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Lehtomäki K, Soveri LM, Osterlund E, Lamminmäki A, Uutela A, Heervä E, Halonen P, Stedt H, Aho S, Muhonen T, Ålgars A, Salminen T, Kallio R, Nordin A, Aroviita L, Nyandoto P, Kononen J, Glimelius B, Ristamäki R, Isoniemi H, Osterlund P. Resectability, Resections, Survival Outcomes, and Quality of Life in Older Adult Patients with Metastatic Colorectal Cancer (the RAXO-Study). J Clin Med 2023; 12:jcm12103541. [PMID: 37240646 DOI: 10.3390/jcm12103541] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Older adults are underrepresented in metastatic colorectal cancer (mCRC) studies and thus may not receive optimal treatment, especially not metastasectomies. The prospective Finnish real-life RAXO-study included 1086 any organ mCRC patients. We assessed repeated centralized resectability, overall survival (OS), and quality of life (QoL) using 15D and EORTC QLQ-C30/CR29. Older adults (>75 years; n = 181, 17%) had worse ECOG performance status than adults (<75 years, n = 905, 83%), and their metastases were less likely upfront resectable. The local hospitals underestimated resectability in 48% of older adults and in 34% of adults compared with the centralized multidisciplinary team (MDT) evaluation (p < 0.001). The older adults compared with adults were less likely to undergo curative-intent R0/1-resection (19% vs. 32%), but when resection was achieved, OS was not significantly different (HR 1.54 [CI 95% 0.9-2.6]; 5-year OS-rate 58% vs. 67%). 'Systemic therapy only' patients had no age-related survival differences. QoL was similar in older adults and adults during curative treatment phase (15D 0.882-0.959/0.872-0.907 [scale 0-1]; GHS 62-94/68-79 [scale 0-100], respectively). Complete curative-intent resection of mCRC leads to excellent survival and QoL even in older adults. Older adults with mCRC should be actively evaluated by a specialized MDT and offered surgical or local ablative treatment whenever possible.
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Grants
- 2016, 2018, 2019, 2020, 2021, 2022, 2023 Finska Läkaresällskapet
- 2019-2020, 2021, 2022-23 Finnish Cancer Foundation
- 2023 Swedish Cancer Society
- 2022-2023 Radium Hemmets Research Funds
- 2020-2022 Relander's Foundation
- 2016, 2017, 2018, 2019, 2020, 2021,2022, 2023 Competitive State Research Financing of the Expert Responsibility Area of Tampere, Helsinki and Turku
- Tukisäätiö 2019, 2020; OOO 2020 Tampere University Hospital
- 2019, 2020, 2021, 2022 Helsinki University Hospital
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Affiliation(s)
- Kaisa Lehtomäki
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Leena-Maija Soveri
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Home Care, Joint Municipal Authority for Health Care and Social Services in Keski-Uusimaa, 05850 Hyvinkää, Finland
| | - Emerik Osterlund
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Annamarja Lamminmäki
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Aki Uutela
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Eetu Heervä
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Päivi Halonen
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Hanna Stedt
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Sonja Aho
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Timo Muhonen
- Department of Oncology, South Carelia Central Hospital, Valto Käkelän Katu 1, 53130 Lappeenranta, Finland
| | - Annika Ålgars
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Tapio Salminen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Raija Kallio
- Department of Oncology, Oulu University Hospital, Kajaanintie 50, 90220 Oulu, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Laura Aroviita
- Department of Oncology, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland
| | - Paul Nyandoto
- Department of Oncology, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Juha Kononen
- Docrates Cancer Centre, Docrates Hospital, Saukonpaadenranta 2, 00180 Helsinki, Finland
- Department of Oncology, Central Finland Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Raija Ristamäki
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Helena Isoniemi
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Pia Osterlund
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Department of Gastrointestinal Oncology, Tema Cancer, Karolinska Universitetssjukhuset, Eugeniavägen 3, 17176 Solna, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solnavägen 1, 17177 Solna, Sweden
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Parmar KL, O'Reilly D, Valle J, Braun M, Malcomson L, Jones RP, Balaa F, Rees M, Welsh FKS, Filobbos R, Renehan AG. Protocol for the CoNoR Study: A prospective multi-step study of the potential added benefit of two novel assessment tools in colorectal liver metastases technical resectability decision-making. BMJ Open 2023; 13:e059369. [PMID: 36997247 PMCID: PMC10069542 DOI: 10.1136/bmjopen-2021-059369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Liver resection is the only curative treatment for colorectal liver metastases (CLM). Resectability decision-making is therefore a key determinant of outcomes. Wide variation has been demonstrated in resectability decision-making, despite the existence of criteria. This paper summarises a study protocol to evaluate the potential added value of two novel assessment tools in assessing CLM technical resectability: the Hepatica preoperative MR scan (MR-based volumetry, Couinaud segmentation, liver tissue characteristics and operative planning tool) and the LiMAx test (hepatic functional capacity). METHODS AND ANALYSIS This study uses a systematic multistep approach, whereby three preparatory workstreams aid the design of the final international case-based scenario survey:Workstream 1: systematic literature review of published resectability criteria.Workstream 2: international hepatopancreatobiliary (HPB) interviews.Workstream 3: international HPB questionnaire.Workstream 4: international HPB case-based scenario survey.The primary outcome measures are change in resectability decision-making and change in planned operative strategy, resulting from the novel test results. Secondary outcome measures are variability in CLM resectability decision-making and opinions on the role for novel tools. ETHICS AND DISSEMINATION The study protocol has been approved by a National Health Service Research Ethics Committee and registered with the Health Research Authority. Dissemination will be via international and national conferences. Manuscripts will be published. REGISTRATION DETAILS The CoNoR Study is registered with ClinicalTrials.gov (registration number NCT04270851). The systematic review is registered on the PROSPERO database (registration number CRD42019136748).
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Affiliation(s)
- Kat L Parmar
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Cancer Research Centre, Manchester, UK
| | - Derek O'Reilly
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Department of Hepatobiliary Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Juan Valle
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Michael Braun
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Lee Malcomson
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Cancer Research Centre, Manchester, UK
| | - Robert P Jones
- Department of Hepatobiliary Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Fady Balaa
- Department of Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Myrddin Rees
- Department of Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Fenella K S Welsh
- Department of Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Rafik Filobbos
- Department of Radiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew G Renehan
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Cancer Research Centre, Manchester, UK
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Aquina CT, Brown ZJ, Beane JD, Ejaz A, Cloyd JM, Tsung A, Adam MO, Pawlik TM, Kim AC. Disparities in Care Access to Liver-Directed Therapy Among Medicare Beneficiaries with Colorectal Cancer Liver Metastasis. Ann Surg Oncol 2023; 30:335-344. [PMID: 36149611 PMCID: PMC9510323 DOI: 10.1245/s10434-022-12513-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver-directed therapies (LDT) are important components of the multidisciplinary care of patients with colorectal cancer liver metastases (CRCLM) that contribute to improved long-term outcomes. Factors associated with receipt of LDT are poorly understood. PATIENTS AND METHODS Patients > 65 years old diagnosed with CRCLM were identified within the Medicare Standard Analytic File (2013-2017). Patients with extrahepatic metastatic disease were excluded. Mixed-effects analyses were used to assess patient factors associated with the primary outcome of LDT, defined as hepatectomy, ablation, and/or hepatic artery infusion chemotherapy (HAIC), as well as the secondary outcome of hepatectomy. RESULTS Among 23,484 patients with isolated CRCLM, only 2004 (8.5%) received LDT, although resectability status could not be determined for the entire cohort. Among patients who received LDT, 61.7% underwent hepatectomy alone, 28.1% received ablation alone, 8.5% underwent hepatectomy and ablation, and 1.8% received HAIC either alone (0.8%) or in combination with hepatectomy and/or ablation (0.9%). Patient factors independently associated with lower odds of LDT included older age, female sex, Black race, greater comorbidity burden, higher social vulnerability index, primary rectal cancer, synchronous liver metastasis, and further distance from a high-volume liver surgery center (p < 0.05). Results were similar for receipt of hepatectomy. CONCLUSIONS Despite the well-accepted role of LDT for CRCLM, only a small proportion of Medicare beneficiaries with CRCLM receive LDT. Increasing access to specialized centers with expertise in LDT, particularly for Black patients, female patients, and those with higher levels of social vulnerability or long travel distances, may improve outcomes for patients with CRCLM.
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Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Surgical Health Outcomes Consortium (SHOC), Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, FL, USA.
| | - Zachary J Brown
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joal D Beane
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mohamed O Adam
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alex C Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Meyer YM, Olthof PB, Grünhagen DJ, Swijnenburg RJ, Elferink MAG, Verhoef C. Interregional practice variations in the use of local therapy for synchronous colorectal liver metastases in the Netherlands. HPB (Oxford) 2022; 24:1651-1658. [PMID: 35501243 DOI: 10.1016/j.hpb.2022.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the Dutch regional practice variation in treatment of synchronous colorectal liver metastases (CRLM) over time and assess their impact on patients survival. METHODS Two cohorts of patients with synchronous CRLM were selected from the Netherlands Cancer Registry (NCR). All patients diagnosed between 2014 and 2018 were selected to analyze interregional practice variations in local therapy (LT) with multivariable logistic regression. Overall survival (OS) was assessed for patients diagnosed from 2008 to 2013 using Kaplan Meier method and Cox regression analyses. RESULTS The proportion of patients who underwent LT increased from 15.5% to 21.9%. Interregional use of LT varied from 19.1% to 25.0%. Multivariable logistic regression showed significant differences between regions in the use of LT (p = 0.001) in 2014-2018. There was no association between OS and region of diagnosis for patients who underwent LT after correction for confounders.The use of LT for CRLM increased from 15.5% in 2008-2013 to 21.9% in 2014-2018. Three-year OS increased from 16% to 19% respectively. CONCLUSION Interregional practice variations have decreased. The remaining differences are not associated with OS. The use of local therapy and 3-year overall survival have increased over time. Local practice should be monitored to prevent undesirable variation in outcomes.
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Affiliation(s)
- Yannick M Meyer
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Pim B Olthof
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Dirk J Grünhagen
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | | | - Marloes A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Cornelis Verhoef
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands.
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5
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Chávez-Villa M, Ruffolo LI, Tomiyama K, Hernandez-Alejandro R. Where Are We Now With Liver Transplant for Colorectal Metastasis? CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00373-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alveolar Echinococcosis-A Challenging Task for the Hepatobiliary Surgeon. Pathogens 2021; 11:pathogens11010040. [PMID: 35055988 PMCID: PMC8778716 DOI: 10.3390/pathogens11010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/19/2021] [Accepted: 12/28/2021] [Indexed: 11/29/2022] Open
Abstract
(1) Background: Alveolar echinococcosis (AE) is an ultimately fatal disease, whose only curative treatment is surgery. Due to its late presentation extended liver resections are often necessary. The true benefit of extensive surgery has yet to be established; (2) Methods: We present a single center experience of 33 cases of Echinococcus multilocularis that have been treated at a high-volume hepatobiliary surgery center between 2004 and 2021. (3) Results: Of the 33 patients 24 patients underwent major liver resection (73%). In addition to the liver resection patients frequently underwent complex extrahepatic procedures such as lymphadenectomy (n = 21, 61%), vascular resections and reconstructions (n = 9, 27%) or resections and reconstruction of the extrahepatic bile duct (n = 11, 33%). Seven patients suffered from ≥ grade III complications (21%). Complete resection was achieved in 17 patients. Fourteen patients had R1 resections and two had macroscopic parasitic remnant (R2). Progressive disease was reported in three patients (The two R2 patients and one R1 resected patient). At a median follow-up of 54 months no mortality has occurred in our cohort; (4) Conclusions: Liver resection remains the gold standard for AE. Even in extensive disease the combination of complex resection and perioperative benzimidazoles can achieve favorable long-term outcomes.
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Diehl TM, Abbott DE. Molecular Determinants and Other Factors to Guide Selection of Patients for Hepatic Resection of Metastatic Colorectal Cancer. Curr Treat Options Oncol 2021; 22:82. [PMID: 34224023 DOI: 10.1007/s11864-021-00878-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 01/10/2023]
Abstract
OPINION STATEMENT Treatment for metastatic colorectal cancer (CRC) has changed significantly over the last few decades as cytotoxic and targeted chemotherapies have evolved and resection of (technically feasible) colorectal liver metastases (CRLM) has become standard of care for eligible patients. Overall, survival for metastatic CRC has considerably improved, but recurrences are common. Numerous clinical risk scores have been suggested to guide patient selection for CRLM resection, but none perfectly predict outcomes; therefore, a personalized approach to metastatic CRC treatment using genetic profiles for risk stratification and prognostication is a critically important advancement. All patients with suspected metastatic CRC should undergo genetic testing for common oncogene mutations (e.g., KRAS, BRAF, and NRAS) in addition to a triphasic CT scan of the chest, abdomen, and pelvis; if hepatectomy may be entertained and there is concern about the future liver remnant (FLR), liver volumetrics should also be performed. MRI and PET are useful adjuncts for cases in which diagnosis or extent of disease is unclear. The decision to operate should be individualized and based on each patient's condition, tumor biology, and technical resectability. Genetic profiles should be used to inform multidisciplinary meetings surrounding topics of chemotherapy and surgical resection, as well as patient discussions concerning the risks and benefits of surgery. In the end, most patients with technically resectable colorectal cancers and adequate cardiopulmonary fitness benefit from surgical resection, as it remains the only chance of long-term survival.
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Affiliation(s)
- Thomas M Diehl
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA.
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Azoulay D, Eshkenazy R, Pery R, Cordoba M, Haviv Y, Inbar Y, Zisman E, Lahat E, Salloum C, Lim C. The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output. ANNALS OF SURGERY OPEN 2021; 2:e066. [PMID: 37636559 PMCID: PMC10455269 DOI: 10.1097/as9.0000000000000066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023] Open
Abstract
Objective To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production. Background Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field. Methods The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared. Results Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity. Conclusions A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.
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Affiliation(s)
- Daniel Azoulay
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Rony Eshkenazy
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ron Pery
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Mordechai Cordoba
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Haviv
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Inbar
- Department of Radiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eliyahu Zisman
- Department of Anesthesiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eylon Lahat
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Chady Salloum
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
| | - Chetana Lim
- Department of HPB and Liver Transplantation, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
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Isoniemi H, Uutela A, Nordin A, Lantto E, Kellokumpu I, Ovissi A, Kosunen J, Kallio R, Soveri LM, Salminen T, Ålgars A, Lamminmäki A, Halonen P, Ristamäki R, Räsänen J, Karjula H, Vaalavuo Y, Lavonius M, Osterlund P. Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study. Br J Surg 2021; 108:817-825. [PMID: 33749772 PMCID: PMC10364914 DOI: 10.1093/bjs/znaa145] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases. METHODS The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival. RESULTS Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively. CONCLUSION Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.
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Affiliation(s)
- H Isoniemi
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - A Uutela
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - A Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E Lantto
- Department of Radiology, Helsinki University Hospital, Päijät-Häme Central Hospital, Lahti, Finland
| | - I Kellokumpu
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - A Ovissi
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Kosunen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - R Kallio
- Department of Oncology, Oulu University Hospital, Oulu, Finland
| | - L M Soveri
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland.,Hyvinkää Hospital and Home Care, Hyvinkää, Finland
| | - T Salminen
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - A Ålgars
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - A Lamminmäki
- Department of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - P Halonen
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland
| | - R Ristamäki
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - J Räsänen
- Department of Thoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - H Karjula
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Y Vaalavuo
- Department of Surgery, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - M Lavonius
- Department of Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - P Osterlund
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland.,Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
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10
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Evolution of Surgical Treatment of Colorectal Liver Metastases in the Real World: Single Center Experience in 1212 Cases. Cancers (Basel) 2021; 13:cancers13051178. [PMID: 33803257 PMCID: PMC7967178 DOI: 10.3390/cancers13051178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In recent years, the treatment of colorectal liver metastases (CRLM) has undergone significant evolution thanks to technical improvements as well as oncological advances, which have been the subject of targeted studies aimed at understanding the details of this heterogeneous disease. The purpose of this study is to put together pieces of this complex scenario by providing an overview of the evolution that has occurred in the context of a single center within a multidisciplinary management approach. METHODS Between 2005 and 2020, 1212 resections for CRLM were performed at the Hepatobiliary Surgery Division of San Raffaele Hospital, Milan. The series was divided into three historical periods, which were compared in terms of disease characteristics and short- and long-term outcomes: Period 1, 2005-2009 (293 cases); Period 2, 2010-2014 (353 cases); Period 3, 2015-2020 (566 cases). The trends for surgical technical complexity, oncological burden of the disease, use of the laparoscopic approach and use of techniques for hepatic hypertrophy were analyzed year by year. Uni- and multivariate analyses were performed to identify factors associated with inclusion to a laparoscopic approach and with long-term prognosis. RESULTS The number of resections performed over the years progressively increased, with an increase in the number of cases with a high Clinical Risk Score and a high profile of technical complexity. The proportion of cases performed laparoscopically increased, but less rapidly compared to other malignant tumors. The risk of postoperative morbidity and mortality was similar in the three analyzed periods. Long-term survival, stratified by Clinical Risk Score, improved in Period 3, while overall survival remained unchanged. CONCLUSION The cultural background, the maturation of technical expertise and the consolidation of the multidisciplinary team have resulted in safe expansion of the possibility to offer a curative opportunity to patients, while continuously implementing into clinical practice evidence provided by the literature.
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11
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Drefs M, Schoenberg MB, Schiergens TS, Albertsmeier M, Andrassy J, Angele MK, Westphalen CB, Seidensticker M, Werner J, Guba MO. Chances, challenges and outcomes of patients with complex bilobar colorectal liver metastases approached by a combined multimodal therapy with liver resection and local ablative therapy. J Surg Oncol 2021; 123:1578-1591. [PMID: 33684241 DOI: 10.1002/jso.26443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES In treatment of colorectal liver metastases (CRC-LM), liver surgery combined with systemic therapies and local ablation (LAT) allows improved survival. This study aims at the outcomes of patients with complex bilobar CRC-LM who were intended to undergo multimodal therapy with liver resection and LAT. METHODS Forty-three CRC-LM patients with recommendation for multimodal treament were extracted from 5878 tumor board decisions between 2014 and 2017. Outcome variables included patient survival, as well as completion of hepatic clearance. Prognostic factors were identified by correlation and a Cox proportional hazards model. RESULTS Out of 43 patients only 23 achieved complete clearance of CRC-LM. One- and 3-year overall survival of patients with cleared liver disease was 100% and 91.7%, respectively, as compared to 83.8% and 12.1%. Incomplete hepatic clearance was the strongest independent risk factor for overall survival (hazards ratio [HR], 5.86; p = .009). Risk factors for incomplete clearance were higher age (r = .34; p = .026), comorbidities (r = .40; p = .008), major complications (r = .34; p = .024), and prolonged intensive care unit stay (r = .41; p = .017). CONCLUSION Completion of hepatic clearance is crucial to achieve long-term survival in patients with complex bilobar CRC-LM. Careful patient selection and treatment planning should avoid treatment failure before completing the intended therapy plan when multimodal treatments are planned.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Markus B Schoenberg
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Markus Albertsmeier
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | | | - Max Seidensticker
- Department of Radiology, University Hospital of Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Markus O Guba
- Department of General, Visceral, and Transplant Surgery, University Hospital of Munich, Munich, Germany
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12
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Osterlund P, Salminen T, Soveri LM, Kallio R, Kellokumpu I, Lamminmäki A, Halonen P, Ristamäki R, Lantto E, Uutela A, Osterlund E, Ovissi A, Nordin A, Heervä E, Lehtomäki K, Räsänen J, Murashev M, Aroviita L, Jekunen A, Lindvall-Andersson R, Nyandoto P, Kononen J, Lepistö A, Poussa T, Muhonen T, Ålgars A, Isoniemi H. Repeated centralized multidisciplinary team assessment of resectability, clinical behavior, and outcomes in 1086 Finnish metastatic colorectal cancer patients (RAXO): A nationwide prospective intervention study. LANCET REGIONAL HEALTH-EUROPE 2021; 3:100049. [PMID: 34557799 PMCID: PMC8454802 DOI: 10.1016/j.lanepe.2021.100049] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Resection of colorectal cancer (CRC) metastases provides good survival but is probably underused in real-world practice. Methods A prospective Finnish nationwide study enrolled treatable metastatic CRC patients. The intervention was the assessment of resectability upfront and twice during first-line therapy by the multidisciplinary team (MDT) at Helsinki tertiary referral centre. The primary outcome was resection rates and survival. Findings In 2012–2018, 1086 patients were included. Median follow-up was 58 months. Multiple metastatic sites were present in 500 (46%) patients at baseline and in 820 (76%) during disease trajectory. In MDT assessments, 447 (41%) were classified as resectable, 310 (29%) upfront and 137 (18%) after conversion therapy. Six-hundred and ninety curative intent resections or local ablative therapies (LAT) were performed in 399 patients (89% of 447 resectable). Multiple metastasectomies for multisite or later developing metastases were performed in 148 (37%) patients. Overall, 414 liver, 112 lung, 57 peritoneal, and 107 other metastasectomies were performed. Median OS was 80·4 months in R0/1-resected (HR 0·15; CI95% 0·12–0·19), 39·1 months in R2-resected/LAT (0·39; 0·29–0·53) patients, and 20·8 months in patients treated with “systemic therapy alone” (reference), with 5-year OS rates of 66%, 40%, and 6%, respectively. Interpretation Repeated centralized MDT assessment in real-world metastatic CRC patients generates high resectability (41%) and resection rates (37%) with impressive survival, even when multisite metastases are present or develop later. Funding The funders had no role in the study design, analysis, and interpretation of the data or writing of this report.
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Affiliation(s)
- Pia Osterlund
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland.,Department of Oncology, Helsinki University Hospital, Helsinki, Finland.,Department of Oncology/Pathology, Karolinska Insitutet and Karolinska University Hospital, Stockholm, Sweden
| | - Tapio Salminen
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Leena-Maija Soveri
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland.,Department of palliative care, Hyvinkää Hospital and Home Care, Hyvinkää, Finland
| | - Raija Kallio
- Department of Oncology, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Ilmo Kellokumpu
- Department of Gastrointestinal Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Annamarja Lamminmäki
- Department of Oncology, Kuopio University Hospital and University of Kuopio, Kuopio, Finland
| | - Päivi Halonen
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland
| | - Raija Ristamäki
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - Eila Lantto
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Radiology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Aki Uutela
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Emerik Osterlund
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Immunology, Genetics and Pathology, Uppsala University and Akademiska sjukhuset, Uppsala, Sweden
| | - Ali Ovissi
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eetu Heervä
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Lehtomäki
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Jari Räsänen
- Department of Thoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maija Murashev
- Department of Oncology, Satakunta Central Hospital, Pori, Finland
| | - Laura Aroviita
- Department of Oncology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Antti Jekunen
- Department of Oncology, Vaasa Central Hospital, Vaasa, Finland
| | | | - Paul Nyandoto
- Department of Oncology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Juha Kononen
- Department of Oncology, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Anna Lepistö
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Timo Muhonen
- Department of Oncology, South Carelia Central Hospital, Lappeenranta, Finland
| | - Annika Ålgars
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - Helena Isoniemi
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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13
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Hermunen K, Soveri LM, Boisen MK, Mustonen HK, Dehlendorff C, Haglund CH, Johansen JS, Osterlund P. Postoperative serum CA19-9, YKL-40, CRP and IL-6 in combination with CEA as prognostic markers for recurrence and survival in colorectal cancer. Acta Oncol 2020; 59:1416-1423. [PMID: 32790589 DOI: 10.1080/0284186x.2020.1800086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In colorectal cancer (CRC) patients, guidelines only recommend measurement of preoperative carcinoembryonic antigen (CEA), although postoperative CEA may be more informative. However, the sensitivity of both preoperative and postoperative CEA in identifying relapse is limited. We studied whether CA19-9, YKL-40, C-reactive protein (CRP) and interleukin (IL)-6 add prognostic information combined with postoperative CEA. MATERIAL AND METHODS This post-hoc analysis included 147 radically resected stage II (n = 38), III (n = 91) and IV (n = 18) CRC patients treated with adjuvant 5-fluorouracil (5-FU)-based therapy in the phase III LIPSYT study (ISRCTN98405441). We collected postoperative blood samples a median of 48 days after surgery. We analysed relapses, sensitivity, positive predictive value (PPV) and disease-free (DFS) and overall survival (OS) by bootstrap, Kaplan-Meier and adjusted Cox-models in the elevated vs. normal biomarker groups. RESULTS Elevated postoperative CEA associated with impaired DFS (HR 7.23; CI95% 3.85-13.58), impaired OS (HR 7.16; CI95% 3.76-13.63), and more relapses (HR 7.9; CI95% 3.4-18.2); but sensitivity for CEA in finding relapses was only 31% (CI95% 21-48%). Normal CEA combined with an elevated YKL-40 or elevated CRP showed more relapses (HR for YKL-40 2.13 [CI95% 1.10-4.13], HR for CRP 3.14 [CI95% 1.21-8.16]), impaired DFS (HR 2.18 [CI95% 1.12-4.24] or 3.23 [CI95% 1.34-7.82]), and impaired OS (2.33 [CI95%1.24-4.40] or 2.68 [CI95%1.12-6.44]). Elevated CEA combined with a concomitantly elevated CA19-9, YKL-40, CRP or IL-6 showed a respective PPV of 100, 90, 100, and 100%. CONCLUSION In radically operated stage II to IV CRC patients who received adjuvant 5-FU-based chemotherapy, a postoperatively elevated CEA alone or in combination with CA19-9, YKL-40, CRP, or IL-6, or a normal CEA combined with an elevated YKL-40 or with an elevated CRP, may indicate patients at high risk of relapse.
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Affiliation(s)
- Kethe Hermunen
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena-Maija Soveri
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Hyvinkää Hospital and Hyvinkää Homecare, Hyvinkää, Finland
| | - Mogens Karsbøl Boisen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Harri K. Mustonen
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Research Programs Unit, Translational Cancer Medicine Program, University of Helsinki, Helsinki, Finland
| | - Christian Dehlendorff
- Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - Caj H. Haglund
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Research Programs Unit, Translational Cancer Medicine Program, University of Helsinki, Helsinki, Finland
| | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pia Osterlund
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
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14
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Choices of Therapeutic Strategies for Colorectal Liver Metastases Among Expert Liver Surgeons: A Throw of the Dice? Ann Surg 2020; 272:715-722. [PMID: 32833764 DOI: 10.1097/sla.0000000000004331] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To test the degree of agreement in selecting therapeutic options for patients suffering from colorectal liver metastasis (CRLM) among surgical experts around the globe. SUMMARY/BACKGROUND Only few areas in medicine have seen so many novel therapeutic options over the past decades as for liver tumors. Significant variations may therefore exist regarding the choices of treatment, even among experts, which may confuse both the medical community and patients. METHODS Ten cases of CRLM with different levels of complexity were presented to 43 expert liver surgeons from 23 countries and 4 continents. Experts were defined as experienced surgeons with academic contributions to the field of liver tumors. Experts provided information on their medical education and current practice in liver surgery and transplantation. Using an online platform, they chose their strategy in treating each case from defined multiple choices with added comments. Inter-rater agreement among experts and cases was calculated using free-marginal multirater kappa methodology. A similar, but adjusted survey was presented to 60 general surgeons from Asia, Europe, and North America to test their attitude in treating or referring complex patients to expert centers. RESULTS Thirty-eight (88%) experts completed the evaluation. Most of them are in leading positions (92%) with a median clinical experience of 25 years. Agreement on therapeutic strategies among them was none to minimal in more than half of the cases with kappa varying from 0.00 to 0.39. Many general surgeons may not refer the complex cases to expert centers, including in Europe, where they also engage in complex liver surgeries. CONCLUSIONS Considerable inconsistencies of decision-making exist among expert surgeons when choosing a therapeutic strategy for CRLM. This might confuse both patients and referring physicians and indicate that an international high-level consensus statements and widely accepted guidelines are needed.
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15
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Huiskens J, Bolhuis K, Engelbrecht MR, De Jong KP, Kazemier G, Liem MS, Verhoef C, de Wilt JH, Punt CJ, van Gulik TM. Outcomes of Resectability Assessment of the Dutch Colorectal Cancer Group Liver Metastases Expert Panel. J Am Coll Surg 2019; 229:523-532.e2. [PMID: 31520695 DOI: 10.1016/j.jamcollsurg.2019.08.1445] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Decision making on optimal treatment strategy in patients with initially unresectable colorectal cancer liver metastases (CRLM) remains complex because uniform criteria for (un)resectability are lacking. This study reports on the feasibility and short-term outcomes of The Dutch Colorectal Cancer Group Liver Expert Panel. STUDY DESIGN The Expert Panel consists of 13 hepatobiliary surgeons and 4 radiologists. Resectability assessment is performed independently by 3 randomly assigned surgeons, and CRLM are scored as resectable, potentially resectable, or permanently unresectable. In absence of consensus, 2 additional surgeons are invited for a majority consensus. Patients with potentially resectable or unresectable CRLM at baseline are evaluated every 2 months of systemic therapy. Once CRLM are considered resectable, a treatment strategy is proposed. RESULTS Overall, 398 panel evaluations in 183 patients were analyzed. The median time to panel conclusion was 7 days (interquartile range [IQR] 5-11 days). Intersurgeon disagreement was observed in 205 (52%) evaluations, with major disagreement (resectable vs permanently unresectable) in 42 (11%) evaluations. After systemic treatment, 106 patients were considered to have resectable CRLM, 84 of whom (79%) underwent a curative procedure. R0 resection (n = 41), R0 resection in combination with ablative treatment (n = 26), or ablative treatment only (n = 4) was achieved in 67 of 84 (80%) patients. CONCLUSIONS This study analyzed prospective resectability evaluation of patients with CRLM by a panel of radiologists and liver surgeons. The high rate of disagreement among experienced liver surgeons reflects the complexity in defining treatment strategies for CRLM and supports the use of a panel rather than a single-surgeon decision.
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Affiliation(s)
- Joost Huiskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Karen Bolhuis
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marc Rw Engelbrecht
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Koert P De Jong
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, VU University, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mike Sl Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Cornelis Verhoef
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Cornelis Ja Punt
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Garlipp B, Gibbs P, Van Hazel GA, Jeyarajah R, Martin RCG, Bruns CJ, Lang H, Manas DM, Ettorre GM, Pardo F, Donckier V, Benckert C, van Gulik TM, Goéré D, Schoen M, Pratschke J, Bechstein WO, de la Cuesta AM, Adeyemi S, Ricke J, Seidensticker M. Secondary technical resectability of colorectal cancer liver metastases after chemotherapy with or without selective internal radiotherapy in the randomized SIRFLOX trial. Br J Surg 2019; 106:1837-1846. [PMID: 31424576 PMCID: PMC6899564 DOI: 10.1002/bjs.11283] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Background Secondary resection of initially unresectable colorectal cancer liver metastases (CRLM) can prolong survival. The added value of selective internal radiotherapy (SIRT) to downsize lesions for resection is not known. This study evaluated the change in technical resectability of CRLM with the addition of SIRT to FOLFOX‐based chemotherapy. Methods Baseline and follow‐up hepatic imaging of patients who received modified FOLFOX (mFOLFOX6: fluorouracil, leucovorin, oxaliplatin) chemotherapy with or without bevacizumab (control arm) versus mFOLFOX6 (with or without bevacizumab) plus SIRT using yttrium‐90 resin microspheres (SIRT arm) in the phase III SIRFLOX trial were reviewed by three or five (of 14) expert hepatopancreatobiliary surgeons for resectability. Reviewers were blinded to one another, treatment assignment, extrahepatic disease status, and information on clinical and scanning time points. Technical resectability was defined as at least 60 per cent of reviewers (3 of 5, or 2 of 3) assessing a patient's liver metastases as surgically removable. Results Some 472 patients were evaluable (SIRT, 244; control, 228). There was no significant baseline difference in the proportion of technically resectable liver metastases between SIRT (29, 11·9 per cent) and control (25, 11·0 per cent) arms (P = 0·775). At follow‐up, significantly more patients in both arms were deemed technically resectable compared with baseline: 159 of 472 (33·7 per cent) versus 54 of 472 (11·4 per cent) respectively (P = 0·001). More patients were resectable in the SIRT than in the control arm: 93 of 244 (38·1 per cent) versus 66 of 228 (28·9 per cent) respectively (P < 0·001). Conclusion Adding SIRT to chemotherapy may improve the resectability of unresectable CRLM.
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Affiliation(s)
- B Garlipp
- Otto-von-Guericke-University Hospital, Magdeburg, Germany
| | - P Gibbs
- Department of Medical Oncology, Western Health, Melbourne, Victoria, Australia
| | - G A Van Hazel
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - R Jeyarajah
- Methodist Richardson Medical Center, Dallas, Texas, USA
| | - R C G Martin
- Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - C J Bruns
- University Hospital Cologne, Cologne, Germany
| | - H Lang
- General, Visceral and Transplant Surgery, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - D M Manas
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | | | - F Pardo
- Hepato-Pancreatico-Biliary Surgery and Oncology, Clinica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - V Donckier
- Jules Bordet Institute, Brussels, Belgium
| | - C Benckert
- Vivantes Klinikum Am Friedrichshain, Berlin, Germany
| | | | - D Goéré
- Institut Gustave Roussy, Villejuif, France
| | - M Schoen
- Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Pratschke
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - W O Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | | | - S Adeyemi
- Statsxperts Consulting Limited, Hemel Hempstead, UK
| | - J Ricke
- Deutsche Akademie für Mikrotherapie, Magdeburg, Germany.,Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
| | - M Seidensticker
- Otto-von-Guericke-University Hospital, Magdeburg, Germany.,Deutsche Akademie für Mikrotherapie, Magdeburg, Germany.,Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
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