Recurrence After Partial Hepatectomy for Metastatic Colorectal Cancer: Potentially Curative Role of Salvage Repeat Resection

Surgical Management of Colorectal Cancer Liver Metastases

Approximately 50% of colorectal cancer patients develop liver metastases. Hepatic metastases represent the most common cause of colorectal cancer-related mortality. Metastasectomy, if possible, represents the most effective treatment strategy; 20% of patients will be cured and more than 50% survive at least 5 years. Nuances to treatment planning hinge on whether patients present with resectable disease upfront, whether the future liver remnant is adequate, and whether the primary tumor, if present, is colon versus rectal in origin. This article discusses considerations impacting our approach to patients with colorectal liver metastases and the role for various multimodal treatment options.

The Effect of Hepatic Surgical Margins of Colorectal Liver Metastases on Prognosis: A Systematic Review and Meta-Analysis

Introduction: Colorectal cancer is the third most common malignancy, with around half of patients developing liver metastases. Hepatectomy is the preferred treatment, but its success depends on several factors, including surgical margins. Various surgical margins have been suggested to achieve optimal results. This systematic review and meta-analysis aim to explore the impact of negative surgical margins ranging from 1 to 10 mm, and >10 mm on survival, with the objective of identifying optimal surgical margins. Methods: A systematic literature search was conducted on the MEDLINE, Scopus, and Cochrane databases. The six included studies that examined the effect of surgical margins at the aforementioned distances on patient survival. Studies were assessed for risk of bias using the Quality in Prognosis Studies tool. Statistical analysis was performed using SPSS software. Results: The results of the meta-analysis revealed the superiority of wider surgical margins (>10) on overall survival compared to smaller margins (1-10 mm), as the HR was calculated to be 1.38 [1.10; 1.73]. Specifically, negative margins between 1 and 10 mm are linked to a 38% increased risk of mortality compared to margins larger than 10 mm. The low heterogeneity indicates consistent findings across studies, and the statistically significant hazard ratio underscores the importance of aiming for larger surgical margins to enhance patient outcomes. In the subgroup that included only studies in which patients received neoadjuvant therapy, the HR was 1.48 [1.06; 2.07], further emphasizing the importance of ensuring negative surgical margins in today's era. Conclusions: In summary, this systematic review and meta-analysis highlights the impact of surgical margin width on the survival of patients with colorectal liver metastases, as well as the importance of margin optimization in surgical management strategies.

Prognostic Factors of Oligometastasis After Stereotactic Body Radiotherapy: The Real-World Utility of the European Society for Radiotherapy and Oncology/European Organisation for Research and Treatment of Cancer Classification

AIM

The efficacy of local therapy for oligometastatic disease (OMD) remains unclear. This study aimed to evaluate the prognostic utility of the classification system for OMD and explore which groups may benefit from stereotactic body radiation therapy (SBRT).

METHODS

This single-center retrospective study included 45 patients (52 sites) with solid tumors and 1-3 extracranial oligometastases who underwent SBRT for all metastases at our institution between January 2018 and December 2021. OMD states were classified based on the European Society for Radiotherapy and Oncology (ESTRO) and the European Organisation for Research and Treatment of Cancer (EORTC) classification system. Local control (LC), overall survival (OS), and progression-free survival (PFS) for each group were analyzed using the Kaplan-Meier method. Acute and late adverse events (AEs) were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.

RESULTS

The median follow-up period was 14 months (range: 0-48 months). The numbers of patients in the de novo (first diagnosis of OMD), repeat (previous history of OMD), and induced (previous history of polymetastatic disease) OMD groups were 15, 17, and 13, respectively. The LC rates at one year for the entire, de novo, repeat, and induced cohorts were 87.2%, 87.5%, 90.2%, and 83.9%, respectively (p=0.80). The one-year PFS rates for each group were 35.0%, 56.7%, and 29.9%, respectively (p=0.58). The one-year OS rates for each group were 80.0%, 86.2%, and 80.8%, respectively (p=0.50). Grade 2 or 3 AEs occurred in five patients (10.4%). No grade 4 or 5 AEs were observed.

CONCLUSIONS

SBRT is safe and highly effective for local control. Patients with repeat OMD demonstrated a trend of longer PFS, suggesting that this subgroup may benefit from local therapy at metastatic sites.

Extended Right Hepatectomy following Clearance of the Left Liver Lobe and Portal Vein Embolization for Curatively Intended Treatment of Extensive Bilobar Colorectal Liver Metastases: A Single-Center Case Series

BACKGROUND

Two-staged hepatectomy (TSH) including portal vein embolization (PVE) may offer surgical treatment for extensive bilobar colorectal liver metastases (CRLM). This study aimed to investigate the feasibility and outcomes of extended right hepatectomy (ERH) within TSH including PVE for patients with extended CRLM.

METHODS

We retrospectively collected data of patients who underwent TSH for extended CRLM between 2015 and 2021 at our institution. Clearance of the left liver lobe (clear-up, CU) associated with PVE was followed by ERH.

RESULTS

Minimally invasive (n = 12, 46%, MIH) or open hepatectomy (n = 14, 54%, OH) was performed. Postoperative major morbidity and 90-day mortality were 54% and 0%. Three-year overall survival was 95%. Baseline characteristics, postoperative and long-term outcomes were comparable between MIH and OH. However, hospital stay was significantly shorter after MIH (8 vs. 15 days, p = 0.008). Additionally, the need for intraoperative transfusions tended to be lower in the MIH group (17% vs. 50%, p = 0.110).

CONCLUSIONS

ERH following CU and PVE for extended CRLM is feasible and safe in laparoscopic and open approaches. MIH for ERH may result in shorter postoperative hospital stays. Further high-volume, multicenter studies are required to evaluate the potential superiority of MIH.

The Use of Hepatic Artery Infusion Chemotherapy for Unresectable Colorectal Cancer Liver Metastases

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in men and women (Siegel et al. in CA Cancer J Clin 72(1):7-33). Over one-half of newly diagnosed individuals will develop liver metastases. Among those with liver-only metastatic disease, only about one in five will be candidates for potentially curable resection.

The High Incidence of Occult Carcinoma in Total Hepatectomy Specimens of Patients Treated for Unresectable Colorectal Liver Metastases With Liver Transplant

OBJECTIVE

To describe the rate of occult carcinoma deposits in total hepatectomy specimens from patients treated with liver transplant (LT) for colorectal liver metastases (CRLM).

BACKGROUND

Previous studies have shown that patients with CRLM treated with systemic therapy demonstrate a high rate of complete radiographic response or may have disappearing liver metastases. However, this does not necessarily translate into a complete pathologic response, and residual invasive cancer may be found in up to 80% of the disappearing tumors after resection.

METHODS

Retrospective review of 14 patients who underwent LT for CRLM, at 2 centers. Radiographic and pathologic correlation of the number of tumors and their viability before and after LT was performed.

RESULTS

The median (interquartile range) number of tumors at diagnosis was 11 (4-23). The median number of chemotherapy cycles was 24 (16-37). Hepatic artery infusion was used in 5 patients (35.7%); 6 (42.9%) underwent surgical resection, and 5 (35.7%) received locoregional therapy. The indication for LT was unresectability in 8 patients (57.1%) and liver failure secondary to oncologic treatment in the remaining 6 (42.9%). Before LT, 7 patients (50%) demonstrated fluorodeoxyglucose-avid tumors and 7 (50%) had a complete radiographic response. Histopathologically, 11 patients (78.6%) had a viable tumor. Nine (64.2%) of the 14 patients were found to have undiagnosed metastases on explant pathology, with at least 22 unaccounted viable tumors before LT. Furthermore, 4 (57.1%) of the 7 patients who demonstrated complete radiographic response harbored viable carcinoma on explant pathology.

CONCLUSIONS

A complete radiographic response does not reliably predict a complete pathologic response. In patients with unresectable CRLM, total hepatectomy and LT represent a promising treatment options to prevent indolent disease progression from disappearing CRLM.

Liver transplantation for unresectable colorectal liver metastasis

PURPOSE OF REVIEW

To summarize the current state of liver transplantation (LT) for unresectable colorectal liver metastases (uCRLM), and to address future directions.

RECENT FINDINGS

The Norwegian secondary cancer (SECA) I and SECA II studies demonstrated that after LT the 5-year survival of a highly selected group of patients with uCRLM could be as high as 60% and 83%, respectively. After long-term follow-up, the 5- and 10-year survival was shown to be 43% and 26%, respectively. Furthermore, data has accumulated in other countries and a North American study reported a 1.5-year survival of 100%. In addition, steady growth has been demonstrated in the US, with 46 patients transplanted to date and 19 centers enrolling patients for this indication. Lastly, although recurrence is almost universal in patients with a high tumor burden, it has not been an accurate surrogate for survival, reflecting the relatively indolent nature of recurrence after LT.

SUMMARY

Growing evidence has shown that excellent survival and even cure can be achieved in highly selected patients with uCRLM, with survival rates far superior than in patients treated with chemotherapy. The next step is to create national registries to standardize selection criteria and establish the optimal approach and best practices for incorporating LT for uCRLM into the treatment armamentarium.

Liver transplantation in metastatic colorectal cancer: are we ready for it?

Colorectal cancer (CRC) is a prevalent disease worldwide, with more than 50% of patients developing metastases to the liver. Five-year overall survival remains modest among patients with metastatic CRC (mCRC) treated with conventional therapies however, liver transplantation in a highly selected population can improve clinical outcomes with an impressive 5-year overall survival of 83%. Despite liver transplantation appearing to be a promising therapeutical option for well-selected patients with mCRC with the liver-limited disease, these data come from small monocentric trials which included a heterogeneous population. Currently, several clinical trials are evaluating liver transplantation in this scenario, aiming for a more accurate patient selection by integrating liquid biopsy, tissue profiling, and nuclear medicine to the already known clinical biomarkers that eventually may lead to a survival improvement. In this paper, the clinical outcomes and inclusion criteria from the most relevant clinical trials and clinical series involving liver transplantation in patients with liver-limited disease colorectal cancer are reviewed as well as the trials currently recruiting.

Stage IV Colorectal Cancer Management and Treatment

(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.

Five-year survival post hepatectomy for colorectal liver metastases in a real-world Chinese cohort: Recurrence patterns and prediction for potential cure

BACKGROUND

Patients with a 5-year recurrence-free survival post liver resection for colorectal cancer liver metastases (CRLM) are considered to be potentially cured. However, there is a deficit of data on long-term follow-up and the recurrence status among these patients in the Chinese population. We analyzed real-world follow-up data of patients with CRLM who underwent hepatectomy, explored the recurrence patterns, and established a prediction model for a potential cure scenario.

METHODS

Patients who underwent radical hepatic resection for CRLM during 2000-2016, with actual follow-up data for at least 5 years, were enrolled. The observed survival rate was calculated and compared among the groups with different recurrence patterns. The predictive factors for 5-year non-recurrence were determined using logistic regression analysis; a recurrence-free survival model was developed to predict long-term survival.

RESULTS

A total of 433 patients were included, of whom 113 patients were found non-recurrence after 5 years follow-up, with a potential cure rate of 26.1%. Patients with late recurrence (>5 months) and lung relapse showed significantly superior survival. Repeated localized treatment significantly improved the long-term survival of patients with intrahepatic or extrahepatic recurrences. Multivariate analysis showed that RAS wild-type CRC, preoperative CEA <10 ng/ml, and liver metastases ≤3 were independent factors for a 5-year disease-free recurrence. A cure model was developed based on the above factors, achieving good performance in predicting long-term survival.

CONCLUSIONS

About one quarter patients with CRLM could achieve potential cure with non-recurrence at 5-year after surgery. The recurrence-free cure model could well distinguish the long-term survival, which would aid clinicians in determining the treatment strategy.

Predicting early extrahepatic recurrence after local treatment of colorectal liver metastases

BACKGROUND

Patients who develop early extrahepatic recurrence (EHR) may not benefit from local treatment of colorectal liver metastases (CRLMs). This study aimed to develop a prediction model for early EHR after local treatment of CRLMs using a national data set.

METHODS

A Cox regression prediction model for EHR was developed and validated internally using data on patients who had local treatment for CRLMs with curative intent. Performance assessment included calibration, discrimination, net benefit, and generalizability by internal-external cross-validation. The prognostic relevance of early EHR (within 6 months) was evaluated by landmark analysis.

RESULTS

During a median follow-up of 35 months, 557 of the 1077 patients had EHR and 249 died. Median overall survival was 19.5 (95 per cent c.i. 15.6 to 23.0) months in patients with early EHR after CRLM treatment, compared with not reached (45.3 months to not reached) in patients without an early EHR. The EHR prediction model included side and stage of the primary tumour, RAS/BRAFV600E mutational status, and number and size of CRLMs. The range of 6-month EHR predictions was 5.9-56.0 (i.q.r. 12.9-22.0) per cent. The model demonstrated good calibration and discrimination. The C-index through 6 and 12 months was 0.663 (95 per cent c.i. 0.624 to 0.702) and 0.661 (0.632 to 0.689) respectively. The observed 6-month EHR risk was 6.5 per cent for patients in the lowest quartile of predicted risk compared with 32.0 per cent in the highest quartile.

CONCLUSION

Early EHR after local treatment of CRLMs can be predicted.

Prognostic Significance of the Histopathological Growth Pattern and Tumor-Infiltrating Lymphocytes in Stratifying Survival After Hepatectomy for Colorectal Liver Metastases

BACKGROUND

A histopathological growth pattern (HGP) occurs at the interface between tumor cells and the surrounding liver parenchyma. Desmoplastic HGP (dHGP) is associated with a favorable prognosis and shows denser infiltration of lymphocytes than other HGPs. Tumor-infiltrating lymphocytes (TILs) exert antitumor immunity, nonetheless, their prognostic significance in patients with dHGP is unknown. This study aimed to identify the prognostic significance of HGP and TILs in colorectal liver metastasis (CRLM).

METHODS

The study analyzed 140 patients who underwent hepatectomy for CRLM. Depending on the type of HGP and TIL, the patients were categorized into four groups (dHGP/high TIL, dHGP/low TIL, non-dHGP/high TIL, and non-dHGP/low TIL) for a comparison of their recurrence-free survival (RFS) and overall survival (OS). Uni- and multivariate analyses were performed using a Cox proportional hazards model.

RESULTS

The RFS and OS curves differed significantly between the groups. The multivariate analysis showed that a combination of HGP and TIL could stratify the recurrence and survival outcomes.

CONCLUSION

This study indicated that a combination of HGP and TIL can stratify the risk of survival after hepatectomy in patients with CRLM.

Survival by Number and Sites of Resections of Recurrence after First Curative Resection of Colorectal Liver Metastases

BACKGROUND

Recurrence after curative hepatectomy for colorectal liver metastases (CRLM) is common. We sought to determine if number and sites of resections of recurrence after hepatectomy for CRLM impact survival.

METHODS

The study included patients who underwent resection of recurrence following complete curative-intent resection of CRLM during 1998-2016 at two academic medical centers in Houston, USA, and Rome, Italy. The survival impacts of number and sites of resections of recurrence were evaluated. Patients with synchronous extrahepatic disease at curative CRLM resection were excluded.

RESULTS

Among 2163 patients who underwent curative hepatectomy, 1456 (67.3%) developed a recurrence. Four hundred seventy-eight patients underwent one (322/478; 67.4%) or two or more (156/478; 32.6%) resections of recurrence. The 5-year overall survival (OS) rate was higher in patients with resected than unresected recurrence (70.2% vs. 24.0%; p < 0.001). In patients who underwent only one resection of recurrence, the 5-year OS rate differed by location (lung, 81.6%; liver, 64.3%; other, 54.1%). In patients who underwent two or more resections of recurrence, the 5-year OS rate was similar for liver-only resection (87.5%) and resection of liver and other sites (66.1%) (p = 0.223) and for liver-only resection and other-sites-only resection (80.7%) (p = 0.258); 5-year OS rate by site of first resection of recurrence did not differ between liver (78.5%) and lung (81.8%) (p = 0.502) but was worse for other sites (61.1%) than for lung (p = 0.045).

CONCLUSION

When recurrence after initial CRLM resection is resectable, the ability to undergo resection was associated with improved survival and can be considered as an option regardless of the number of recurrence and resection. Sites of resection of recurrence impact survival and should be considered.

Recurrence-free survival versus overall survival as a primary endpoint for studies of resected colorectal liver metastasis: a retrospective study and meta-analysis

BACKGROUND

Recurrence-free survival has been used as a surrogate endpoint for overall survival in trials involving patients with resected colorectal liver metastases. We aimed to assess the correlation between recurrence-free survival and overall survival after resection of colorectal liver metastases to determine the adequacy of this surrogate endpoint.

METHODS

In this retrospective study and meta-analysis, we compiled an institutional cohort of consecutive patients who had complete resection of colorectal liver metastases from the Memorial Sloan Kettering Cancer Center (New York, NY, USA) prospective database. Patients were eligible for inclusion if they were aged 18 years or older, and underwent hepatectomy, with or without operative ablation, between Jan 1, 1991, and April 30, 2019. We estimated overall survival and recurrence-free survival probabilities at various timepoints using the Kaplan-Meier method, and we assessed pairwise associations between these endpoints using Spearman's rank correlation. We also did a meta-analysis of adjuvant phase 3 clinical trials for colorectal liver metastases to assess the correlation between hazard ratios (HRs) for recurrence-free survival and overall survival. We searched MEDLINE for articles of phase 3 randomised controlled trials analysing adjuvant treatment strategies for resected colorectal metastases from database inception to Jan 1, 2022. The titles and abstracts of identified studies were screened before full-text screening and summary data were either recalculated or extracted manually from the published Kaplan-Meier curves (depending on data availability).

FINDINGS

Data were available for 3299 patients in the institutional database, of whom 2983 were eligible for inclusion in our cohort. Median follow-up was 8·4 years (95% CI 7·9-9·1) , during which time there were 1995 (67%) disease recurrences and 1684 (56%) deaths. Median recurrence-free survival was 1·3 years (95% CI 1·3-1·4) and median overall survival was 5·2 years (95% CI 5·0-5·5). 1428 (85%) of 1684 deaths were preceded by recurrence, and median time from recurrence to death was 2·0 years (IQR 1·0-3·4). Pairwise correlations between recurrence-free survival and overall survival were low to moderate, with a correlation estimate ranging from 0·30 (SD 0·17) to 0·56 (0·13). In the meta-analysis of adjuvant clinical trials, the Spearman's correlation coefficient between recurrence-free survival HR and overall survival HR was r=0·20 (p=0·71).

INTERPRETATION

We found a minimal correlation between recurrence-free survival and overall survival after resection of colorectal liver metastases. Recurrence-free survival is an inadequate surrogate endpoint for overall survival in this disease setting.

FUNDING

US National Cancer Institute.

C-reactive protein/albumin ratio and Glasgow prognostic score are associated with prognosis and infiltration of Foxp3+ or CD3+ lymphocytes in colorectal liver metastasis

BACKGROUND

Inflammatory indices and tumor-infiltrating lymphocytes (TILs) have prognostic value in many cancer types. This study aimed to assess the prognostic value of inflammatory indices and evaluate their correlation with survival and presence of TILs in patients with colorectal liver metastasis (CRLM).

METHODS

Medical records of 117 patients who underwent hepatectomy for CRLM were retrospectively reviewed. We calculated inflammatory indices comprising the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, C-reactive protein/albumin ratio (CAR), and Glasgow prognostic score (GPS). Furthermore, we evaluated the relationship between these ratios and the GPS and survival rates and immunohistochemical results of tumor-infiltrating CD3+, CD8+, and Foxp3+ lymphocytes.

RESULTS

The patients with low CAR values and low GPS had significantly better overall survival as per the log-rank test (p = 0.025 and p = 0.012, respectively). According to the multivariate analysis using the Cox proportional hazard model, the CAR (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.99; p = 0.048) and GPS (HR, 0.40; 95% CI, 0.19-0.83; p = 0.013) were independent prognostic factors. Additionally, Foxp3+ lymphocytes were more common in samples from the patients with a low CAR (p = 0.041). Moreover, the number of CD3+ TILs was significantly higher in the patients with a low GPS (p = 0.015).

CONCLUSIONS

The CAR and GPS are simple, inexpensive, and objective markers associated with predicting survival in patients with CRLM. Moreover, they can predict the presence of Foxp3+ and CD3+ lymphocytes in the invasive margin of a tumor.

TRIAL REGISTRATION

Retrospectively registered. https://www.kurume-u.ac.jp/uploaded/attachment/14282.pdf .

Patterns, treatments, and prognosis of tumor recurrence after resection for hepatocellular carcinoma with microvascular invasion: a multicenter study from China

BACKGROUND

Microvascular invasion (MVI) is a risk factor of post-hepatectomy tumor recurrence for hepatocellular carcinoma (HCC). The patterns, treatments, and prognosis have not been documented in HCC patients with MVI.

METHODS

A multicenter database of patients with HCC and MVI following resection was analyzed. The clinicopathological and initial operative data, timing and first sites of recurrence, recurrence management, and long-term survival outcomes were analyzed.

RESULTS

Of 1517 patients included, the median follow-up was 39.7 months. Tumor recurrence occurred in 928 patients, with 49% within 6 months of hepatectomy and 60% only in the liver. The incidence of intrahepatic only recurrence gradually increased with time after 6 months. Patients who developed recurrence within 6 months of hepatectomy had worse survival outcomes than those who developed recurrence later. Patients who developed intrahepatic only recurrence had better prognosis than those with either extrahepatic only recurrence or those with intra- and extrahepatic recurrence. Repeat resection of recurrence with curative intent resulted in better outcomes than other treatment modalities.

CONCLUSION

Post-hepatectomy tumor recurrence in patients with HCC and MVI had unique characteristics and recurrence patterns. Early detection of tumor recurrence and repeat liver resection with curative intent resulted in improved long-term survival outcomes.

A transcriptomic signature that predicts cancer recurrence after hepatectomy in patients with colorectal liver metastases

BACKGROUND

Cancer recurrence is an important predictor of survival outcomes in patients with colorectal cancer-associated liver metastasis (CRLM), who undergo radical hepatectomy. Therefore, identification of patients with the greatest risk of recurrence is critical for developing a precision oncology strategy that might include frequent surveillance (in low-risk patients) or a more aggressive treatment approach (in high-risk patients). We performed genome-wide expression profiling, to identify and develop a transcriptomic signature for predicting recurrence in patients with CRLM.

METHODS

We analysed a total of 383 patients with CRLM, including 63 patients from a publicly available data set (the NCBI's Gene Expression Omnibus with accession number GSE81423). and 320 patients from whom surgical specimens were collected for independent training (n = 169) and validation (n = 151) of identified biomarkers. Using Cox's proportional hazard regression analysis, we evaluated the clinical significance of the identified gene signature by comparing its performance with several key clinical factors.

RESULTS

We identified a six-gene panel that robustly categorised patients with recurrence in the discovery (area under the curve (AUC) = 0.90). We showed that the panel was a significant predictor of recurrence in the clinical training (AUC = 0.83) and validation cohorts (AUC = 0.81). By combining our panel with key clinical factors, we established a risk-stratification model that emerged as an independent predictor of recurrence (AUC = 0.85; univariate: hazard ratio (HR) = 4.34, 95% confidence interval (CI) = 2.71-6.93, P < 0.001; multivariate: HR = 3.40, 95% CI = 1.76-6.56, P < 0.001). The stratification model revealed recurrence prediction in 89% of high-risk group and non-recurrence in 62% of low-risk group.

CONCLUSIONS

We established a novel transcriptomic signature that robustly predicts recurrence, which has significant implications for the management of patients with CRLM.

Genomic Stratification of Resectable Colorectal Liver Metastasis Patients and Implications for Adjuvant Therapy and Survival

OBJECTIVE

To determine whether genomic risk groups identified by somatic mutation testing of colorectal liver metastasis (CRLM) can be used for "molecularly-guided" selection for adjuvant systemic chemotherapy and hepatic artery infusion of FUDR (SYS+HAI-FUDR).

BACKGROUND

Several genomic biomarkers have been associated with clinical phenotype and survival for patients with resectable CRLM. It is unknown whether prognostication afforded by genomic stratification translates into enhanced patient selection for adjuvant hepatic artery infusion therapy.

METHODS

Consecutive patients with resected CRLM and available mutational characterization via Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets were reviewed from a prospective institutional database. Patients were stratified into three genomic risk groups based on previously defined alterations in SMAD4, EGFR and the RAS/RAF pathway. The association between SYS+HAI-FUDR and overall survival, relative to adjuvant chemotherapy alone (SYS), was evaluated in each genomic risk group by Cox proportional hazard regression and propensity score matched analyses.

RESULTS

A total of 334 patients (SYS+HAI-FUDR 204; SYS 130) were identified; the rates of RAS/RAF alterations and SMAD4 inactivation were 47.4% and 11.7%, respectively. After a median follow-up of 58 months, adjuvant SYS+HAI-FUDR was independently associated with a reduced risk of death (HR 0.50, 95%CI 0.26-0.98, P = 0.045) in the low-risk genomic group, but not in the moderate-risk (HR 1.07, 95%CI 0.5-2.07, P = 0.749) or high-risk (HR 1.62, 95%CI 0.29-9.12, P = 0.537) cohorts. Following propensity score matching, adjuvant SYS+HAI-FUDR remained associated with significant improvements in long-term survival selectively in the low-risk genomic cohort (5-year actuarial survival: 89% vs. 68%, P = 0.019).

CONCLUSIONS

Genomic alterations in RAS/RAF, SMAD4, and EGFR may be useful to guide treatment selection in resectable CRLM patients and warrant external validation and integration in future clinical trial design.

Repeated hepatectomy after ALPPS for recurrence of colorectal liver metastasis: the edge of limits?

BACKGROUND

Repeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described.

METHODS

Patients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival.

RESULTS

Thirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy.

CONCLUSION

Repeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.

Recurrent colorectal liver metastasis patients could benefit from repeat hepatic resection

Background

Local treatment remains the best option for recurrent colorectal liver metastasis (CRLM). The current study aimed to investigate predictive factors of survival outcomes and select candidates for local treatment for CRLM at first recurrence.

Methods

Data were collected retrospectively from CRLM patients who underwent hepatic resection and developed first recurrence between 2000 and 2019 at our institution.
A nomogram predicting overall survival was established based on a multivariable Cox model of clinicopathologic factors. The predictive accuracy and discriminative ability of the nomogram were determined by the concordance index and calibration curve.

Results

Among 867 patients who underwent curative hepatic resection, 549 patients developed recurrence. Three hundred patients were evaluated and had resectable and liver-limited disease. Among them, repeat liver resection and percutaneous radiofrequency ablation were performed in 88 and 85 patients, respectively. The other 127 patients received only systemic chemotherapy. Multivariable analysis identified primary lymph node positivity, tumor size > 3 cm, early recurrence, RAS gene mutation and no local treatment as independent risk factors for survival outcomes. Integrating these five variables, the nomogram presented a good concordance index of 0.707. Compared with patients who received only systemic chemotherapy, radical local treatment did not significantly improve survival outcomes (median OS: 21 vs. 15 months, p = 0.126) in the high-risk group (total score ≥ 13).

Conclusion

Radical local treatment improved the survival of recurrent CRLM patients. The proposed model facilitates personalized assessments of prognosis for patients who develop first recurrence in the liver.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01323-y.

Colon Rectal Liver Metastases: The Role of the Liver Transplantation in the Era of the Transplant Oncology and Precision Medicine

The development of liver metastases in colon rectal cancer has a strong impact on the overall survival (OS) of the patient, with a 5-year survival rate of 5% with palliative treatment. Surgical resection combined with pharmacological treatment can achieve a 5-year OS rate of 31-58%. However, in only 20% of patients with colon rectal liver metastases (CRLMs), liver resection is feasible. In highly selected patients, recent trials and studies proved that liver transplantation (LT) for non-resectable CRLM is a surgical option with an excellent long-term OS. The paper aims to review the indications and outcome of LT for CRLMs, with a special focus on immunosuppressive therapy and the management of local and extrahepatic recurrence after LT.

Hyaluronic acid/ carboxymethyl cellulose-based adhesion barrier reduces surgical difficulty and complication in repeat hepatectomy

BACKGROUND

There has been no solid evidence regarding the actual efficacy of adhesion barriers in liver surgery.

METHODS

Difficulty grade of lysis of adhesion was evaluated in 122 patients who underwent repeat hepatectomy (ReHx) using the TORAD score. Technical difficulty of lysis of adhesion and incidence of complication were then compared between the group of patients who received a sheet-type adhesion barrier (Seprafilm®) in the previous hepatectomy (n = 70) and those who did not (n = 52) using the inverse probability weighting method.

RESULTS

Use of Seprafilm was significantly associated with lower grade of difficulty of lysis of adhesion according to the TORAD score (P < 0.001). Postoperative morbidity rate was lower and postoperative stay was shorter in the Seprafilm group in the propensity-score adjusted population (37% vs. 74%, P < 0.001 and 12 days vs. 14 days in median, P = 0.048). Multivariate analysis confirmed that use of Seprafilm was independent predictor for severity of adhesion (odds ratio [OR] 0.24, 95% CI, 0.09-0.65, P = 0.005) and decreased incidence of postoperative morbidity at ReHx (OR, 0.34; 95% CI, 0.14-0.84, P = 0.020).

CONCLUSIONS

Use of Seprafilm may be associated with decreased technical difficulty of lysis of adhesion and may correlate with lower risk of postoperative morbidity in patients undergoing ReHx.

Preoperative CA19-9: a competitive predictor of recurrence in patients with colorectal cancer liver metastases after hepatectomy

PURPOSE

The role of preoperative carbohydrate antigen 19-9 (CA19-9) in colorectal cancer liver metastases (CRLM) patients is still unclear. The present study aimed to explore the prognostic significance of preoperative CA19-9 in those patients.

METHODS

A total of 691 CRLM patients were included in this study. X-tile analyses were performed to determine the optimal cut-off values of CA19-9 and carcinoembryonic antigen (CEA). Prognostic predictors were identified by multivariate analyses.

RESULTS

The optimal cut-off values of CA19-9 and CEA for 5-year recurrence-free survival (RFS) were 35.24 U/ml and 20.4 ng/ml, respectively. Patients with high-level CA19-9 had significantly worse RFS and overall survival (OS) than those with low-level CA19-9 (P = 0.001 and P = 0.002, respectively). In addition, patients with high-level CA19-9 had poor RFS and OS (P = 0.028 and P = 0.011, respectively) at low-level CEA. Multivariate analyses confirmed that preoperative CA19-9 was an independent predictor for RFS (hazard ratio [HR] 1.295; 95% confidence interval [CI] 1.043-1.607; P = 0.019) but not for OS (HR 1.213; 95% CI 0.902-1.631; P = 0.201).

CONCLUSION

CA19-9 is a promising predictor of recurrence for CRLM patients undergoing hepatectomy, and an effective supplement for patients with low-level CEA.

Imaging and clinical features of colorectal liver metastases with macroscopic intrabiliary growth

PURPOSE

The purpose of this study was to evaluate imaging and clinical features of colorectal liver metastases complicated with macroscopic intrabiliary growth, and correlate the unusual pattern of spread with treatment and follow-up.

METHODS

A retrospective analysis of the clinical, imaging and follow-up files of all patients with surgically resected colorectal liver metastases from January 2016 to October 2020 was reviewed to identify those with macroscopic intrabiliary growth. Two radiologists evaluated the radiological features of colorectal liver metastasis with macroscopic intrabiliary growth. The histopathological findings and follow-up results were also investigated.

RESULTS

A total of 555 patients were included. Colorectal liver metastasis with macroscopic intrabiliary growth was present in 5 patients (0.9 %). Four patients experienced tumor recurrence or progression after surgical treatment (80 %), and recurrent tumors retained propensity for intraductal growth. CT (n = 6) and MR (n = 6) examinations were performed before 8 operations with the pathological examination confirmed macroscopic intrabiliary colorectal metastases. According to the location, intrabiliary colorectal metastases were classified into two categories: peripheral (n = 3) and central involvement (n = 5). The lengths of tumoral extension into the downstream bile duct were more than those of extension into the upstream bile duct (P = 0.029). On CT images, all cases showed dilated bile ducts filled with soft tissue attenuation presenting moderate (n = 4) or obvious (n = 2) enhancement. On MR images, all intra-hepatic and intrabiliary components of the metastases showed restricted diffusion on diffusion-weighted imaging, and peritumoral wedge-shaped T1-weighted hyperintensity appeared in the cases with obstruction of intrahepatic bile ducts.

CONCLUSIONS

The propensity for colorectal liver metastasis with intrabiliary growth to grow longitudinally and extend beyond the intrahepatic tumor edge elevates the risk of high recurrence after operation. Intrabiliary growth of liver metastasis exhibits characteristic MR and CT imaging features, which help to make an accurate diagnosis and improve treatment plans.

A novel prognostic nomogram for colorectal cancer liver metastasis patients with recurrence after hepatectomy

PURPOSE

We aimed to construct a nomogram to predict personalized post-recurrence survival (PRS) among colorectal cancer liver metastasis (CRLM) patients with post-hepatectomy recurrence.

METHODS

Colorectal cancer liver metastasis patients who received initial hepatectomy and had subsequent recurrence between 2001 and 2019 in Sun Yat-sen University Cancer Center from China were included in the study. Patients were randomly assigned to a training cohort and a validation cohort on a ratio of 2:1. Univariable analysis was first employed to select potential predictive factors for PRS. Then, the multivariable Cox regression model was applied to recognize independent prognostic factors. According to the model, a nomogram to predict PRS was established. The nomogram's predictive capacity was further assessed utilizing concordance index (C-index) values, calibration plots, and Kaplan-Meier curves.

RESULTS

About 376 patients were finally enrolled, with a 3-year PRS rate of 37.3% and a 5-year PRS rate of 24.6%. The following five independent predictors for PRS were determined to construct the nomogram: the largest size of liver metastases at initial hepatectomy, relapse-free survival, CEA level at recurrence, recurrent sites, and treatment for recurrence. The nomogram displayed fairly good discrimination and calibration. The C-index value was 0.742 for the training cohort and 0.773 for the validation cohort. Patients were grouped into three risk groups very well by the nomogram, with 5-year PRS rates of 45.2%, 23.3%, and 9.0%, respectively (p < 0.001) in the training cohort and 36.0%, 9.2%, and 4.6%, respectively (p < 0.001) in the validation cohort.

CONCLUSION

A novel nomogram was built and validated to enable the prediction of personal PRS in CRLM patients with post-hepatectomy recurrence. The nomogram may help physicians in decision making.

The Role of Neoadjuvant Chemotherapy in Repeat Local Treatment of Recurrent Colorectal Liver Metastases: A Systematic Review and Meta-Analysis

The additive value of neoadjuvant chemotherapy (NAC) prior to repeat local treatment of patients with recurrent colorectal liver metastases (CRLM) is unclear. A systematic search was performed in PubMed, Embase, Web of Science, and an additional search in Google Scholar to find articles comparing repeat local treatment by partial hepatectomy and/or thermal ablation with versus without NAC. The search included randomized trials and comparative observational studies with univariate/multivariate analysis and/or matching as well as (inter)national guidelines assessed using the AGREE II instrument. The search identified 21,832 records; 172 were selected for full-text review; 20 were included: 20 comparative observational studies were evaluated. Literature to evaluate the additive value of NAC prior to repeat local treatment was limited. Outcomes of NAC were often reported as subgroup analyses and reporting of results was frequently unclear. Assessment of the seven studies that qualified for inclusion in the meta-analysis showed conflicting results. Only one study reported a significant difference in overall survival (OS) favoring NAC prior to repeat local treatment. However, further analysis revealed a high risk for residual bias, because only a selected group of chemo-responders qualified for repeat local treatment, disregarding the non-responders who did not qualify. All guidelines that specifically mention recurrent disease (3/3) recommend repeat local treatment; none provide recommendations about the role of NAC. The inconclusive findings of this meta-analysis do not support recommendations to routinely favor NAC prior to repeat local treatment. This emphasizes the need to investigate the additive value of NAC prior to repeat local treatment of patients with recurrent CRLM in a future phase 3 randomized controlled trial (RCT).

Surgical Management of Colorectal Cancer Liver Metastases

Approximately 50% of colorectal cancer patients develop liver metastases. Hepatic metastases represent the most common cause of colorectal cancer-related mortality. Metastasectomy, if possible, represents the most effective treatment strategy; 20% of patients will be cured and more than 50% survive at least 5 years. Nuances to treatment planning hinge on whether patients present with resectable disease upfront, whether the future liver remnant is adequate, and whether the primary tumor, if present, is colon versus rectal in origin. This article discusses considerations impacting our approach to patients with colorectal liver metastases and the role for various multimodal treatment options.

Perioperative Chemotherapy for Liver Metastasis of Colorectal Cancer

The liver is the dominant site of metastasis for patients with colorectal cancer. For those with isolated liver metastases, surgical resection with systemic therapy has led to long-term remission in as high as 80% of patients in well-selected cohorts. This review will focus on how systemic therapy should be integrated with resection of liver metastases; in particular, the use of clinical risk scores based on clinicopathological features that help with patient selection, various approaches to the treatment of micro-metastatic disease (peri-operative versus post-operative chemotherapy), as well as conversion chemotherapy for those with initially upfront unresectable disease will be discussed.

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis

Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.

Liver transplantation for colorectal liver metastases: What do we need to know?

Adenocarcinoma of the colon and rectum (CRC) is the second leading cause of cancer mortality, driven by stage IV disease (Rahib et al., 2014) [1]. While surgical resection of liver metastases has demonstrated a survival advantage, a minority of patients are candidates for resection due to anatomic involvement of disease. Recent advances in liver surgery, chemotherapy, and decision making guided by stratification at the time of presentation has better equipped us to perform aggressive metastasectomies, with resulting improved survival (Fong et al., 1999; Abdalla et al., 2001; Cremolini et al., 2017) [2-4]. As a result, there is a resurgent interest in the concept of total hepatectomy and liver transplantation (LT) for colorectal liver metastases (CRLM). As of this writing, eight prospective clinical trials in six countries are assessing the viability of split or whole LT for CRLM. However, LT for CRLM remains controversial. Recent prospective trials have illustrated the importance of patient selection, and a disciplined respect for tumor biology. Here we present the current status of LT for CRLM, and suggest clinical decision criteria aimed at matching survival benefit comparable to other indications for LT.

Stereotactic radiofrequency ablation (SRFA) for recurrent colorectal liver metastases after hepatic resection

BACKGROUND

To evaluate the efficacy, safety and overall clinical outcome of multiprobe SRFA as a treatment for recurrent colorectal liver metastases after hepatic resection (HR).

METHODS

A retrospective, single center study carried out between 2006 and 2018. 64 consecutive patients with recurrent or new CRLM after previous HR were treated by SRFA for 217 lesions (median size 2.7 cm, 1-7.5) in 103 ablation sessions. Endpoints consisted of i) technical efficacy ii) complication and mortality rates iii) local and distant recurrence, iv) disease free survival (DFS), and v) overall survival (OS).

RESULTS

213/217 tumors were successfully ablated at initial SRFA (97.7% primary technical efficacy rate). Four tumors required repeat ablation, resulting in a secondary technical efficacy rate of 99.5% (216/217). Local recurrence developed in 25/217 lesions (11.5%). Major complication rate was 5.8% (6/103 sessions) and mortality rate was 1.0% (1/103 ablation sessions), respectively.1-, 3-, and 5- year OS rates from date of first SRFA were 90.1%, 46.2%, and 34.8% (median 33.1 months). DFS rates were 54.2%, 17.2%, and 17.2%, at 1-, 3- and 5- years, respectively (median 13.3 months).

CONCLUSION

SRFA is a safe, feasible and effective option for CRLM after HR with low morbidity levels and favorable clinical outcome.

Extrahepatic recurrence rates in patients receiving adjuvant hepatic artery infusion and systemic chemotherapy after complete resection of colorectal liver metastases

BACKGROUND

This study investigated the effect of the reduced dose of systemic chemotherapy (SYS) on recurrence patterns in patients receiving adjuvant hepatic artery infusion (HAI) chemotherapy after complete colorectal liver metastases (CRLM) resection.

METHODS

Patients undergoing complete CRLM resection between 2000 and 2007 were selected from a prospectively maintained database and categorized as receiving SYS or HAI + SYS. Those with pre and/or intraoperative extrahepatic disease, documented death, or recurrence within 30 days of CRLM resection were excluded. Competing risk, Fine and Gray's tests were used to compare SYS versus HAI + SYS for time-to-organ recurrence.

RESULTS

Of 361 study patients, 153 (42.4%) received SYS and 208 (57.6%) received HAI + SYS. The median follow-up for survivors was 100 (range = 12-185) and 156 months (range = 18-217) for SYS and HAI + SYS, respectively. The 5-year cumulative incidence (CI) of any liver recurrence was greater for those receiving SYS (SYS = 41.9% vs. HAI + SYS = 28.6%, p = .005). The 5-year CI of developing any lung or extrahepatic recurrence for SYS patients was 36.2% and 47.9% compared with 44.5% (p = .242) and 51.7% (p = .551), respectively, in patients receiving HAI + SYS.

CONCLUSION

Despite the reduced dose of SYS, adjuvant HAI + SYS after CRLM resection is not associated with a significantly increased risk of extrahepatic recurrence.

Liver transplantation for unresectable colorectal liver metastases in patients and donors with extended criteria (SECA-II arm D study)

BACKGROUND

Patients with metastatic colorectal cancer receiving palliative chemotherapy have a 5-year survival rate of approximately 10 per cent. Liver transplantation using strict selection criteria in patients with colorectal cancer and unresectable liver-only disease will result in a 5-year survival rate of 56-83 per cent. The aim of this study was to evaluate survival of patients with colorectal liver metastases (CRLM) after liver transplantation using extended criteria for both patients and donors.

METHODS

This was a prospective single-arm study. Patients with synchronous unresectable CRLM who were not suitable for arms A, B or C of the SEcondary CAncer (SECA) II study who had undergone radical resection of the primary tumour and received chemotherapy were included; they underwent liver transplantation with extended criteria donor grafts. Patients who had resectable pulmonary metastases were eligible for inclusion. The main exclusion criteria were BMI above 30 kg/m2 and liver metastases larger than 10 cm. Survival was estimated using Kaplan-Meier analysis.

RESULTS

Ten patients (median age 54 years; 3 women) were included. They had an extensive liver tumour load with a median of 20 (range 1-45) lesions; the median size of the largest lesion was 59 (range 15-94) mm. Eight patients had (y)pN2 disease, six had poorly differentiated or signet ring cell-differentiated primary tumours, and five had primary tumour in the ascending colon. The median Fong clinical risk score was 3 (range 2-5) and the median Oslo score was 1 (range 1-4). The median plasma carcinoembryonic antigen level was 4·3 (range 2-4346) μg/l. Median disease-free and overall survival was 4 and 18 months respectively.

CONCLUSION

Patients with unresectable liver-only CRLM undergoing liver transplantation with extended patient and donor criteria have relatively short overall survival.

Oncological outcomes of repeat metastasectomy for recurrence after hepatectomy for colorectal liver metastases. A case series

Background

Although hepatectomy is the standard and only curative treatment for colorectal liver metastases, recurrence occurs in various organs, including the remnant liver, lung, peritoneum, and others. The outcomes and predictive factors of repeat metastasectomy for recurrence after initial hepatectomy remains controversial.

Methods

We retrospectively assessed a consecutive series of 132 patients who underwent hepatectomy for colorectal liver metastases in a single institute.

Results

There were 99 recurrence cases after initial hepatectomy, and 42 patients underwent metastasectomy (first repeat metastasectomy) to achieve R0 (17 liver cases, 16 lung cases, and 9 multiple or other cases), while 19 patients underwent subsequent second repeat metastasectomy (4 liver cases, 7 lung cases, and 8 multiple or other cases). Among the 99 recurrent cases after initial hepatectomy, the 5-year overall survival rate of the patients who underwent first repeat metastasectomy was significantly higher than that of chemotherapy/BSC (best supportive care) patients (60% vs. 14%, P < 0.0001). Furthermore, among the 26 recurrent cases after first repeat metastasectomy, the 5-year overall survival rate of the patients who underwent second repeat metastasectomy was significantly higher than that of chemotherapy/BSC patients (P = 0.024). A multivariate analysis revealed that lack of adjuvant chemotherapy, a short (<12 months) disease-free interval, and right-side colon primary were the independent poor prognostic factors for the overall survival after first repeat metastasectomy.

Conclusion

The current study indicated that repeat metastasectomy for recurrence after initial hepatectomy for colorectal liver metastases could achieve a longer survival time, especially for patients with favorable predictive factors.

•

Forty-two patients underwent repeat metastasectomy for recurrence after hepatectomy for colorectal liver metastases.

•

Five-year survival rate of the repeat metastasectomy group was significantly higher than that of chemotherapy group.

•

A short disease-free interval was the independent poor prognostic factors for survival after repeat metastasectomy.

Characterisation and classification of oligometastatic disease: a European Society for Radiotherapy and Oncology and European Organisation for Research and Treatment of Cancer consensus recommendation

Oligometastatic disease has been proposed as an intermediate state between localised and systemically metastasised disease. In the absence of randomised phase 3 trials, early clinical studies show improved survival when radical local therapy is added to standard systemic therapy for oligometastatic disease. However, since no biomarker for the identification of patients with true oligometastatic disease is clinically available, the diagnosis of oligometastatic disease is based solely on imaging findings. A small number of metastases on imaging could represent different clinical scenarios, which are associated with different prognoses and might require different treatment strategies. 20 international experts including 19 members of the European Society for Radiotherapy and Oncology and European Organisation for Research and Treatment of Cancer OligoCare project developed a comprehensive system for characterisation and classification of oligometastatic disease. We first did a systematic review of the literature to identify inclusion and exclusion criteria of prospective interventional oligometastatic disease clinical trials. Next, we used a Delphi consensus process to select a total of 17 oligometastatic disease characterisation factors that should be assessed in all patients treated with radical local therapy for oligometastatic disease, both within and outside of clinical trials. Using a second round of the Delphi method, we established a decision tree for oligometastatic disease classification together with a nomenclature. We agreed oligometastatic disease as the overall umbrella term. A history of polymetastatic disease before diagnosis of oligometastatic disease was used as the criterion to differentiate between induced oligometastatic disease (previous history of polymetastatic disease) and genuine oligometastatic disease (no history of polymetastatic disease). We further subclassified genuine oligometastatic disease into repeat oligometastatic disease (previous history of oligometastatic disease) and de-novo oligometastatic disease (first time diagnosis of oligometastatic disease). In de-novo oligometastatic disease, we differentiated between synchronous and metachronous oligometastatic disease. We did a final subclassification into oligorecurrence, oligoprogression, and oligopersistence, considering whether oligometastatic disease is diagnosed during a treatment-free interval or during active systemic therapy and whether or not an oligometastatic lesion is progressing on current imaging. This oligometastatic disease classification and nomenclature needs to be prospectively evaluated by the OligoCare study.

FDG PET/CT in colorectal cancer

Colorectal cancer is the third most frequent cancer worldwide. Although its incidence is increasing, mainly in those aged under50, mortality has decreased by 50% in the more developed countries, principally due to the adoption of new practices in prevention, diagnosis and treatment. In particular, the various diagnostic imaging modalities allow improved therapeutic decision-making, evaluation of the response and early detection of recurrence. The aim of this paper is to review the available scientific evidence on the value of positron emission tomography with ¹⁸F-FDG (¹⁸F-FDG PET/CT) in the colorectal cancer, with special emphasis on the indications of the guidelines and recommendations of the main international scientific associations regarding this imaging technique.

Laparoscopic Parenchymal-Sparing Hepatectomy for Multiple Colorectal Liver Metastases Improves Outcomes and Salvageability: A Propensity Score-Matched Analysis

BACKGROUND

Parenchymal-sparing hepatectomy (PSH) is regarded as the standard of care for colorectal liver metastases (CRLMs) in open surgery. However, the surgical and oncological benefits of laparoscopic PSH compared with laparoscopic major hepatectomy (MH) have not been fully documented.

METHODS

A total of 269 patients who underwent initial laparoscopic liver resections with curative intent for CRLMs between 2004 and 2017 were enrolled. Preoperative patient characteristics and tumor burden were adjusted with propensity score matching, and laparoscopic PSH was compared with laparoscopic MH after matching.

RESULTS

PSH was performed in 148 patients, while MH was performed in 121 patients. After propensity score matching, 82 PSH and 82 MH patients showed similar preoperative characteristics. PSH was associated with lower rates of major postoperative complications compared with MH (6.1 vs. 15.9%; p = 0.046). Recurrence-free survival (RFS) and liver-specific RFS rates were comparable between both groups (p = 0.595 and 0.683). Repeat hepatectomy for liver recurrence was more frequently performed in the PSH group (63.9 vs. 36.4%; p = 0.022), and the PSH group also showed a trend toward a higher overall survival (OS) rate (5-year OS 79.4 vs. 64.3%; p = 0.067). Multivariate analyses revealed that initial MH was one of the risk factors to preclude repeat hepatectomy after liver recurrence (hazard ratio 2.39, p = 0.047).

CONCLUSIONS

Laparoscopic PSH provided surgical and oncological benefits for CRLMs, with less complications, similar recurrence rates, and increased salvageability through repeat hepatectomy, compared with laparoscopic MH. PSH should be the standard approach, even in laparoscopic procedures.

Salvage RFA in patients with intrahepatic recurrence after major hepatic surgery for colorectal cancer liver metastases: mid-term outcome

OBJECTIVES

To evaluate the mid-term outcome of salvage radiofrequency ablation (RFA) treatment in patients who exhibited intrahepatic recurrence after major hepatectomy for colorectal liver metastases (CRCLM).

METHODS

Observational study on 23 consecutive patients (mean age 59 ± 9 years; 14/9 male/female) who, after a single (11/23) or multiple rounds (12/23) of major hepatic surgery, developed recurrent CRCLM in the liver remnant. Patients with a maximum of three metastases measuring up to 3 cm, and without relevant extrahepatic disease, underwent CT-guided RFA. Using the Kaplan-Meier-method, median intrahepatic progression-free-survival (ihPFS) and overall survival (OS) times after salvage RFA were compared with the same patients' time between the respective last round of surgery and diagnosis of intrahepatic recurrence leading to RFA.

RESULTS

Median follow-up was 26 months (range 12-103 months). Median ihPFS time after RFA was 8 months (range 1-81 months). Median ihPFS time after the respective last round of surgery and RFA in the same patients had been 5 months (range 1-23 months), thus yielding similar ihPFS times after surgery vs. after salvage RFA (p = 0.238; Mood's median test). After RFA, 15/23 (65%) of patients developed new hepatic metastases within the first year post-RFA. Median OS was 37 months, with a 1-year OS rate of 100%, 3-year OS rate of 57%, and 5-year OS rate of 24%. No major complications were observed.

CONCLUSIONS

Patients who exhibit intrahepatic recurrence of CRCLM after major hepatectomy will experience intrahepatic recurrence after salvage RFA as well, and after similar time intervals. However, long-term ihPFS may still be achieved in some patients.

KEY POINTS

• Patients who exhibit intrahepatic recurrence of colorectal liver metastases after major hepatectomy will experience intrahepatic recurrence after salvage RFA as well, and after similar time intervals. • About two-thirds of all patients develop new metastases elsewhere in the liver within 1 year after RFA. • However, long-term intrahepatic progression-free survival may still be achieved in some patients.

Nomogram predicted disease free survival for colorectal liver metastasis patients with preoperative chemotherapy followed by hepatic resection

BACKGROUND

Hepatic resection is regarded to as a potentially curative option for colorectal cancer liver metastases (CRLM), but it is associated with a high rate of recurrence. The present study intended to establish an effective nomogram to predict disease free survival (DFS) and select candidates of hepatic resection.

METHODS

The nomogram was based on a retrospective study on 447 CRLM patients treated with preoperative chemotherapy followed by hepatic resection using a multicentric database between January 1st, 2010 and December 31st, 2017. Results were validated using bootstrap resampling on 117 patients. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index) and calibration curve. Overall survival, disease free survival, and local recurrence rate for patients with colorectal cancer were measured.

RESULTS

Based on multivariate analysis of the primary cohort, independent factors for DFS included tumor size larger than 5 cm, multiple liver metastases(>1), RAS mutation, primary lymph node metastasis and tumor size increase after preoperative chemotherapy. These five factors were all considered in the nomogram. The C-index of the nomogram for predicting survival was 0.675. With external validation, the C-index of the nomogram for the prediction of the DFS was 0.77, which demonstrated that this model has a good level of discriminative ability. For the 382 patients (66.7%) who developed recurrence, the optimal cutoff point for early recurrence was determined to be 12 months after hepatic resection.

CONCLUSIONS

The proposed nomogram demonstrated accurate prognostic prediction of DFS for CRLM patients with preoperative chemotherapy followed by hepatic resection.

Role of Repeat Resection in Patients With Metastatic Colorectal Cancer: A Multicenter Retrospective Study

BACKGROUND

Little is known about repeat resection for recurrence exclusive of the liver and lungs and the natural history after the first curative resection in patients with metastatic colorectal cancer.

OBJECTIVE

This study aimed to investigate the role of repeat resection for recurrence of metastatic colorectal cancer in a Japanese cohort.

DESIGN

This is a multi-institution retrospective observational study.

SETTING

This study was conducted at participating tertiary referral hospitals.

PATIENTS

Patients with metastatic colorectal cancer who had synchronous distant metastases and underwent simultaneous resection of primary and distant disease or sequential staged resection at short intervals between 1997 and 2007 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were patterns of recurrence site, treatments, and survival.

RESULTS

A total of 1133 patients were identified, of whom 1073 were eligible. In total, 809 of the 1073 patients developed recurrence after curative resection, and 323 of these underwent repeat resection for recurrence. Of these, 211 developed re-recurrence; 80 of these patients underwent a second repeat resection. When stratified by site of recurrence, the 5-year overall survival rate in patients who underwent repeat resection was 56% in those with recurrence in the liver only, 43% in those with recurrence in the lung only, 30% in those with peritoneal seeding only, and 28% in those with multiple organ involvement. In patients who underwent a second repeat resection, the 5-year overall survival rates were 56%, 46%, 100%, and 50%.

LIMITATIONS

This study was limited by its retrospective study design.

CONCLUSIONS

Repeat surgery could have long-term survival benefit in patients with metastatic colorectal cancer who develop recurrence or re-recurrence in the liver or lung following curative resection. However, repeat surgery should be considered carefully in patients with peritoneal seeding only or recurrence at multiple sites. See Video Abstract at http://links.lww.com/DCR/A838.

Long-term quality of life after liver transplantation for non-resectable colorectal metastases confined to the liver

BACKGROUND

Liver transplantation for patients with non-resectable colorectal liver metastases offers increased survival, with median overall survival of more than 5 years. The aim of this study was to compare quality of life before and up to 3 years after liver transplantation for colorectal liver metastases.

METHODS

Quality of life was assessed using the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire version 3.0. The patients received the questionnaire before and up to 3 years after liver transplantation.

RESULTS

Some 23 patients were included in the analysis. Three months after liver transplantation they reported reduced quality of life (global health status scale), physical function and role function, and increased dyspnoea. At 6 months, global health status, physical function and role function had returned to pretransplant values. Three years after liver transplantation all symptom and function scores were comparable to baseline values. Patients with high scores for fatigue, pain and appetite loss at baseline had reduced 3-year overall survival.

CONCLUSION

Patients with non-resectable colorectal liver-only metastases receiving liver transplantation had good long-term quality of life. Patients with high symptom scores before transplantation had reduced 3-year overall survival.

Salvage treatment for recurrences after first resection of colorectal liver metastases: the impact of histopathological growth patterns

The majority of patients recur after resection of colorectal liver metastases (CRLM). Patients with CRLM displaying a desmoplastic histopathological growth pattern (dHGP) have a better prognosis and lower probability of recurrence than patients with non-dHGP CRLM. The current study evaluates the impact of HGP type on the pattern and treatment of recurrences after first resection of CRLM. A retrospective cohort study was performed, including patients with known HGP type after complete resection of CRLM. All patients were treated between 2000 and 2015. The HGP was determined on the CRLM resected at first partial hepatectomy. The prognostic value of HGPs, in terms of survival outcome, in the current patient cohort were previously published. In total 690 patients were included, of which 492 (71%) developed recurrent disease. CRLM displaying dHGP were observed in 103 patients (21%). Amongst patients with dHGP CRLM diagnosed with recurrent disease, more liver-limited recurrences were seen (43% vs. 31%, p = 0.030), whereas patients with non-dHGP more often recurred at multiple locations (34% vs. 19%, p = 0.005). Patients with dHGP CRLM were more likely to undergo curatively intended local treatment for recurrent disease (adjusted odds ratio: 2.37; 95% confidence interval (CI) [1.46-3.84]; p < 0.001) compared to patients with non-dHGP. The present study demonstrates that liver-limited disease recurrence after complete resection of CRLM is more often seen in patients with dHGP, whereas patients with non-dHGP more frequently experience multi-organ recurrence. Recurrences in patients with dHGP at first CRLM resection are more likely to be salvageable by local treatment modalities, but no prognostic impact of HGPs after salvage therapy for recurrent disease was found.

Radiofrequency ablation versus resection for technically resectable colorectal liver metastasis: a propensity score analysis

BACKGROUND

Liver resection is the first-line treatment for patients with resectable colorectal liver metastasis (CRLM), while radiofrequency ablation (RFA) can be used for small unresectable CRLM because of disease extent, poor anatomical location, or comorbidities. However, the long-term outcomes are unclear for RFA treatment in resectable CRLM. This study aimed to compare the recurrence rates and prognosis between resectable CRLM patients receiving either liver resection or RFA.

METHODS

Consecutive patients who underwent RFA or hepatic resection from November 2010 to December 2015 were assigned in this retrospective study. Propensity score analysis was used to eliminate baseline differences between groups. Survival and recurrence rates were compared between patients receiving liver resection and RFA.

RESULTS

With 1:2 ratio of propensity scoring, 46 patients in the RFA group and 92 in the resection group were successfully matched. Overall survival was similar between the two groups, but the resection group had a higher disease-free survival (median, 22 months vs. 14 months). Whereas among patients with a tumor size of ≤ 3 cm, disease-free survival was similar in the two groups (median, 24 months vs. 21 months). Compared to the resection group, the RFA group had a higher rate of intrahepatic recurrence (34.8% vs. 12.0%) and a shorter recurrence free period. The local and systemic recurrence rate and recurrence-free period for the same were insignificant in the two groups. Poor disease-free survival was associated with RFA, T4, tumor diameter > 3 cm, and lymph node positivity.

CONCLUSION

Among patients with technically resectable CRLM, resection provided greater disease-free survival, although both treatment modalities provided similar overall survival.