Multimodality liver directed treatment for colorectal liver metastasis: Array of complementary options can improve outcomes - A single centre experience from India

Budget Impact of Shifting the Treatment Setting of Unresectable Liver Metastases Associated with Primary Colorectal Cancer Using Y-90 Resin Microspheres from the Outpatient Hospital to the Office-Based Laboratory

Purpose

In the wake of ever-increasing health care costs, solutions are sought to make health care more affordable, such as moving hospital outpatient procedures to office-based laboratory (OBL) settings. A budget impact model was constructed to estimate the health plan cost benefit of moving 50% of yttrium-90 resin microspheres (Y-90) selective internal radiation therapy (SIRT) procedures for unresectable liver metastases associated with primary colorectal cancer (CRC) from a traditional hospital outpatient setting (HOPPS) to an OBL setting.

Methods

The eligible population was estimated using an incidence-based approach for a hypothetical health plan with 1 million covered lives. Modeled costs were based on 2024 Medicare reimbursement rates. Three treatment scenarios were considered: 1) base case HOPPS, 2) hybrid (HOPPS/OBL), and 3) OBL settings. Budget impacts were estimated as the differences in annual total cost of treatment after switching 50% of Y-90 SIRTs from HOPPS to the hybrid (HOPPS/OBL) or OBL setting. Per-member-per-month (PMPM) budget impacts were also calculated. Sensitivity analyses were conducted by varying the proportions of patients shifting settings and the treatment setting they were shifting into.

Results

Annually, 28 patients were estimated to have metastatic CRC and unresectable liver metastases in a health plan of 1 million members. Average estimated per-patient cost savings would be $8,791 by switching one patient to a hybrid setting and $17,697 for a patient switched to the OBL. Switching 50% of eligible procedures resulted in PMPM cost benefits to the plan of $0.0102 for hybrid setting and $0.0206 for OBL. In sensitivity analyses, annual cost savings for the health plan were affected by both the proportion of patients shifted and the setting they were shifted into.

Conclusion

Shifting a percentage of the treatment of unresectable liver metastases with Y-90 SIRT to the OBL setting results in modest cost benefits for US health plans.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

The Current State of Perioperative Chemotherapy in Resectable Colorectal Liver Metastases: A Narrative Review

Perioperative chemotherapy has emerged as a critical component in managing resectable colorectal liver metastases (CRLM), aiming to improve long-term survival, although data supporting its use remains controversial. This narrative review explores the current state of perioperative chemotherapy in patients with resectable CRLM, focusing on its role in different oncological risk categories. The review highlights ongoing controversies, such as optimal patient selection and the role of post- versus preoperative treatment in specific scenarios.

Optimal treatment strategies for borderline resectable liver metastases from colorectal cancer

BACKGROUND

Traditionally, colorectal liver metastases (CRLMs) are divided into "initially resectable" and "initially unresectable." The terminology "borderline resectable" continues to be elusive without any common consensus or definition. This narrative review aims to decode the conundrum of "borderline resectable CRLM (BR-CRLM)" and to discuss optimal treatment strategies.

METHODS

A comprehensive review was performed using Medline/PubMed and Web of Science databases with a search period ending on January 1, 2024. Using PubMed, the terms "CRLM," "BR-CRLM," and "management of BR-CRLM" were searched.

RESULTS

The 2016 European Society for Medical Oncology guidelines defined the term "resectability" in CRLM using the "technical (surgical) criteria" and the "oncologically criteria." These 2 criteria form the basis of defining BR-CRLM. Thus, BR-CRLM can be either technically easy but with unfavorable oncologically criteria or technically difficult with favorable oncologically criteria. Although defining BR-CRLM by incorporating both these criteria seems to be the most logical way forward, there is currently a lot of heterogeneity in the literature. It is generally agreed upon that some form of chemotherapy needs to be administered in BR-CRLM before embarking on surgery. Conversion chemotherapy is used in patients with BR-CRLM in which there is a possibility of resection after effective downsizing. Along with improved effective chemotherapy, great strides have been made in pushing the limits of surgery to achieve resectability in this subset of patients.

CONCLUSION

Advanced surgical techniques and locoregional liver-directed therapies coupled with perioperative chemotherapy with or without targeted therapy have made long-term survival benefit, a reality in patients with BR-CRLM. Thus, the time has come to recognize "BR-CRLM" as a distinct entity.

Patterns and Predictors of Recurrence After Curative Resection of Colorectal Liver Metastasis (CRLM)

BACKGROUND

Our study aims to determine the predictors and patterns of relapses after curative colorectal liver metastasis (CRLM) resection.

METHODS

A single-centre, retrospective study of CRLM patients operated between 2010 and 2022 was performed. The site of first recurrence was either hepatic (marginal (≤ 1 cm) or extramarginal), extrahepatic, or both. Factors that predicted relapse patterns and overall survival were determined by multivariable Cox regression analysis with backward elimination of variables.

RESULTS

The study consisted of 258 patients, with a similar proportion of synchronous (144; 56%) and metachronous(114; 43%) metastasis. At a 43-month median follow-up, 156 patients (60.4%) developed recurrences with 33 (21.1%) in the liver, 62(24.03%) extra-hepatic recurrences, and 58 (22.48%) having both. Isolated marginal liver relapses were seen in seven (9.89%) liver recurrence patients. The median overall and relapse-free survivals were 38 months (30-54) and 13 months (11-16), respectively. The 3-year liver-relapse-free survival was 54.4% (44.9-60.6). Size of liver metastases > 5 cm (HR 2.06 (1.34-3.17), involved surgical margins (HR 2.16 (1.27-3.68)), and adjuvant chemotherapy (HR 1.89 (1.07-3.35)) were predictors of hepatic recurrences. Node positivity of primary (HR 1.61 (1.02-2.56)), presence of baseline extra-hepatic metastases (HR 0.30 (0.18-0.51)), size of liver metastases > 5 cm (HR 2.02 (1.37-2.99)), poorly differentiated histology (HR 2.25 (1.28-3.49)), presence of LVI (HR 2.25 (1.28-3.94)), and adjuvant chemotherapy (HR 2.15 (1.28-3.61)) were predictors of extra-hepatic recurrences.

CONCLUSION

The study found majority relapses occurred at extrahepatic sites whilst isolated marginal recurrences were few. The consistent predictors of recurrence were size and inability to deliver adjuvant therapy. A tailored adjuvant therapy might improve outcomes after liver metastasectomy in colorectal cancers.

New definition of borderline resectable colorectal liver metastasis based on prognostic outcomes

BACKGROUND

Although surgical resection is the curative treatment for colorectal liver metastases (CRLM), the efficacy of neoadjuvant chemotherapy (NAC) has been discussed due to recent remarkable advances in chemotherapy. The definition of borderline resectable (BR) is most important, where neoadjuvant chemotherapy should be administered. This study aimed to examine a new definition of BR CRLM based on the results of the treatment outcomes.

METHODS

This study included 127 patients who underwent liver resection for CRLM after exclusion of conversion cases between April 2010 and December 2023. Upfront resection was performed for synchronous and single liver metastasis or metachronous liver metastases. NAC was administered for multiple synchronous liver metastases. In order to find a new definition of BR, we examined the prognostic factors obtained from the treatment outcomes.

RESULTS

CA19-9 level > 37.0 was the only prognostic factor in the upfront group [hazard ratio (HR) 2.386, 95% CI, 1.583-4.769; p = 0.049]. in the NAC group, a maximum tumor diameter ˃3 cm (HR 2.248, 95% CI 1.038-4,867, p = 0.040), CA19-9 level > 37.0 (HR 2.239, 95% CI 1.044-4.800, p = 0.038), and a right-sided primary tumor in the colon (HR 2.770, 95% CI 1.284-5.988, p = 0.009) were identified as significant prognostic factors.

CONCLUSIONS

In cases of CRLM, patients with CA19-9 levels > 37.0, or CA19-9 level with < 37.0 but with a primary tumor in the right colon or a maximum tumor diameter of > 3 cm can be defined as BR CRLM and should be treated with NAC.

Tata Memorial Centre Evidence Based Management of Colorectal cancer

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.