Simple definition of biologically borderline resectable colorectal liver metastases based on early surgical failure

BACKGROUND

The benefit of neoadjuvant chemotherapy (NAC) in patients with resectable colorectal liver metastasis (CRLM) is debatable. This study aimed to establish a definition of biologically borderline resectable CRLM based on early surgical failure.

METHODS

One hundred forty-two patients who underwent upfront surgery for resectable CRLM were examined. Potential predictors of early surgical failure were investigated to establish a definition of biologically borderline resectable CRLM. The impact of NAC on overall survival (OS) in patients with borderline resectable CRLM was examined, as were predictors of OS.

RESULTS

Extrahepatic lesions (p < 0.01) and tumor ≥ 30 mm with carcinoembryonic antigen (CEA) concentration ≥ 20 ng/mL (p = 0.02) were independent predictors of early surgical failure. Borderline resectable CRLM was defined as extrahepatic lesions or tumor size ≥ 30 mm with CEA concentration ≥ 20 ng/mL. Fifty-eight patients had borderline resectable CRLM. Three-year OS was significantly higher in borderline resectable CRLM patients who received NAC than in those who did not (71.8% vs. 52.7%) and 5-year survival was also significantly higher in this group (62.8% vs. 25.5%).

CONCLUSION

We have proposed a simple definition of biologically borderline resectable CRLM based on early surgical failure. NAC could be a good indication for patients who met the definition.

Proposal of "borderline resectable" colorectal liver metastases based on analysis of risk factors for early surgical failure

PURPOSE

We aimed to define borderline resectable colorectal liver metastases (CRLM) based on the analysis of risk factors for early surgical failure and investigate the efficacy of neoadjuvant chemotherapy in these patients.

METHODS

This was a retrospective analysis of a multi-institutional cohort of patients diagnosed with technically resectable CRLM. Early surgical failure within 6 months of liver surgery was defined as ESF6. We classified CRLM into three grades (A, B, and C) according to the definition of the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

Among the 249 patients with technically resectable CRLM, 46 (18.5%) developed ESF6. The survival rate of these patients was significantly lower than that of the patients without ESF6. In the multivariate analysis of synchronous CRLM patients, no neoadjuvant chemotherapy, Grade B/C, and Charlson comorbidity index ≥ 3 were independent predictors of ESF6. Among patients with synchronous and Grade B/C CRLM, ESF6 rates, surgical failure-free survival, and overall survival in the neoadjuvant chemotherapy group were significantly better relative to the upfront surgery group.

CONCLUSIONS

Patients with synchronous and Grade B/C CRLM are at a high risk of early surgical failure, have a poor long-term prognosis, and can be defined as borderline resectable and good candidates for neoadjuvant chemotherapy.

Treatment outcomes and prognostic factors in patients with colorectal cancer and synchronous lung metastases in the conversion therapy era

PURPOSE

The Japanese Grade Classification based on the status of pulmonary and mesenteric nodal metastases and the presence of extrapulmonary metastases had a prognostic value in patients with colorectal lung metastases previously. Because the survival of such patients has improved in the era of conversion therapy, this classification needs to be reaudited.

METHODS

This study reviewed the treatment sequences of 126 colorectal cancer patients with synchronous lung metastases between 2010 and 2022 at our hospital. Patients were divided into Japanese Classification Grade A, B, and C. Prognostic factors for overall survival (OS) were analyzed.

RESULTS

Thirty patients were initially diagnosed with resectable disease. Among these, 6 (35%) of 17 patients who were scheduled to undergo upfront surgery developed unresectable disease. In contrast, 3 (23%) of 13 patients receiving neoadjuvant therapy could not undergo curative resection. Twelve (13%) of 96 patients with initially unresectable metastases underwent conversion to complete resection after systemic therapy. On multivariate analysis, curative resection and H3 (> 5 liver metastases and maximum diameter > 5 cm) at diagnosis were independent prognostic factors, whereas the Japanese Grade Classification was not associated with OS.

CONCLUSION

Instead of the Japanese classification, a new prognostic classification incorporating H3 should be established.

Efficacy of neoadjuvant chemotherapy in patients with high-risk resectable colorectal liver metastases

BACKGROUND

The role of preoperative neoadjuvant chemotherapy (NAC) in patients with resectable colorectal liver metastases (CRLM) remains undetermined. This study aimed to assess the efficacy of NAC in patients with resectable CRLM, especially in high-risk subgroups for recurrence, with special reference to synchronicity and the CRLM grade in the Japanese classification system.

METHODS

A retrospective analysis of a multi-institutional cohort who was diagnosed with resectable CRLM was performed. CRLM was classified into three grades (A, B, and C) according to the combination of H stage (H1: ≤ 4 lesions and ≤ 5 cm, H2: ≥ 5 lesions or > 5 cm, H3: ≥ 5 lesions and > 5 cm), nodal status of the primary tumor (pN0/1: ≤ 3 metastases, pN2: ≥ 4 metastases), and the presence of resectable extrahepatic metastases.

RESULTS

Among 222 patients with resectable CRLM, 97 (43.7%) had synchronous CRLM. The surgical failure-free survival (SF-FS) of patients with synchronous CRLM (without NAC) was significantly worse than that of patients with metachronous CRLM (P = 0.0264). The SF-FS of patients with Grade B/C was also significantly worse than that of Grade A (P = 0.0058). Among the 53 patients with synchronous and Grade B/C CRLM, 31 were assigned to NAC, and all of them underwent liver surgery. In this high-risk subgroup, the SF-FS and OS in the NAC group were significantly better than those in the upfront surgery group (P < 0.0001 and P = 0.0004, respectively).

CONCLUSIONS

Patients with synchronous and Grade B/C CRLM could be good candidates for indication of NAC.

Proposal of a novel H category-based classification of colorectal liver metastases based on a Japanese nationwide survey

BACKGROUND

The conventional H category-based classification for colorectal liver metastases (CRLM) was created by equal weighting of tumor number and tumor size; however, our previous nomogram to predict postoperative disease-free survival demonstrated that CRLM ≥5 as a parameter provided 4.5 times greater impact compared with a largest CRLM size >5 cm.

METHODS

A total of 3815 patients newly diagnosed with CRLM between 2005 and 2007, including 2220 resectable cases, were investigated. Six groups were created based on largest lesion size (≤ 5 vs >5 cm) and lesion number (1, 2-4, and ≥5).

RESULTS

The novel (n) H1, nH2, and nH3 categories were defined as solitary lesions with a size ≤5 cm; lesions other than nH1 or nH3; and ≥5 lesions with any lesion size, respectively. In the resectable cohort, the 5-year cumulative overall survival rates were 64.0%, 53.5%, and 42.6% in the nH1, nH2, and nH3 groups, respectively (P < .001), and no significant differences were observed between the conventional H2 and H3 categories. In the overall cohort, the discrimination ability of the two classifications were comparable.

CONCLUSION

The novel H category-based classification might be beneficial in predicting overall survival in patients with CRLM independent of their resectability.

Proposal of a modified subclassification system for stage III colorectal cancer: A multi-institutional retrospective analysis

AIM

The prognostic value of the stage III subclassification system based on the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma has not yet been clarified. This study aimed to develop a modified system with optimal risk stratification and compare its performance with the current staging systems.

METHODS

Clinicopathological data from 6855 patients with stage III colorectal cancers who underwent D3 dissection were collected from a nationwide multicenter database. After determining patient survival rates across 13 divisions based on pathological N stage (N1, N2a, and N2b/N3) and tumor depth (T1, T2, T3, T4a, and T4b), except for T1N2a and T1N2b/N3 due to the small number, we categorized patients into three groups and developed a trisection staging system according to the Akaike information criterion. We then compared the Akaike information criterion of the developed system with those of the current staging systems.

RESULTS

The T1N1[rank, 1] division (98.5%) had the most favorable prognosis in terms of 5-year cancer-specific survival, followed by T2N1[2] (93.9%), T2N2a[3] (92.0%), T3N1[4] (87.0%), T3N2a[5] (78.8%), T4aN1[6] (78.7%), T2N2b/N3[7] (77.8%), T4aN2a[8] (75.2%), T4bN1[9] (73.5%), T3N2b/N3[10] (64.7%), T4aN2b/N3[11] (61.5%), T4bN2b/N3[12] (43.0%), and T4bN2a[13] (42.5%). Compared to the categorizations of the Japanese and tumor-node-metastasis systems (Akaike information criterion, 22 684.6 and 22 727.1, respectively), the following stage categorizations were proven to be the most clinically efficacious: T1N1[1 ]-T3N1[4], T3N2a[5 ]-T4bN1[9], and T3N2b/N3[10 ]-T4bN2a[13] (Akaike information criterion, 22 649.2).

CONCLUSION

The proposed modified system may be useful in the risk stratification of patients with stage III colorectal cancer who had undergone D3 dissection.

Pan-Asian adapted ESMO consensus guidelines for the management of patients with metastatic colorectal cancer: a JSMO-ESMO initiative endorsed by CSCO, KACO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) consensus guidelines for the treatment of patients with metastatic colorectal cancer (mCRC) was published in 2016, identifying both a more strategic approach to the administration of the available systemic therapy choices, and a greater emphasis on the use of ablative techniques, including surgery. At the 2016 ESMO Asia Meeting, in December 2016, it was decided by both ESMO and the Japanese Society of Medical Oncology (JSMO) to convene a special guidelines meeting, endorsed by both ESMO and JSMO, immediately after the JSMO 2017 Annual Meeting. The aim was to adapt the ESMO consensus guidelines to take into account the ethnic differences relating to the toxicity as well as other aspects of certain systemic treatments in patients of Asian ethnicity. These guidelines represent the consensus opinions reached by experts in the treatment of patients with mCRC identified by the Presidents of the oncological societies of Japan (JSMO), China (Chinese Society of Clinical Oncology), Korea (Korean Association for Clinical Oncology), Malaysia (Malaysian Oncological Society), Singapore (Singapore Society of Oncology) and Taiwan (Taiwan Oncology Society). The voting was based on scientific evidence and was independent of both the current treatment practices and the drug availability and reimbursement situations in the individual participating Asian countries.