Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?

Multimodal Management of Colorectal Liver Metastases: State of the Art

Liver is the most common site of colorectal cancer (CRC) metastases. Treatment of CRC liver metastases (CRLM) includes different strategies, prevalently based on the clinical and oncological intent. Valid approaches in liver-limited or liver-prevalent disease include surgery, percutaneous ablative procedures (radiofrequency ablation, microwave ablation), intra-arterial perfusional techniques (chemo-embolization, radio-embolization) as well as stereotactic radiotherapy. Systemic treatments, including chemotherapy, immunotherapy and other biological agents, are the only options for patients with no chance of locoregional approaches. The use of chemotherapy in other settings, such as neoadjuvant, adjuvant or conversion therapy of CRLM, is commonly accepted in the clinical practice, although data from several clinical trials have been mostly inconclusive. The optimal integration of all these strategies, when applicable and clinically indicated, should be ever considered in patients affected by CRLM based on clinical evidence and multidisciplinary experience. Here we revised in detail all the possible therapeutic approaches of CRLM focusing on the current evidences, the studies still in progress and the often contradictory data.

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

BACKGROUND

Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management.

METHODS

This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements.

RESULTS

Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed.

CONCLUSION

The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

BACKGROUND

Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management.

METHODS

This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements.

RESULTS

Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed.

CONCLUSION

The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Combination therapy with antibody‑drug conjugate RC48 (disitamab vedotin) and zimberelimab (PD‑1 inhibitor) successfully controlled recurrent HER2‑positive breast cancer resistant to trastuzumab emtansine: A case report

Options for later-line therapy are limited for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer who have exhibited resistance to several systemic treatments. Antibody drug conjugates (ADCs) and immune checkpoint inhibitors are novel approaches for HER2-positive breast cancer, but few reports have been published regarding the efficacy of their combinations, particularly in patients with prior ADC failure. The present report describes a case of recurrent metastatic HER2-positive breast cancer, which responded poorly to several perioperative systemic therapies, including chemotherapies, HER2-targeted antibodies, small molecule inhibitors and trastuzumab emtansine (an ADC), along with post-surgical radiotherapy. Following failure of front-line therapies for recurrent cancer located in the chest wall, combination treatment with another HER2-targeted ADC, disitamab vedotin (120 mg), and zimberelimab (240 mg), a fully humanized anti-programmed cell death protein-1 (PD-1) antibody, administered intravenously every 2 weeks, was initiated. The tumor lesions improved slightly after two cycles of treatment and shrunk markedly, and almost disappeared at the end of the sixth cycle of therapy. The patient is still in remission at present. The present findings suggest the potential efficacy of HER2-targeted ADCs combined with PD-1 inhibitors for patients with HER2-positive breast cancer, including those resistant to prior HER2-targeted ADCs.

Exploration of novel clusters and prognostic value of immune‑related signatures and identify HAMP as hub gene in colorectal cancer

Immune checkpoint inhibitors currently serve an important role in prolonging patients' overall survival. However, the prognostic signatures of immune checkpoint inhibitors in colorectal cancer (CRC) remain uncertain and more knowledge on the genetic characteristics of colorectal cancer is needed. Patients with CRC from The Cancer Genome Atlas were classified into high-immunity group and low-immunity group based on median scores from single-sample gene set enrichment analysis using the GSVA package. We explored immune status by immune scores, stromal scores and tumor purity scores in ESTIMATE package and surveyed the difference of immune cells distribution with CIBERSORT package. Eighteen genes were selected using the LASSO Cox regression method and a prognostic risk model was constructed. Compared with patients in the low-risk group, those in the high-risk group had a significantly shorter survival time. For assessment of the prognostic validity of the risk model, receiver operating characteristic curves with areas under the curve of 0.769, 0.774 and 0.771 for 1, 3 and 5 years respectively. Differences in molecular mechanisms between high- and low-risk groups were analyzed using the clusterProfiler package. Tumor Immune Dysfunction and Exclusion data were downloaded and analyzed. The top 5 enriched pathways in the high-risk group involved 'calcium signaling', 'dilated cardiomyopathy', 'extracellular matrix receptor interaction', 'hypertrophic cardiomyopathy' and 'neuroactive ligand receptor interaction'. HAMP was identified as a hub gene, which was highly expressed in tumor samples. The results of the present study indicate that the prognostic model based on both immune-related genes and HAMP has the potential to support personalized treatment.

Cytochrome P2E1 (CYP2E1) Gene Polymorphism as a Potential Prognostic Biomarker in Colorectal Cancer

BACKGROUND

Colon cancer is the most common type of gastrointestinal cancer. Genetic factors have been shown to have a role in the development of colorectal cancers. The aim of this study was to assess the expression of Cytochrome P2E1 (CYP2E1) gene polymorphism as a potential prognostic biomarker in the diagnosis, treatment, and prognosis evaluation of patients with colorectal cancer.

METHODS

in this cross-sectional study, all of our 100 patients with colorectal cancer who underwent surgical operation were included. DNA was extracted from the tumor specimens to assess Cytochrome P2E1 (CYP2E1) Gene polymorphism by Conventional-PCR. RFLP-PCR method was used for RsaI polymorphism evaluation. Patients' characteristics were also recorded and their associations with CYP2E1 were assessed.

RESULTS

One hundred tumor specimens were assessed. In total, 88 had wild-type, 8 had purely a 96 bp insertion in CYP2E1, and 4 were partially mutated by a single allele insertion. Generally, 10% of samples had positive results for the RsaI polymorphism. There were no statistically significant associations between CYP2E1 gene polymorphism and number of lymph nodes removed during the operation (P = 0.353), number of positive lymph nodes (P = 0.668), tumor specificity including mucinous or non-mucinous (P = 0.053), tumor invasion (P = 0.074), grading (P = 0.898), differentiation (P = 0.941), tumor location (P = 0.42) or staging (P = 0.182).

CONCLUSION

There was no association between RsaI type CYP2E1 polymorphism and colorectal cancer risk. Our study does not support the use of this biomarker to evaluate the prognosis of colon cancer.

Concurrent major hepatic resection with primary colorectal cancer increases risk of organ space infections

INTRODUCTION

Patients with colorectal cancer frequently present with liver metastases requiring either concurrent colon and liver resection or staged resection for curative therapy. The goal of this study is to determine if synchronous resection increases risk of perioperative adverse outcomes such as surgical site infections (SSIs).

METHODS AND PROCEDURES

We conducted a cross-sectional retrospective analysis of the targeted hepatectomy NSQIP database from 2015 to 2019. The primary outcome was surgical site infections stratified into superficial, deep, organ space, and wound dehiscence. We performed univariate followed by a multivariate logistic regression to determine if there were higher odds of SSIs in patients undergoing hepatic resection concurrently with primary colorectal resection. Additionally, we performed stratified analyses by size of hepatic resections (partial, total left, total right, and trisegmentectomy).

RESULTS

Of the 7,445 patients included in the study, 431(5.8%) underwent synchronous resection and 7,014 metachronous resection. On average, synchronous resections prolonged surgery by 62 min. There was no difference in superficial and deep SSIs between the groups; however, there was a significant difference in organ space SSIs. Patients undergoing synchronous resection had 1.51 times the odds of developing an organ space SSI (OR 1.51, 95%CI 1.10, 2.17, p = 0.04) compared to patients with metachronous resection on multivariate analysis. Patients undergoing a total right hepatectomy concurrently with a colorectal resection had 2.30 times the odds of developing an organ space SSI (OR 2.30, 95%CI 1.20, 6.86, p = 0.010).

CONCLUSIONS

Prior studies demonstrated that synchronous resections are safe in properly selected patients with no difference in long-term outcomes. Few studies have explored immediate perioperative outcomes between the two approaches. After controlling for confounders, we demonstrate that synchronous resection with major hepatic surgery increases the risk of organ space SSIs. Future studies should elucidate the precise source of organ space SSIs in order to decrease the risk of this adverse outcome.

Management of Colorectal Cancer with Synchronous Liver Metastases: An Inception Cohort Study (CoSMIC)

BACKGROUND

Approximately one-fifth of patients with colorectal cancer present with hepatic metastases. There are limited prospective data on the outcomes of synchronous combined liver and bowel surgery and liver-first or bowel-first routes where contemporary chemo(radio)therapy is integrated into management.

METHODS

Between 1 April 2014 and 31 March 2017, 125 patients with colorectal cancer and synchronous liver metastases were recruited. Data are reported on pathway-specific outcomes, including perioperative complications, treatment completion, and overall and disease-free survival. The study was registered with ClinicalTrials.gov (NCT02456285).

RESULTS

There was no difference in age, body mass index, or Charlson score between surgical groups. Neoadjuvant chemotherapy was used in 50 (40%) patients for a mean duration of 4.6 months (standard deviation [SD] 5.4), and mean time from completion of chemotherapy to surgery was 2.6 months (SD 1.9). Complications were similar between patients completing the synchronous and staged pathways (p = 0.66). Mean total inpatient stay was 16.5 days (SD 8.1) for staged surgery compared with 16.8 days (SD 10.3) for the synchronous group (t-test; p = 0.91). There was no difference in time to treatment completion between pathways. Thirty six (35%) patients were disease-free at 12 months, with no significant difference between groups (Chi-square, p = 0.448). Quality of life was similar in all surgical groups.

CONCLUSIONS

Perioperative complications and oncological and healthcare occupancy outcomes are equivalent between patients completing staged and synchronous pathways for the management of patients with colorectal cancer and synchronous liver metastases. Future studies should focus on optimizing the criteria for pathway selection, incorporation of cancer genomics data, and patient (user) preferences.

Protein profile of MCF-7 breast cancer cell line treated with lectin delivered by CaCO3NPs revealed changes in molecular chaperones, cytoskeleton, and membrane-associated proteins

The second most predominant cancer in the world and the first among women is breast cancer. We aimed to study the protein abundance profiles induced by lectin purified from the Agaricus bisporus mushroom (ABL) and conjugated with CaCO₃NPs in the MCF-7 breast cancer cell line. Two-dimensional electrophoresis (2-DE) and orbitrap mass spectrometry techniques were used to reveal the protein abundance pattern induced by lectin. Flow cytometric analysis showed the accumulation of ABL-CaCO₃NPs treated cells in the G1 phase than the positive control. Thirteen proteins were found different in their abundance in breast cancer cells after 24 h exposure to lectin conjugated with CaCO₃NPs. Most of the identified proteins were showing a low abundance in ABL-CaCO₃NPs treated cells in comparison to the positive and negative controls, including V-set and immunoglobulin domain, serum albumin, actin cytoplasmic 1, triosephosphate isomerase, tropomyosin alpha-4 chain, and endoplasmic reticulum chaperone BiP. Hornerin, tropomyosin alpha-1 chain, annexin A2, and protein disulfide-isomerase were up-regulated in comparison to the positive. Bioinformatic analyses revealed the regulation changes of these proteins mainly affected the pathways of 'Bcl-2-associated athanogene 2 signalling pathway', 'Unfolded protein response', 'Caveolar-mediated endocytosis signalling', 'Clathrin-mediated endocytosis signalling', 'Calcium signalling' and 'Sucrose degradation V', which are associated with breast cancer. We concluded that lectin altered the abundance in molecular chaperones/heat shock proteins, cytoskeletal, and metabolic proteins. Additionally, lectin induced a low abundance of MCF-7 cancer cell proteins in comparison to the positive and negative controls, including; V-set and immunoglobulin domain, serum albumin, actin cytoplasmic 1, triosephosphate isomerase, tropomyosin alpha-4 chain, and endoplasmic reticulum chaperone BiP.

Synchronous Versus Metachronous Colorectal Liver Metastasis Yields Similar Survival in Modern Era

BACKGROUND

Synchronous colorectal cancer liver metastasis (CRLM) has been viewed as being more aggressive and having shorter survival than metachronous disease. Advances in CRLM management led us to examine differences in treatment characteristics of synchronous versus metachronous CRLM patients along with survival and recurrence.

MATERIALS AND METHODS

A retrospective review of hepatic resection for CRLM at a tertiary academic medical center was performed for two periods: a historic cohort from 1992 to 2010 (n = 121), and a modern cohort (n = 179) from 2012 to 2018. Clinical variables were compared between the patient groups, and survival outcomes were characterized.

RESULTS

Five-year disease-specific survival for the modern synchronous group compared to the historic synchronous group was 71.7% versus 44.3% (P = 0.02). Modern metachronous versus modern synchronous 5-y disease-specific survival rates were 49.8% versus 71.7% (P = 0.31). Compared to the historic cohort, the modern one had significantly different timing of hepatic resection (P < 0.01) with increased use of liver-first (30.1% versus 7.5%) and simultaneous liver-colon resections (24.1% versus 10.4%), along with greater use of neoadjuvant chemotherapy (96.4% versus 65.6%; P < 0.01). Significantly more patients in the modern synchronous cohort had disease-free or alive-with-disease status at last follow-up, compared to the historic group (P < 0.01), and experienced less disease recurrence (62.7% versus 77.6%; P < 0.05).

CONCLUSIONS

Modern synchronous CRLM patients who underwent hepatic resection experienced significantly improved survival compared to a historic cohort. We postulate that increased use of neoadjuvant chemotherapy and liver-first/simultaneous liver-colon resections in the modern synchronous cohort contributed to improved survival.

Challenges and shifting treatment strategies in the surgical treatment of locally advanced rectal cancer

The current standard treatment for locally advanced rectal cancer (LARC) in Korea and Western countries is a multimodal approach incorporating preoperative long-course chemoradiotherapy (LCRT) followed by total mesorectal excision (TME) and adjuvant chemotherapy. This approach has significantly improved local control and reduced recurrence rates; however, the overall survival benefit has not been established. Although LCRT is a good option, there remain challenging unresolved problems for colorectal surgeons. We focused on four challenging issues in this review article. The first is LARC with resectable liver metastases, for which there has been no consensus regarding optimal management and practice thus far. The second is cancer progression at the time of restaging after completion of preoperative LCRT. To date, there have been few reports on this issue. The third is early recurrence after TME following preoperative LCRT, the reason for which is thought to be the delayed systemic chemotherapy in the preoperative LCRT protocol. The fourth is cost-effectiveness. The preoperative LCRT protocol takes 5 weeks. After a 6-8-week waiting period, surgery is performed. Therefore, it is more time-consuming than short-course chemoradiotherapy. To overcome these issues, total neoadjuvant treatment (TNT) modalities, performed using various protocols, have been conducted globally based on cumulative experience. We also attempted to discuss previous TNT protocols in this article. One treatment strategy is not sufficient for patients with varying clinical characteristics. Therefore, we should revisit current treatment strategies based on recent clinical experience.

Evaluation of MR elastography as a response parameter for transarterial chemoembolization of colorectal liver metastases

OBJECTIVE

The aim of this study was to evaluate magnetic resonance elastography (MRE) as a response parameter in patients who received transarterial chemoembolization (TACE) for the treatment of colorectal liver metastases.

MATERIALS AND METHODS

Forty-two patients (29 male patients; mean age, 61.5 years; range, 41-84 years) with repeated TACE therapy of colorectal liver metastases underwent on average 2 repetitive magnetic resonance imaging (MRI) and MRE exams in 4- to 6-week intervals using a 1.5-T scanner. MRE-based liver stiffness measurements were performed in normal liver parenchyma and in metastatic lesions. Moreover, the size of the liver metastases was assessed during treatment and compared with the results of the MRE analysis.

RESULTS

Liver metastases showed a significantly higher degree of stiffness compared with the normal liver parenchyma (p < 0.001). However, only a weak correlation was found between the lesion size and stiffness (r = - 0.32, p = 0.1). MRE analysis revealed an increase in stiffness of the colorectal liver metastases from 4.4 to 7.1 kPa after three cycles of TACE (p < 0.001). Also, the mean size of the metastases decreased from 17.0 to 11.3 cm2 (p < 0.001). Finally, the entire liver stiffness increased from 2.9 to 3.1 kPa over the three cycles of TACE therapy.

CONCLUSION

In conclusion, MRE showed a significant change in stiffness and size of liver metastases. Therefore, MRE may provide an added value for an evaluation of treatment response in patients with colorectal liver metastases undergoing TACE.

KEY POINTS

• MRE showed an increase in stiffness of the colorectal liver metastases during TACE therapy. • Liver metastases showed a significantly higher degree of stiffness compared with the normal liver parenchyma. • However, only a weak correlation was found between the lesion size and stiffness.

Plant-Derived Lectins as Potential Cancer Therapeutics and Diagnostic Tools

Cancer remains a global health challenge, with high morbidity and mortality, despite the recent advances in diagnosis and treatment. Multiple compounds assessed as novel potential anticancer drugs derive from natural sources, including microorganisms, plants, and animals. Lectins, a group of highly diverse proteins of nonimmune origin with carbohydrate-binding abilities, have been detected in virtually all kingdoms of life. These proteins can interact with free and/or cell surface oligosaccharides and might differentially bind cancer cells, since malignant transformation is tightly associated with altered cell surface glycans. Therefore, lectins could represent a valuable tool for cancer diagnosis and be developed as anticancer therapeutics. Indeed, several plant lectins exert cytotoxic effects mainly by inducing apoptotic and autophagic pathways in malignant cells. This review summarizes the current knowledge regarding the basis for the use of lectins in cancer diagnosis and therapy, providing a few examples of plant-derived carbohydrate-binding proteins with demonstrated antitumor effects.

Effect of high ligation on survival of patients undergoing surgery for primary colorectal cancer and synchronous liver metastases

Background

Although R0 surgery is recommended for stage IV colorectal cancer, the degree of required lymphadenectomy has not been established. The aim of this study was to investigate the prognostic impact of high ligation (HL) of the feeding artery and the number of retrieved lymph nodes after R0 surgery for colorectal cancer and synchronous colorectal cancer liver metastasis (CRLM).

Methods

This was a multi‐institutional retrospective analysis of patients with colorectal cancer and synchronous CRLM who had R0 surgery between January 1997 and December 2007. Clinical and pathological features were compared in patients who underwent HL and those who had a low ligation (LL). Kaplan–Meier analysis was performed to estimate the effect of HL on overall survival (OS). The impact of several risk factors on survival was analysed using the Cox proportional hazards model.

Results

Of 549 patients, 409 (74·5 per cent) had HL. Median follow‐up was 51·4 months. HL significantly improved the 5‐year OS rate (58·2 per cent versus 49·3 per cent for LL; P = 0·017). Multivariable analysis revealed HL to be a significant prognostic factor compared with LL (5‐year mortality: hazard ratio (HR) 0·68, 95 per cent c.i. 0·51 to 0·90; P = 0·007). In subgroup analysis, the positive effect of HL on OS was greatest in patients with lymph node metastasis.

Conclusion

HL of the feeding artery was associated with improved OS in patients with colorectal cancer and synchronous CRLM after R0 surgery.

Long-term results of simultaneous and delayed liver resections of synchronous colorectal cancer liver metastases

BACKGROUND

Complete resection is the only potential curative treatment of synchronous colorectal liver metastases. Although simultaneous liver and colon resections became an accepted procedure at specialized centres for selected patients, there is still little data about the long-term results of simultaneous operative procedures compared with those of delayed operations. In this retrospective study, the long-term survival rates of the patients who underwent simultaneous or delayed resections were presented.

METHODS

A retrospective analysis of liver resections in our institution between 1997 and 2012 was performed. Among 131 patients presented with synchronous colorectal liver metastases, 52 underwent simultaneous and 79 delayed resection. Patients with extrahepatic metastases were excluded, except for 10 patients with metastases limited to liver and lungs that were qualified as resectable.

RESULTS

Age, sex and localization of the primary tumour were similar in the two groups. In the delayed resection group, the majority of colon resections were performed in different hospitals. The frequency of complications did not differ between the groups. The 1, 5 and 10 years survival rates were 77%, 43% and 20% in simultaneous and 86%, 37% and 19% in delayed resection group, respectively. No cancer related deaths occurred after more than 10 years of observation.

CONCLUSION

The long-term outcome of simultaneous resection of synchronous colorectal liver metastases is comparable to delayed resection.

Novel strategy in the treatment of liver metastases - Hepatic resection combined with stereotactic body radiotherapy

BACKGROUND

To evaluate the safety, feasibility and outcomes of patients treated for colorectal liver metastases (CLM) with an innovative combined approach - hepatic resection and Stereotactic body radiotherapy (SBRT) using CyberKnife® system.

METHODS

This was a retrospective cohort study conducted in a single institution. Patients with CLM and no evidence of extrahepatic disease were included during a 6-year study period.

RESULTS

In total, 19 patients with 63 liver lesions underwent liver resection combined with SBRT of unresectable lesions. Major hepatectomy was performed in 42.1% patients; postoperative complications were noted in 31.6% patients. 27 unresectable lesions were treated by SBRT with a total dose of 50-60 Gy in five fractions. The median follow-up of study patients was 29.7 ± 20.58 months. Local control of CLM at 1 and 2 years was achieved in 89.5% of patients. Out-of-field hepatic recurrence was diagnosed in 63.1% patients. The 1-year disease-free survival (DFS) was 52.6%; 2-year DFS was 31.6%. The overall actuarial survival rates at 1 and 2 years were 88.2% and 50.4%.

CONCLUSION

Liver resection combined with SBRT presents a promising therapeutic option for patients with CLM which traditionally are unresectable. The additional use of SBRT allows for the effective clearance of the disease for thoroughly selected patients.

LncRNA, a novel target biomolecule, is involved in the progression of colorectal cancer

Colorectal cancer is one of the most commonly diagnosed malignancies among males and females worldwide. Although China is a country with a low incidence of colorectal cancer, with the improvement of China's economy and lifestyle changes, the incidence rate in China has generally increased in recent years, and the morbidity and mortality of colorectal cancer rank fifth among those of all malignant tumours. Furthermore, despite recent improvements in screening strategies and treatments for colorectal cancer, the prognosis of advanced colorectal cancer is still poor, mainly due to the recurrence or distant metastasis of this disease. Thus, colorectal cancer still seriously threatens the health and life of people and is a major public health problem worthy of further study. Recently, accumulating evidence has revealed that colorectal carcinogenesis might be a multistep process driven by progressive genetic abnormalities, including changes in lncRNA expression. Moreover, a large number of studies have discovered and studied the abnormal expression of lncRNAs in colorectal cancer, providing a promising target for the diagnosis and treatment of colorectal cancer, which will promote human understanding of the pathogenesis of colorectal cancer and improve diagnosis and treatment. Therefore, in the present review, we mainly summarize the present status of colorectal cancer, the characteristics, functions and clinical perspectives of lncRNAs, and the current therapeutic methods used for colorectal cancer, especially the application of lncRNAs in the treatment of colorectal cancer. It is hoped that this review will give readers a new understanding of the roles of lncRNAs in colorectal cancer.

Partial response after treatment with Conversion chemotherapy: A case report of a patient with colon cancer and unresectable hepatic metastases

RATIONALE

Many studies have reported radical resection for liver metastasis and the primary tumor could represent an important prognostic factor in patients affected by colorectal liver metastases (CRLM). However, resection of huge liver metastases from colon cancer has been seldom reported.

PATIENT CONCERNS

A 58-year-old man presented with huge liver metastases from colon cancer. Laboratory tests revealed elevated tumor markers and a wild-type mutation in the K-RAS gene. A computed tomography scan demonstrated unresectable liver masses with a 16.5-cm maximum diameter and intrahepatic duct dilatation due to compression by the liver metastases.

DIAGNOSIS

The patient was diagnosed with stage IV descending colon carcinoma with multiple huge hepatic metastases.

INTERVENTIONS

He was administered 3 treatment courses, including 9 cycles of combined chemotherapy with mFOLFOX6 plus cetuximab (mFOLFOX6 + Cet), and the liver masses reduced. After a preoperative assessment by a multidisciplinary team when the 9 cycles of systemic chemotherapy had been completed, the patient underwent hepatectomy, followed 4 months later by a laparoscopic colectomy. We used a reverse strategy (liver-first) for the patient.

OUTCOMES

In this case, liver-first treatment (systemic chemotherapy of mFOLFOX6 + Cet) was an effective treatment for unresectable CRLM. No postoperative complications occurred. The patient continued to receive postoperative chemotherapy (mFOLFOX6 + Cet) at the latest follow-up. During the 17 months of follow-up, tumor recurrence was un-noted.

LESSONS

Treating colorectal cancer patients with huge hepatic metastases is possible, and surgeons should consider various treatment options in the management of these patients.

Metastatic gastric cancer: Does the site of metastasis make a difference?

BACKGROUND

Metastatic gastric cancer has a poor prognosis. We aim to study how clinical features and prognosis differs between different metastatic sites, and to identify prognostic factors for overall survival.

METHODS

We retrospectively reviewed patients with metastatic gastric adenocarcinoma managed at a tertiary referral cancer center over a 5-year period. We divided our cohort into three groups based on the site(s) of metastasis at presentation-peritoneal metastasis only (P), distant metastasis only (D), and peritoneal and distant metastases (PD).

RESULTS

We studied 470 patients with 175 (37.2%), 193 (41.1%) and 102 (21.7%) patients in the P, D and PD groups, respectively. Patients with peritoneal disease (both P and PD) had higher proportions of patients experiencing chemotherapy disruption due to unplanned hospitalizations, which were also of a longer average duration. The P group had the longest overall median survival of 8.9 months compared to the PD and D groups with 7.4 and 5.5 months, respectively (P < 0.001). On multivariate Cox regression analysis, the presence of ≥1 metastatic site (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.23-2.28; P  =  0.001) was significantly associated with increased overall mortality, whereas palliative systemic chemotherapy (HR 0.29; 95% CI, 0.22-0.37; P < 0.001) and palliative gastrectomy (HR 0.24; 95% CI, 0.15-0.39; P < 0.001) were significantly associated with decreased overall mortality.

CONCLUSION

Metastatic gastric cancer represents a heterogeneous disease, with specific disease complications and treatment outcomes unique to different metastatic sites. We can consider novel multimodality therapies for patient subgroups with isolated metastatic disease and good prognostic factors in a bid to improve long-term survival.

Current status of surgical treatment of colorectal liver metastases

Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.

Stereotactic body radiotherapy using the CyberKnife® system in the treatment of patients with liver metastases: state of the art

Background

The management of patients with liver metastases presents a challenging problem in clinical oncology. Patients with limited involvement of the liver may be suitable for surgical resection or local ablative techniques. Stereotactic body radiotherapy (SBRT) presents an emerging new technology that has shown high efficacy in ablating tumors at various disease sites.

Methods

A comprehensive literature search was performed to identify articles in regard to the SBRT in the treatment of patients with liver metastases.

Results

SBRT allows for the delivery of high-dose radiation in few fractions to the tumor with extreme accuracy, while minimizing the damage to normal surrounding tissue. The CyberKnife^® system is an image-guided robotic system that delivers SBRT, tracks tumors during respiration, and automatically adjusts treatment for any patient movement. The most frequently used indications for CyberKnife^® therapy are ≤5 liver metastases with maximum tumor sizes of 6 cm, no extrahepatic disease, good performance status, and adequate hepatic functions. Local control rates range from 70%-100% at 1 year and from 60%-90% at 2 years. Severe toxicity related to SBRT is uncommon - grade three side effects occur in less than 5% of cases. Despite excellent local control rates, out-of-field metastatic progression (out-of-field hepatic metastases and extrahepatic metastases) develops in a substantial proportion of patients after SBRT. Therefore, it seems essential to improve the selection of patients with liver metastases for SBRT.

Conclusion

The CyberKnife^® system presents an effective minimally invasive treatment modality for patients with hepatic oligometastases who are not suitable candidates for radical liver resection. The available data suggest that liver metastases can be treated by CyberKnife therapy with very low toxicity and excellent local control rates.

The liver-first approach for synchronous colorectal liver metastases: more than a decade of experience in a single centre

BACKGROUND

The feasibility of the liver-first approach for synchronous colorectal liver metastases (CRLM) has been established. We sought to assess the short-term and long-term outcomes for these patients.

METHODS

Outcomes of patients who underwent a liver-first approach for CRLM between 2005 and 2015 were retrospectively evaluated from a prospective database.

RESULTS

Of the 92 patients planned to undergo the liver-first strategy, the paradigm could be completed in 76.1%. Patients with concurrent extrahepatic disease failed significantly more often in completing the protocol (67% versus 21%; p = 0.03). Postoperative morbidity and mortality were 31.5% and 3.3% following liver resection and 30.9% and 0% after colorectal surgery. Of the 70 patients in whom the paradigm was completed, 36 patients (51.4%) developed recurrent disease after a median interval of 20.9 months. The median overall survival on an intention-to-treat basis was 33.1 months (3- and 5-year overall survival: 48.5% and 33.1%). Patients who were not able to complete their therapeutic paradigm had a significantly worse overall outcome (p = 0.03).

CONCLUSION

The liver-first approach is feasible with acceptable perioperative morbidity and mortality rates. Despite the considerable overall-survival-benefit, recurrence rates remain high. Future research should focus on providing selection tools to enable the optimal treatment sequence for each patient with synchronous CRLM.

Radiologic and pathologic response to neoadjuvant chemotherapy predicts survival in patients undergoing the liver-first approach for synchronous colorectal liver metastases

PURPOSE

To investigate the short- and long-term outcomes of liver first approach (LFA) in patients with synchronous colorectal liver metastases (CRLM), evaluating the predictive factors of survival.

METHODS

Sixty-two out of 301 patients presenting with synchronous CRLM underwent LFA between 2007 and 2016. All patients underwent neoadjuvant chemotherapy. After neoadjuvant treatment patients were re-evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST). Liver resection was scheduled after 4-6 weeks. Changes in non-tumoral parenchyma and the tumor response according to the Tumor Regression Grade score (TRG) were assessed on surgical specimens. Primary tumor resection was scheduled 4-8 weeks following hepatectomy.

RESULTS

Five patients out of 62 (8.1%) showed "Progressive Disease" at re-evaluation after neoadjuvant chemotherapy, 22 (35.5%) showed "Stable Disease" and 35 (56.5%) "Partial Response"; of these latter, 29 (82%) showed histopathologic downstaging. The 5-year survival (OS) rate was 55%, while the 5-year disease-free survival (DFS) rate was 16%. RECIST criteria, T-stage, N-stage and TRG were independently associated with OS. Bilobar presentation of disease, RECIST criteria, R1 margin and TRG were independently associated with DFS. Patients with response to neoadjuvant chemotherapy had better survival than those with stable or progressive disease (radiological response 5-y OS: 65% vs. 50%; 5-y DFS: 20% vs. 10%; pathological response 5-y OS: 75% vs. 56%; 5-y DFS: 45% vs. 11%).

CONCLUSIONS

LFA is an oncologically safe strategy. Selection is a critical point, and the best results in terms of OS and DFS are observed in patients having radiological and pathological response to neoadjuvant chemotherapy.

Pathologic response after preoperative therapy predicts prognosis of Chinese colorectal cancer patients with liver metastases

BACKGROUND

Pathologic response is evaluated according to the extent of tumor regression and is used to estimate the efficacy of preoperative treatment. Several studies have reported the association between the pathologic response and clinical outcomes of colorectal cancer patients with liver metastases who underwent hepatectomy. However, to date, no data from Chinese patients have been reported. In this study, we aimed to evaluate the association between the pathologic response to pre-hepatectomy chemotherapy and prognosis in a cohort of Chinese patients.

PATIENTS AND METHODS

In this retrospective study, we analyzed the data of 380 liver metastases in 159 patients. The pathologic response was evaluated according to the tumor regression grade (TRG). The prognostic role of pathologic response in recurrence-free survival (RFS) and overall survival (OS) was assessed using Kaplan-Meier curves with the log-rank test and multivariate Cox models. Factors that had potential influence on pathologic response were also analyzed using multivariate logistic regression and Kruskal-Wallis/Mann-Whitney U tests.

RESULTS

Patients whose tumors achieved pathologic response after preoperative chemotherapy had significant longer RFS and OS than patients whose tumor had no pathologic response to chemotherapy (median RFS: 9.9 vs. 6.5 months, P = 0.009; median OS: 40.7 vs. 28.1 months, P = 0.040). Multivariate logistic regression and Kruskal-Wallis/Mann-Whitney U tests showed that metastases with small diameter, metastases from the left-side primary tumors, and metastases from patients receiving long-duration chemotherapy had higher pathologic response rates than their control metastases (all P < 0.05). A decrease in the serum carcinoembryonic antigen (CEA) level after preoperative chemotherapy predicted an increased pathologic response rate (P < 0.05). Although the application of targeted therapy did not significantly influence TRG scores of all cases of metastases, the addition of cetuximab to chemotherapy resulted in a higher pathologic response rate when combined with irinotecan-based regimens rather than with oxaliplatin-based regimens.

CONCLUSIONS

We found that the evaluation of pathologic response may predict the prognosis of Chinese colorectal cancer patients with liver metastases after preoperative chemotherapy. Small tumor diameter, long-duration chemotherapy, left primary tumor, and decreased serum CEA level after chemotherapy are associated with increased pathologic response rates.

Laparoscopic resections of colorectal cancer and synchronous liver metastases: a case controlled study

PURPOSE

To investigate the efficacy and safety of laparoscopic simultaneous resections of colorectal cancer and synchronous colorectal liver metastases (SCRLM), relative to open surgery.

METHODS

Between 1 January 2009 and 20 April 2014, 20 of 25 patients who underwent laparoscopic simultaneous colorectal cancer and SCRLM resections were matched with 20 of 29 patients who underwent an open approach, based on prognostic propensity scores. Perioperative results and survival outcomes were compared.

RESULTS

The laparoscopic and open groups were comparable in demographics, cancer characteristics, surgery characteristics, and chemotherapy treatment. No postoperative mortality occurred in either group. The estimated blood loss and postoperative stay were significantly greater in the open group than in the laparoscopic group (all, p < .05). All other perioperative results and postoperative complications were similar between the two groups, as well as three-year overall and disease-free survival rates.

CONCLUSIONS

The postoperative complications and survival rates of patients given laparoscopic simultaneous colorectal cancer and SCRLM resections were similar to those treated with an open approach, but with greater short-term benefits. Laparoscopy in this setting by an experienced surgical team appears safe and effective, and is a feasible alternative to an open approach for selected patients.

Primary tumor location as a predictor of the benefit of palliative resection for colorectal cancer with unresectable metastasis

Background

It is still under debate that whether stage IV colorectal cancer patients with unresectable metastasis can benefit from primary tumor resection, especially for asymptomatic colorectal cancer patients. Retrospective studies have shown controversial results concerning the benefit from surgery. This retrospective study aims to evaluate whether the site of primary tumor is a predictor of palliative resection in asymptomatic stage IV colorectal cancer patients.

Methods

One hundred ninety-four patients with unresectable metastatic colorectal cancer were selected from Sun Yat-sen University Cancer Center Database in the period between January 2007 and December 2013. All information was carefully reviewed and collected, including the treatment, age, sex, carcinoembryonic antigen, site of tumor, histology, cancer antigen 199, number of liver metastases, and largest diameter of liver metastasis. The univariate and multivariate analyses were used to detect the relationship between primary tumor resection and overall survival of unresectable stage IV colorectal cancer patients.

Results

One hundred twenty-five received palliative resection, and 69 received only chemotherapy. Multivariate analysis indicated that primary tumor site was one of the independent factors (RR 0.569, P = 0.007) that influenced overall survival. For left-side colon cancer patients, primary tumor resection prolonged the median overall survival time for 8 months (palliative resection vs. no palliative resection: 22 vs. 14 months, P = 0.009); however, for right-side colon cancer patients, palliative resection showed no benefit (12 vs. 10 months, P = 0.910).

Conclusions

This study showed that left-side colon cancer patients might benefit from the primary tumor resection in terms of overall survival. This result should be further explored in a prospective study.

Resection after preoperative chemotherapy versus synchronous liver resection of colorectal cancer liver metastases: A propensity score matching analysis

This study aimed to determine the prognostic effects of preoperative chemotherapy for colorectal cancer liver metastasis (CLM).We retrospectively evaluated 2 groups of patients between January 2006 and August 2012. A total of 53 patients who had ≥3 hepatic metastases underwent resection after preoperative chemotherapy (preoperative chemotherapy group), whereas 96 patients who had ≥3 hepatic metastases underwent resection with a curative intent before chemotherapy for CLM (primary resection group). A propensity score (PS) model was used to compare the both groups.The 3-year disease-free survival (DFS) rates were 31.7% and 20.4% in the preoperative chemotherapy and primary resection groups, respectively (log-rank = 0.015). Analyzing 32 PS matched pairs, we found that the DFS rate was significantly higher in the preoperative chemotherapy group than in the primary resection group (3-year DFS rates were 34.2% and 16.8%, respectively [log-rank = 0.019]). Preoperative chemotherapy group patients had better DFSs than primary resection group patients in various multivariate analyses, including crude, multivariable, average treatment effect with inverse probability of treatment weighting model and PS matching.Responses to chemotherapy are as important as achieving complete resection in cases of multiple hepatic metastases. Preoperative chemotherapy may therefore be preferentially considered for patients who experience difficulty undergoing complete resection for multiple hepatic metastases.

Medical Image Retrieval Using Vector Quantization and Fuzzy S-tree

The aim of the article is to present a novel method for fuzzy medical image retrieval (FMIR) using vector quantization (VQ) with fuzzy signatures in conjunction with fuzzy S-trees. In past times, a task of similar pictures searching was not based on searching for similar content (e.g. shapes, colour) of the pictures but on the picture name. There exist some methods for the same purpose, but there is still some space for development of more efficient methods. The proposed image retrieval system is used for finding similar images, in our case in the medical area – in mammography, in addition to the creation of the list of similar images – cases. The created list is used for assessing the nature of the finding – whether the medical finding is malignant or benign. The suggested method is compared to the method using Normalized Compression Distance (NCD) instead of fuzzy signatures and fuzzy S-tree. The method with NCD is useful for the creation of the list of similar cases for malignancy assessment, but it is not able to capture the area of interest in the image. The proposed method is going to be added to the complex decision support system to help to determine appropriate healthcare according to the experiences of similar, previous cases.

Treatment sequence of synchronously (liver) metastasized colon cancer

No standards for staging, systemic therapy or the timing of an operation are defined for patients newly diagnosed with synchronous metastases and a primary in the colon. An expert group of radiologists, medical, radiation and surgical oncologists therefore came together to discuss staging and treatment sequence for these patients and came up with a recommendation based on current evidence of potential therapeutic options. The discussion was organized to debate recommendations centred on 5 topics and therefore the position paper is built upon these titles and their subtitles.

Role of a liver-first approach for synchronous colorectal liver metastases

AIM: To evaluate the feasibility and survival outcomes of a liver-first approach.

METHODS: Between January 2009 and April 2013, 18 synchronous colorectal liver metastases (sCRLMs) patients with a planned liver-first approach in the Hepatopancreatobiliary Surgery Department I of the Beijing Cancer Hospital were enrolled in this study. Clinical data, surgical outcomes, morbidity and mortality rates were collected. The feasibility and long-term outcomes of the approach were retrospectively analyzed.

RESULTS: Sixteen patients (88.9%) completed the treatment protocol for primary and liver tumors. The main reason for treatment failure was liver disease recurrence. The 1 and 3 year overall survival rates were 94.4% and 44.8%, respectively. The median survival time was 30 mo. The postoperative morbidity and mortality were 22.2% and 0%, respectively, following a hepatic resection, and were 18.8% and 0%, respectively, after a colorectal surgery.

CONCLUSION: The liver-first approach appeared to be feasible and safe. It can be performed with a comparable mortality and morbidity to the traditional treatment paradigm. This approach might offer a curative opportunity for sCRLM patients with a high liver disease burden.