis in the liver.

Risk factors for acute kidney injury after partial hepatectomy

AIM

To identify risk factors for the occurrence of acute kidney injury (AKI) in the postoperative period of partial hepatectomies.

METHODS

Retrospective analysis of 446 consecutive resections in 405 patients, analyzing clinical characteristics, preoperative laboratory data, intraoperative data, and postoperative laboratory data and clinical evolution. Adopting the International Club of Ascites criteria for the definition of AKI, potential predictors of AKI by logistic regression were identified.

RESULTS

Of the total 446 partial liver resections, postoperative AKI occurred in 80 cases (17.9%). Identified predictors of AKI were: Non-dialytic chronic kidney injury (CKI), biliary obstruction, the Model for End-Stage Liver Disease (MELD) score, the extent of hepatic resection, the occurrence of intraoperative hemodynamic instability, post-hepatectomy haemorrhage, and postoperative sepsis.

CONCLUSION

The MELD score, the presence of non-dialytic CKI and biliary obstruction in the preoperative period, and perioperative hemodynamics instability, bleeding, and sepsis are risk factors for the occurrence of AKI in patients that underwent partial hepatectomy.

Role of imaging for patients with colorectal hepatic metastases: what the radiologist needs to know

Surgical resection of colorectal metastatic disease has increased as surgeons have adopted a more aggressive ideology. Current exclusion criteria are patients for whom a negative resection margin is not feasible or a future liver remnant (FLR) of greater than 20% is not achievable. The goal of preoperative imaging is to identify the number and distribution of liver metastases, in addition to establishing their relation to relevant intrahepatic structures. FLR can be calculated utilizing cross-sectional imaging to select out patients at risk for hepatic dysfunction after resection. MRI, specifically with gadoxetic acid contrast, is currently the preferred modality for assessment of hepatic involvement for patients with newly diagnosed colorectal cancer, to include those who have undergone neoadjuvant chemotherapy. Employment of liver-directed therapies has recently expanded and they may provide an alternative to hepatectomy in order to obtain locoregional control in poor surgical candidates or convert patients with initially unresectable disease into surgical candidates.

Hepatocellular Carcinoma, Fibrolamellar Variant: Diagnostic Pathologic Criteria and Molecular Pathology Update. A Primer

Fibrolamellar hepatocellular carcinoma (FL-HCC) is generally a fairly rare event in routine pathology practice. This variant of hepatocellular carcinoma (HCC) is peculiarly intriguing and,in addition, poorly understood. Young people or children are often the target individuals with this type of cancer. Previously, I highlighted some pathology aspects of FL-HCC, but in this review, the distinctive clinico-pathologic features of FL-HCC and the diagnostic pathologic criteria of FL-HCC are fractionally reviewed and expanded upon. Further, molecular genetics update data with reference to this specific tumor are particularly highlighted as a primer for general pathologists and pediatric histopathologists. FL-HCC may present with metastases, and regional lymph nodes may be sites of metastatic spread. However, peritoneal and pulmonary metastatic foci have also been reported. To the best of our knowledge, FL-HCC was initially considered having an indolent course, but survival outcomes have recently been updated reconsidering the prognosis of this tumor. Patients seem to respond well to surgical resection, but recurrences are common. Thus, alternative therapies, such as chemotherapy and radiation, are ongoing. Overall, it seems that this aspect has not been well-studied for this variant of HCC and should be considered as target for future clinical trials. Remarkably, FL-HCC data seem to point to a liver neoplasm of uncertain origin and unveiled outcome. A functional chimeric transcript incorporating DNAJB1 and PRKACA was recently added to FL-HCC. This sensational result may give remarkable insights into the understanding of this rare disease and potentially provide the basis for its specific diagnostic marker. Detection of DNAJB1-PRKACA seems to be, indeed, a very sensitive and specific finding in supporting the diagnosis of FL-HCC. In a quite diffuse opinion, prognosis of this tumor should be reconsidered following the potentially mandatory application of new molecular biological tools.

Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review

BACKGROUND

Hepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases.

METHODS

We identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4 % of these subjects were resected.

RESULTS

No prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8 %), genito-urinary (21.8 %), and gastrointestinal tract (19.8 %). The median 5- and 10-year overall survival were 32.3 % (range 19-42 %) and 24 % (indicated only in two studies, range 23-25 %), respectively, with 71 % of R0 resections.

CONCLUSIONS

There is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.

Prognostication systems as applied to primary and metastatic hepatic malignancies

Staging systems are an attempt to incorporate the biology and therapy for cancer in a way that enables categorization and prediction of oncologic outcomes. Because of unusual disease biology and complexities related to treatment intervention, efforts to develop reliable staging systems for hepatic malignancies have been challenging. This article discusses the ways in which improved understanding of these diseases has informed the evolution of prognostication systems as applied to hepatocellular carcinoma, cholangiocarcinoma, and hepatic colorectal adenocarcinoma.

The outcome of liver resection and lymphadenectomy for hilar lymph node involvement in colorectal cancer liver metastases

OBJECTIVE

Hepatic hilar lymph node (HLN) involvement is considered as a poor prognostic factor during liver resection in colorectal liver metastases (CLM). The purpose of this study is to identify the clinical factors that distinguish HLN-positive patients from those who are hilar lymph node negative and to evaluate the frequency of macroscopic involvement of hepatic HLN, to investigate the impact of HLN involvement on survival after resection for CLM with lymphadenectomy and adjuvant chemotherapy.

PATIENTS AND METHODS

Between January 2000 and August 2012, 73 selected CLM patients underwent liver resections with lymphadenectomy in the Hepatopancreatobiliary Surgery Department I of Beijing Cancer Hospital. Clinical data, surgical outcome, and prognosis after operation of patients with HLN involvement were compared with that of patients without HLN involvement.

RESULTS

Of the 73 patients who underwent liver resections with lymphadenectomy, 12 (16.4 %) patients had HLN involvement identified by pathology. Compared with patients without HLN involvement, the frequency of lymph nodes metastasis for primary tumor was significantly higher in HLN-positive patients (p = 0.023). For CLM patients with and without HLN involvement, 5-year overall survival (OS) was 16.2 and 37.1 %, respectively (p = 0.04). Five-year disease-free survival (DFS) rates were 0 and 32.9 % (p = 0.034). Multivariate analysis showed that involved resected HLN was an independent risk factor for overall survival.

CONCLUSION

We should suspect HLN involvement in patients with colorectal cancer liver metastases when they have regional lymph nodes of primary tumor metastasis. Liver resection with HLN dissection might offer a unique curative opportunity for CLM patients with HLN involvement.

Lymphatics and colorectal liver metastases: the case for sentinel node mapping

BACKGROUND

Hepatic resection remains the treatment of choice for patients with colorectal liver metastases (CLM). Indications for hepatic resection have been extended to include extrahepatic lymph node groups, resulting in increased survival benefits. The identification of specific lymph pathways and involved nodes is necessary to support the development of guidelines for a more focused approach to the management of this disease. The feasibility of sentinel node mapping should be investigated to define specific lymphatic groups involved in CLM.

METHODS

Scientific papers published from 1950 to 2012 were sought and extracted from the MEDLINE, PubMed and University of Melbourne databases.

RESULTS

Several studies have reported microscopic lymph node involvement in 10-15% of patients undergoing hepatic resection for CLM in which no macroscopic involvement was evident. In retrospect, over 80% of lymphadenectomies are proven unnecessary. Traditional imaging modalities have limited predictive value in detecting lymph node involvement. Sentinel node mapping has proved an extremely accurate tool in detecting lymph node involvement and can identify patients in whom lymphadenectomy may be beneficial.

CONCLUSIONS

Current imaging techniques are inadequate to detect microscopic lymph node involvement in patients with resectable CLM. The use of sentinel node mapping is proposed to identify nodal groups involved and provide management strategies.

[Assessment of resectability of colorectal liver metastases and extended resection]

Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.

The results of surgery for colorectal hepatic metastases following expansion of the indications in 2005

AIM

Safety and survival were investigated in patients treated according to expanded surgical indications for colorectal hepatic metastases.

METHOD

A retrospective analysis of all consecutive patients who underwent resection of colorectal hepatic metastases at Zhongshan Hospital from 2000 to 2010 was conducted. The patients were divided into two groups based on a change in the surgical indications introduced in 2005. Patients in Group I underwent hepatic surgery between 2000 and 2004 and those in Group II between 2005 and 2010. The clinicopathological data and survival rates of both groups were analysed.

RESULTS

There were 530 patients who underwent hepatic surgery between 2000 and 2010. After the expansion of surgical indications, the rate of surgical resection rose from 25.1 to 35.1% (P < 0.05). There was no significant difference in perioperative mortality (2.2% vs 0.9%) or morbidity (20.9% vs 29.8%). Recurrence occurred in 27.5% and 36.7% in Groups I and II, respectively, and 5-year overall survival was 43% and 49%, respectively (not significant).

CONCLUSION

Expanding the indications for surgical resection of hepatic metastases increased the resection rate but had no significant effect on survival.

Management of colorectal cancer patients after resection of liver metastases: can we offer a tailored treatment?

Surgical resection remains the only option of cure for patients with colorectal liver metastases, and no patient should be precluded from surgery. There is much controversy not only regarding the most appropriate therapeutic approach in the neoadjuvant setting but also after surgery is performed. Many patients will experience early relapses but others will be long survivors. We need to establish reliable prognostic and predictive factors to offer a tailored treatment. Several prognostic factors after metastasectomy have been identified: high C-reactive protein levels, a high neutrophil-lymphocyte ratio, elevated neutrophil count and low serum albumin are related to a worst outcome. Elevated CEA and Ki 67 levels, intrahepatic and perihepatic lymph node invasion are also some of the markers related to a worst outcome. In contrast, the administration of preoperative chemotherapy has been associated with a better prognosis after hepatectomy. The administration of adjuvant chemotherapy should be done taking in consideration these factors. Regarding predictive factors, determination of ERCC1, TS, TP and DPD and UGT1 polymorphisms assessment could be considered prior to chemotherapy administration. This would avoid treatment related toxicities and increase this population quality of life.

Outcome of patients with colorectal liver metastasis: analysis of 1,613 consecutive cases

OBJECTIVE

This study was designed to evaluate the long-time outcome of patients with colorectal liver metastasis (CRLM) undergoing different types of therapy and identify prognosis factors.

METHODS

From 2000 to 2010, 1,613 consecutive patients with CRLM were identified. Clinicopathological and outcome data were collected and analyzed by univariate and multivariate analyses.

RESULTS

Synchronous liver metastasis (SLM), female, grade III-IV, T4 and N positive of primary tumor, bilobar disease, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, serum CEA level ≥ 5 ng/ml, and CA19-9 level ≥ 37 u/ml were the predictors of adverse outcome using univariate analysis. The median survival and 5-year survival rate for patients after resection of liver metastases was 49.8 months and 47%, better than that for those after other therapy. In addition, patients without treatment had the poorest survival. Sixty-four initially unresectable patients underwent surgery after conversion therapy with a median survival of 36.9 months and a 5-year survival of 30%. By multivariate analysis, SLM, poorly differentiated primary tumor, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, and no surgical treatment of liver metastases were found to be independent predictors of poor survival.

CONCLUSIONS

Patients with CRLM could get long-term survival benefit from different types of therapy, and resection of liver metastases was the optimal strategy. A predictive model using these above five factors may be of use in stratifying patients who may benefit from intensive surveillance and adjuvant therapy.

Recommendation for standardized surgical management of primary adrenocortical carcinoma

BACKGROUND

Operative resection is the only potentially curative treatment for primary adrenocortical carcinoma (ACC), but standards of operative care are not defined with regards to the extent of local resection. We propose recommendations for operative management.

METHODS

Anatomic and clinical literature review focusing on local management of ACC, including lymphadenectomy and resection of adjacent organs or large vessels.

RESULTS

First-order drainage nodes of the adrenal gland include the renal hilum lymph nodes, the celiac lymph nodes, and the para-aortic and paracaval lymph nodes, mainly above the renal pedicle and ipsilateral to the adrenal glands. Lymph node involvement occurs in about 20% of patients with ACC, and is an important prognostic factor, but lymphadenectomy is performed infrequently. The adrenal glands and kidneys are contained in the same anatomic space, but systematic en bloc nephrectomy has no proven benefits for survival. Direct invasion of the kidney or adjacent organs is rare, but major venous invasion with tumor thrombus is relatively common. Both are associated with decreased survival, but complete resection can lead to long-term survival.

CONCLUSION

Standardization of regional lymphadenectomy including first-order drainage nodes is proposed. Systematic nephrectomy is not necessary in the absence of gross local invasion, but locally involved organs or large veins should be resected en bloc, with tumor thrombus embolectomy, if R0 resection is possible. Operative standardization improves tumor staging, potentially decreases local recurrence, and may be associated with better survival. Evidence-based standards of operative care and prospective investigations within international collaborating groups are necessary.

Colorectal liver metastasis in the setting of lymph node metastasis: defining the benefit of surgical resection

BACKGROUND

For patients with colorectal liver metastasis (CLM), the presence of concomitant perihepatic/para-aortic lymph node metastasis (LNM) is considered a contraindication to liver resection. We sought to determine the benefits of liver resection among patients with CLM + LNM by examining long-term outcomes among a large cohort of patients.

METHODS

Between October 1996 and December 2007, 61 patients with CLM and pathologically proven LNM were identified from an international multi-institutional database of 1629 patients. The effect of LNM, as well as other prognostic factors, on recurrence-free and overall survival was analyzed.

RESULTS

Median overall survival was 32 months, and 1-, 3-, and 5-year overall survival were 86, 35, and 18%, respectively. Five patients were alive and disease-free at last follow-up. Survival was associated with location of LNM. Specifically, 5-year overall survival was 30% among patients with LNM along the hepatoduodenal ligament/retropancreatic area (area 1), 14% among patients with LNM along the common hepatic artery/celiac axis (area 2), and there was only one long-term survivor who experienced recurrent disease among patients who had CLM + para-aortic LNM (area 3) (P = 0.004). On multivariate analyses, overall margin status (hazard ratio [HR] = 2.0), treated number of metastases >6 (HR = 2.3) and para-aortic lymph node involvement (HR = 2.6) each remained significantly associated with increased risk of death (all P < 0.05).

CONCLUSIONS

Although overall survival in the setting of LNM is only 18%, certain subsets of patients with LNM can benefit from surgical resection. Specifically, patients with CLM + LNM isolated to area 1 had a 5-year survival of approximately 30%, while long-term survival among patients with para-aortic LNM was rare.

Hepatic resection for colorectal liver metastases

Colorectal adenocarcinoma remains the third most common cause of cancer death in the United States, with an estimated 146,000 new cases and 50,000 deaths annually. Survival is stage dependent, and the presence of liver metastases is a primary determinant in patient survival. Approximately 25% of new cases will present with synchronous colorectal liver metastases (CLM), and up to one-half will develop CLM during the course of their disease. The importance of safe and effective therapies for CLM cannot be overstated. Safe and appropriately aggressive multimodality therapy for CLM can provide most patients with liver-dominant colorectal metastases with extended survival and an improved quality of life.

Management of the hepatic lymph nodes during resection of liver metastases from colorectal cancer: a systematic review

BACKGROUND

Hepatic lymph node involvement is generally considered a contraindication for liver resection performed for colorectal liver metastases. However, some advocate hepatic lymphadenectomy in the presence of macroscopic involvement and others routine lymphadenectomy. The aim of this review is to assess the role of lymphadenectomy in resection of liver metastases from colorectal cancer.

METHODS

Medline, Embase and Central databases were searched using a formal search strategy. Trials with survival data with a minimum follow-up of 1 year were considered for inclusion. Meta-analysis was performed using Revman.

RESULTS

A total of 4230 references were identified. Ten reports of nine studies including 926 patients qualified for the review. The prevalence of nodal metastases after routine lymphadenectomy was 16.3%. The overall 3-year and 5-year survival rates in node-positive patients were 9/151 (11.3%) and 2/137 (1.5%), respectively, compared to 3-year and 5-year survival rates of 424/787 (53.9%) and 246/767 (32.1%) in node-negative patients. The odds ratios for 3-year and 5-year survivals in node positive disease compared to node-negative disease were 0.12 (95% CI 0.06 to 0.24) and 0.08 (95% CI 0.03 to 0.22). There was no randomized controlled trial which assessed the survival benefit of routine or "selective" lymphadenectomy.

CONCLUSION

Currently, there is no evidence of survival benefit for routine or selective lymphadenectomy. Survival rates are low in patients with positive lymph nodes draining the liver irrespective of whether they are detected by routine lymphadenectomy or by macroscopic involvement. Further trials in this patient group are required.

Surgical resection versus non-surgical treatment for hepatic node positive patients with colorectal liver metastases

BACKGROUND

Involvement of hepatic lymph node in patients with colorectal liver metastases is associated with poor prognosis.

OBJECTIVES

To determine the benefits and harms of curative liver resection with lymphadenectomy versus other treatments for colorectal liver metastases with hepatic node involvement.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until September 2009 for identifying the randomised trials.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing liver resection (alone or in combination with radiofrequency ablation or cryoablation) versus other treatments (neo-adjuvant chemotherapy, chemotherapy, or radiofrequency ablation) in patients with colorectal liver metastases with hepatic node involvement.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials for inclusion.

MAIN RESULTS

We were unable to identify any randomised clinical trial fulfilling the inclusion criteria of this review. We were also unable to identify any quasi-randomised or cohort studies, which could meaningfully answer this important issue.

AUTHORS' CONCLUSIONS

There is no evidence in the literature to assess the role of surgery versus other treatments for patients with colorectal liver metastases with hepatic node involvement. High quality randomised clinical trials are feasible and are necessary to determine the optimal management of patients with colorectal liver metastases with hepatic node involvement.

Hepatectomia para o tratamento de metástases colorretais e não-colorretais: análise comparativa em 30 casos operados

RACIONAL: Hepatectomia é a melhor opção terapêutica curativa para metástases hepáticas de origem colorretal. Mais recentemente, ressecção hepática também tem sido realizada para metástases de etiologia não-colorretal. OBJETIVO: Comparar os resultados em curto e longo prazo de uma série de hepatectomias para 20 doentes com metástase colorretal com uma série de 10 doentes com metástase não-colorretal realizadas pelo Serviço de Cirurgia Geral (Disciplina de Cirurgia do Aparelho Digestivo) da Faculdade Medicina do ABC (Santo André - Brasil). MÉTODOS: Os dados completos de 30 doentes submetidos à hepatectomia por metástase metacrônica entre o período de Janeiro de 2001 e Setembro de 2007 foram avaliados. Vinte com metástase colorretal (Grupo 1) foram comparados com dez com metástase não-colorretal (Grupo 2). Foi realizada análise multivariada dos fatores prognósticos com o programa Epi-Info para Windows. RESULTADOS: Foram realizadas vinte hepatectomias maiores e dez hepatectomias menores. A morbidade foi similar entre os grupos (p >0,05). A mortalidade cirúrgica foi maior no Grupo 1 do que no Grupo 2 (5 % X 0 %), mas não houve significância estatística (p>0,05). Os índices de sobrevida global em 3 e 5 anos foram comparáveis entre os dois grupos (p>0,05). CONCLUSÃO: Nessa amostra, a ressecção hepática para metástase de etiologia não-colorretal apresenta resultados similares aos da metástase colorretal com sobrevida em cinco anos de 20 %. Foram fatores prognósticos adversos: mais que uma metástase e linfonodo positivo.

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.

Bilobar colorectal liver metastases: treatment options

Although prospective, randomized clinical trials never have been conducted, retrospective and comparative studies strongly indicate that hepatic resection is the only available treatment that allows long-term survival in colorectal carcinoma that has metastasized to the liver. Unfortunately, curative resection can be performed in less than 25% of the patients. Ten years ago, hepatic resection was contraindicated in case of multiple or bilobar nodules. Currently, the trend is to be more aggressive and to increase the indications for surgical resection with the development of new strategies using a multidisciplinary approach.

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.

Hepatectomy for colorectal metastases in the presence of extrahepatic disease

This article focuses on hepatectomy for colorectal liver metastases (CLM) in the presence of intra-abdominal extrahepatic disease. The results reported in the literature are reviewed, and the indications and contraindications for hepatectomy in patients who have CLM with extrahepatic disease are discussed in light of the available evidence.

Expanding criteria for resectability of colorectal liver metastases

Surgical resection is the treatment of choice in patients with colorectal liver metastases, with 5-year survival rates reported in the range of 40%-58%. Over the past 10 years, there has been an impetus to expand the criteria for defining resectability for patients with colorectal metastases. In the past, such features as the number of metastases (three to four), the size of the tumor lesion, and a mandatory 1-cm margin of resection dictated who was "resectable." More recently, the criteria for resectability have been expanded to include any patient in whom all disease can be removed with a negative margin and who has adequate hepatic volume/reserve. Specifically, instead of resectability being defined by what is removed, decisions concerning resectability now center around what will remain after resection. Under this new paradigm, the number of patients with resectable disease can be expanded by increasing/preserving hepatic reserve (e.g., portal vein embolization, two-stage hepatectomy), combining resection with ablation, and decreasing tumor size (preoperative chemotherapy). The criteria for resectability have also expanded to include patients with extrahepatic disease. Rather than being an absolute contraindication to surgery, patients with both intra- and extrahepatic disease should potentially be considered for resection based on strict selection criteria. The expansion of criteria for resectability of colorectal liver metastases requires a much more nuanced and sophisticated approach to the patient with advanced disease. A therapeutic approach that includes all aspects of multidisciplinary and multimodality care is required to select and treat this complex group of patients.

Selective inhibition of proprotein convertases represses the metastatic potential of human colorectal tumor cells

The proprotein convertases (PCs) are implicated in the activation of various precursor proteins that play an important role in tumor cell metastasis. Here, we report their involvement in the regulation of the metastatic potential of colorectal tumor cells. PC function in the human and murine colon carcinoma cell lines HT-29 and CT-26, respectively, was inhibited using siRNA targeting the PCs furin, PACE4, PC5, and PC7 or by overexpression of the general PC inhibitor alpha1-antitrypsin Portland (alpha1-PDX). We found that overexpression of alpha1-PDX and knockdown of furin expression inhibited processing of IGF-1 receptor and its subsequent activation by IGF-1 to induce IRS-1 and Akt phosphorylation, all important in colon carcinoma metastasis. These data suggest that the PC furin is a major IGF-1 receptor convertase. Expression of alpha1-PDX reduced the production of TNF-alpha and IL-1alpha by human colon carcinoma cells, and incubation of murine liver endothelial cells with conditioned media derived from these cells failed to induce tumor cell adhesion to activated murine endothelial cells, a critical step in metastatic invasion. Furthermore, colon carcinoma cells in which PC activity was inhibited by overexpression of alpha1-PDX when injected into the portal vein of mice showed a significantly reduced ability to form liver metastases. This suggests that inhibition of PCs is a potentially promising strategy for the prevention of colorectal liver metastasis.

Metachronous liver metastases and resectability: Fong's score and laparoscopic evaluation

BACKGROUND AND AIMS

The aim of this retrospective study was to establish whether Fong's risk score can predict rate of resectability and whether laparoscopic exploration with ultrasonography can reduce the number of useless laparotomies to any extent.

MATERIAL AND METHODS

Fong's score was calculated for each of the 43 potential resectable patients. We analysed: the relation between score and resectability; the probability of unnecessary laparotomy with respect to each level of score; and which of the five Fong parameters was the most indicative of non-resectability. None of our patients was submitted to preoperative laparoscopic staging.

RESULTS

All patients with Fong's score 0 were submitted to liver resection, whereas only 76.9% with score 1, 58.3% with score 2, and 66.6% with score 3. No patients had score 4 and 5. "CEA level" is the parameter that best predicts the "non-resectability" of metastases. In the subgroup with score 0-1, laparoscopy would have spared 12% of unnecessary laparotomies, whereas in subgroup 2-3 this percentage would have risen to 38.9.

CONCLUSIONS

The above data allowed us to quantify statistically the risk associated with non-resectability of liver metastases in a directly proportional manner as the score progresses.

Extending the frontiers of resectability in advanced colorectal cancer

AIM

To review the advances in the past decade that have enabled more patients with colorectal liver metastases (CRLM) to undergo curative hepatic resection.

METHODS

A comprehensive literature review and pertinent data published on advanced CRLM from The University of Texas M. D. Anderson Cancer Center were used for this review.

RESULTS

Criteria for resectability of CRLM have expanded with the advent of effective chemotherapy, improved surgical technique, and novel strategies such as preoperative volumetry, portal vein embolization, and two-stage hepatectomy. Despite the aggressiveness of these approaches to treating patients with advanced disease, recent series show an improvement in 5-year survival rate for patients with CRLM.

CONCLUSIONS

Advances in multidisciplinary management and careful patient selection have enabled more patients to undergo curative resection for CRLM, with corresponding improvement in survival rates.

Radiofrequency ablation versus resection for resectable colorectal liver metastases: time for a randomized trial?

BACKGROUND

Surgical resection is the gold standard in the treatment of resectable colorectal liver metastases (CRLM). In several centers, resection is being replaced by radiofrequency ablation (RFA), even though there is no evidence yet from randomized trials to support this. The aim of this study was to critically review the oncological evidence for and against the use of RFA for resectable CRLM.

METHODS

An exhaustive review of RFA of colorectal metastases was carried out.

RESULTS

Five-year survival data after RFA for resectable CRLM are not available. Percutaneous RFA is associated with worse local control, worse staging, and a small risk of electrode track seeding when compared with resection (level V evidence). For tumors </=3 cm, local control after surgical RFA is equivalent to resection, especially if applied by experienced physicians to nonperivascular tumors (level V evidence). There is indirect evidence for profoundly different biological effects of RFA and resection.

CONCLUSIONS

A subgroup of patients has been identified for whom local control after RFA might be equivalent to resection. Whether this is true, and whether this translates into equivalent survival, remains to be proven. The time has come for a randomized trial.

Modern multimodality approach to hepatic colorectal metastases: solutions and controversies

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of those patients with disease limited to the liver, which translates into only 5-10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort being directed towards novel approaches to permit curative hepatic resection such as: neoadjuvant systemic and regional chemotherapy, pre-operative portal vein embolization for hypertrophy of future liver remnant, staged hepatic resection and radio frequency ablation combined with resection for addressing multiple bilobar metastases. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

Perihepatic lymph node assessment in patients undergoing partial hepatectomy for malignancy

OBJECTIVE

To assess the value of preoperative imaging studies and the intraoperative assessment of perihepatic lymph nodes in patients undergoing partial hepatectomy for malignancy.

SUMMARY BACKGROUND DATA

Perihepatic lymph node status is an important prognostic factor for patients undergoing hepatic resection for 1(o) and metastatic cancer. The value of preoperative imaging studies and intraoperative assessment of perihepatic nodes is unknown.

METHODS

Perihepatic lymph nodes were sampled in 100 patients undergoing resection for 1(o) and metastatic hepatic malignancy. At the time of sampling, participating surgeons assigned a clinical suspicion score (scale, 1-5: 1 = clinically negative, 5 = clinically positive). Preoperative CT scans and PET scans were reviewed in a blinded fashion by 2 radiologists. Clinical assessment, CT, and PET scan results were analyzed in the context of the pathologic status of the lymph nodes.

RESULTS

A mean of 3.2 +/- 0.2 nodes were sampled per patient. Fifteen patients had metastatic disease in perihepatic lymph nodes; 13 had suggestive findings on preoperative CT or PET, and 2 were clinically positive at exploration. Clinical assessment had a high negative predictive value (NPV) = 99% but a low positive predictive value (PPV) = 39%. Similarly, CT scans had a high NPV = 95% and a low PPV = 30%. PET scans had a NPV = 88% and a PPV of 100%. Of the 48 patients with both negative preoperative CT and PET scans, only 1 (2.1%) had metastatic nodal disease, and this was suspected based on the clinical assessment. Of the patients with negative CT and PET scans and a negative clinical assessment (n = 39), none had involved perihepatic nodes.

CONCLUSIONS

In patients with 1(o) and metastatic liver cancer, the incidence of truly occult metastatic disease to perihepatic lymph nodes is low. Routine sampling of perihepatic lymph nodes will therefore have a low yield in patients without some evidence of disease on preoperative CT or PET scans or at the time of exploration.

Vaccination of colorectal cancer patients with CEA-loaded dendritic cells: antigen-specific T cell responses in DTH skin tests

BACKGROUND

Dendritic cells (DCs) are the professional antigen-presenting cells of the immune system. As such they are currently used in clinical vaccination protocols in cancer patients.

PATIENTS AND METHODS

We evaluated the ability of mature DCs pulsed with carcinoembryonic antigen (CEA)-peptide to induce CEA-specific T cell responses in patients with resectable liver metastases from colorectal cancer. CEA-specific T cell reactivity was monitored in peripheral blood, biopsies of vaccination sites and post-treatment DTH skin tests, and when available also in resected abdominal lymph nodes and tumor tissue.

RESULTS

Ten patients were vaccinated intradermally and intravenously with CEA-peptide pulsed mature DCs three times prior to resection of liver metastases. High numbers of CEA-specific T cells were detected in post-treatment DTH biopsies in seven out of 10 patients, which produced high amounts of interferon (IFN)-gamma upon stimulation with CEA-loaded target cells. These responses were not found in biopsies of first vaccination sites, indicating a de novo T cell induction or at least a strong potentiation by the vaccine. In addition, CEA-specific T cells were detected in a resected lymph node in one patient, but not in peripheral blood or tumor tissue.

CONCLUSIONS

Vaccination with CEA-peptide loaded mature DCs induced potent CEA-specific T cell responses in advanced colorectal cancer patients. In this study, antigen-specific T cell responses were readily detected in DTH skin tests, much less in abdominal lymph nodes, and not in peripheral blood and tumor tissue.

Surgical treatment of liver metastases of colorectal cancer: Strategies and controversies in 2006

AIMS

To review the latest strategies and controversies in the surgical treatment of liver metastases of colorectal cancer systemically and comprehensively.

METHODS

A medline based literature search on relevant topics was performed in PubMed for key articles concerning the novel strategies and controversies in the management of liver metastases of colorectal cancer. Some information was obtained from 'Proc Am Soc Clin Oncol' published recently. The findings and discussions were related to our own experiences.

RESULTS

Although for well-indicated patients, a consensus has been reached that hepatic resection is the only management that could provide the patients curability, there still exist many controversies, such as the prognostic evaluation, contraindications to hepatic resection, treatment for synchronous liver metastases, the place of laparoscopic surgery, etc. Meanwhile, various strategies to improve the respectabilities are available, including neoadjuvant chemotherapy, portal vein embolization, two stage hepatectomy, and some locally ablative approaches. The current condition is difficult and sometimes confusing for a relevant surgeon when designing treatment protocols for more complex diseases.

CONCLUSION

As the advancing of the management of liver metastases of colorectal cancer, more patients will become candidates for and benefit from potentially curative surgical resections. Optimal effect could only be achieved when used in a manner tailored to the individual patient.

Strategies to treat primary unresectable colorectal liver metastases

The liver is the most common site of metastases in patients with colorectal cancer (CRC), and hepatic metastases are responsible for fatalities in at least two thirds of patients with colorectal malignancy. However, the only available treatment associated with long-term survival in patients with CRC metastases is liver resection. While recent studies have shown that liver resection achieves a 5-year overall survival from 37% to 58%, only 10% to 20% of patients with colorectal liver metastases are eligible for resection. Pharmacologic developments and conceptual advances in chemotherapy, regional treatment, and aggressive surgical strategies have ultimately changed the current treatment of patients with primary unresectable liver metastases caused by CRC. Patients who were treated by only palliative chemotherapy a few years ago presently have a variety of strategies available to render their disease surgically resectable with the potential for long-term survival. These advances are the result of a strong collaboration between medical oncologists and surgeons. The development of new chemotherapy protocols that offer the potential for curative surgery with optimum timing within the natural history of this metastatic disease is a shared therapeutic challenge.