1
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Olthof PB, van Dam R, Jovine E, Campos RR, de Santibañes E, Oldhafer K, Malago M, Abdalla EK, Schadde E. Accuracy of estimated total liver volume formulas before liver resection. Surgery 2019; 166:247-253. [PMID: 31204072 DOI: 10.1016/j.surg.2019.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Future remnant liver volume is used to predict the risk for liver failure in patients who will undergo major liver resection. Formulas to estimate total liver volume based on biometric data are widely used to calculate future remnant liver volume; however, it remains unclear which formula is most accurate. This study evaluated published estimate total liver volume formulas to determine which formula best predicts the actual future remnant liver volume based on measurements in a large number of patients who underwent associating liver partition and portal vein ligation for staged hepatectomy surgery. METHODS All patients with complete liver volume data in the associating liver partition and portal vein ligation for staged hepatectomy registry were included in this study. Estimate total liver volume and estimated future remnant liver volume were calculated for 16 published formulas. The median over- or underestimation compared with actual measured volumes were determined for estimate total liver volume and future remnant liver volume. The proportion of patients with an under- or overestimated future remnant liver volume for each formula were compared with each other using a 25% cut-off for each formula. RESULTS Among 529 studied patients, the formulas ranged from a 19% underestimation to a 63% overestimation of estimate total liver volume. Estimation of future remnant liver volume lead to a 10% underestimation to a 5% overestimation among the formulas. Of all studied formulas, the Vauthey1 formula was the most accurate, generating underestimation of future remnant liver volume in 20% and overestimation of future remnant liver volume in 6% of patients. CONCLUSION Validation of 16 published total liver volume formulas in a multicenter international cohort of 529 patients that underwent staged hepatectomy revealed that the Vauthey formula (estimate total liver volume = 18.51 × body weight + 191.8) provides the most accurate prediction of the actual future remnant liver volume.
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Affiliation(s)
- Pim B Olthof
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands; Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands, and Universitätsklinikum Aachen, Aachen, Germany
| | - Elio Jovine
- Department of Surgery, C. A. Pizzardi Maggiore Hospital, Bologna, Italy
| | | | | | - Karl Oldhafer
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Massimo Malago
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, University College London, London, UK
| | - Eddie K Abdalla
- Department of Hepato-Pancreato-Biliary Surgery, Northside Hospital Cancer Institute, Atlanta, GA
| | - Erik Schadde
- Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland; Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Surgery, Rush University Medical Center, Chicago, IL
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2
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Schoucair R, Nicolas G, Ahdab R, Bejjani N, Abdalla EK. Posterior reversible encephalopathy syndrome (PRES) in mesenteric leiomyosarcoma: A case report. Int J Surg Case Rep 2018; 49:96-101. [PMID: 29980031 PMCID: PMC6031592 DOI: 10.1016/j.ijscr.2018.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterized by headache, confusion, visual loss and seizures. Many factors influence the appearance of this syndrome, predominantly eclampsia, certain medical treatments and malignant hypertension. Diagnosed by typical transient lesions on magnetic resonance imaging. CASE REPORT We present a case of mesenteric leiomyosarcoma in a 52 year old woman, who had severe headache, abdominal heaviness, and hypertension. Investigations revealed a mesenteric mass and a Posterior Reversible Encephalopathy Syndrome features on brain MRI, suggesting renin secretion by the tumor, causing the patient's symptoms. CONCLUSION Patient's symptoms disappeared after resection of the tumor, suggesting a renin production cessation.
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Affiliation(s)
- Ramy Schoucair
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Gregory Nicolas
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon.
| | - Rechdi Ahdab
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Noha Bejjani
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Eddie K Abdalla
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
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3
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Shebaby W, Abdalla EK, Saad F, Faour WH. Data on isolating mesenchymal stromal cells from human adipose tissue using a collagenase-free method. Data Brief 2016; 6:974-9. [PMID: 26949729 PMCID: PMC4760183 DOI: 10.1016/j.dib.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/20/2016] [Accepted: 02/01/2016] [Indexed: 11/08/2022] Open
Abstract
The present dataset describes a detailed protocol to isolate mesenchymal cells from human fat without the use of collagenase. Human fat specimen, surgically cleaned from non-fat tissues (e.g., blood vessels) and reduced into smaller fat pieces of around 1–3 mm size, is incubated in complete culture media for five to seven days. Then, cells started to spread out from the fat explants and to grow in cultures according to an exponential pattern. Our data showed that primary mesenchymal cells presenting heterogeneous morphology start to acquire more homogenous fibroblastic-like shape when cultured for longer duration or when subcultured into new flasks. Cell isolation efficiency as well as cell doubling time were also calculated throughout the culturing experimentations and illustrated in a separate figure thereafter. This paper contains data previously considered as an alternative protocol to isolate adipose-derived mesenchymal stem cell published in “Proliferation and differentiation of human adipose-derived mesenchymal stem cells (ASCs) into osteoblastic lineage are passage dependent” [1].
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Affiliation(s)
- Wassim Shebaby
- Department of Natural Sciences, School of Arts & Sciences, Lebanese American University, Byblos, Lebanon, P.O. Box 36, Lebanon
| | - Eddie K Abdalla
- Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
| | - Fady Saad
- Saint Louis Hospital, Jounieh, Lebanon
| | - Wissam H Faour
- School of Medicine, Lebanese American University, Byblos, Lebanon, P.O. Box 36, Lebanon
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4
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Akoum R, Abdalla EK, Saade M, Awdeh A, Abi-Aad F, Bejjani N, Ghossain A, Brihi E, Audi A. PREDICTORS OF INFLAMMATORY LOCAL RECURRENCE AFTER BREAST-CONSERVING THERAPY FOR BREAST CANCER: MATCHED CASE-CONTROL STUDY. ACTA ACUST UNITED AC 2016; 63:171-8. [PMID: 26821398 DOI: 10.12816/0017963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inflammatory local recurrence (ILR) after breast-conserving surgery for noninflammatory breast cancer (BC) is associated with dismal prognosis. Risk factors for ILR are not well defined. METHODS Between 2001 and 2010, twelve patients at our hospital developed ILR after breast-conserving surgery, adjuvant chemotherapy, and radiotherapy for BC. We compared their clinico-pathological characteristics to those of 24 patients with noninflammatory local recurrence (non-ILR), 24 patients with distant metastases, and 48 disease-free controls, matched for age and observation period. RESULTS The median time to ILR was 10 months. In univariate analysis, extent of lymph node involvement (p < 0.05), multifocality (p < 0.05), c-erbB2 overexpression (p < 0.05), and lymphovascular invasion (LVI) (p < 0.001) affected the risk of ILR. Conditional logistic regression analysis showed a significant association between ILR and combined LVI and high histopathological grade. The odds ratio (OR) for ILR versus non-ILR was 6.14 (95% confidence interval [CI] 1.48-25.38) and for ILR versus distant metastases it was 3.05 (95% CI 0.09-97.83) when both LVI and high histopathological grade were present. Patients with family history of BC were more likely to present with ILR than non-ILR (OR 5.47; 95% CI 1.55-19.31) or distant relapse (OR 5.62; 95% CI 0.26-119.95). CONCLUSIONS Pre- and postmenopausal women with high-grade BC and LVI are at increased risk to develop ILR, especially in the presence of family history of BC. Identification of risk factors for this lethal form of recurrent BC may lead to more effective preventive treatment strategies in properly selected patients.
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Thomas RM, Aloia TA, Truty MJ, Tseng WH, Choi EA, Curley SA, Vauthey JN, Abdalla EK. Treatment sequencing strategy for hepatic epithelioid haemangioendothelioma. HPB (Oxford) 2014; 16:677-85. [PMID: 24308564 PMCID: PMC4105907 DOI: 10.1111/hpb.12202] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The biology of hepatic epithelial haemangioendothelioma (HEHE) is variable, lying intermediate to haemangioma and angiosarcoma. Treatments vary owing to the rarity of the disease and frequent misdiagnosis. METHODS Between 1989 and 2013, patients retrospectively identified with HEHE from a single academic cancer centre were analysed to evaluate clinicopathological factors and initial treatment regimens associated with survival. RESULTS Fifty patients with confirmed HEHE had a median follow-up of 51 months (range 1-322). There was no difference in 5-year survival between patients presenting with unilateral compared with bilateral hepatic disease (51.4% versus 80.7%, respectively; P = 0.1), localized compared with metastatic disease (69% versus 78.3%, respectively; P = 0.7) or an initial treatment regimen of Surgery, Chemotherapy/Embolization or Observation alone (83.3% versus 71.3% versus 72.4%, respectively; P = 0.9). However, 5-year survival for patients treated with chemotherapy at any point during their disease course was decreased compared with those who did not receive any chemotherapy (43.6% versus 82.9%, respectively; P = 0.02) and was predictive of a decreased overall survival on univariate analysis [HR 3.1 (CI 0.9-10.7), P = 0.02]. CONCLUSIONS HEHE frequently follows an indolent course, suggesting that immediate treatment may not be the optimal strategy. Initial observation to assess disease behaviour may better stratify treatment options, reserving surgery for those who remain resectable/transplantable. Prospective cooperative trials or registries may confirm this strategy.
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Affiliation(s)
- Ryan M Thomas
- Department of Surgery, NF/SG VA Medical CenterGainesville, FL, USA,Department of Surgery, University of Florida College of MedicineGainesville, FL, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Mark J Truty
- Department of Surgery, Division of Gastrointestinal and General Surgery, Mayo Clinic College of MedicineRochester, MN, USA
| | - Warren H Tseng
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Eugene A Choi
- Department of Surgery, Sections of General Surgery and Surgical Oncology, University of Chicago HospitalsChicago, IL, USA
| | - Steven A Curley
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Jean N Vauthey
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Eddie K Abdalla
- Department of Surgery, Division of Surgical Oncology, Lebanese American UniversityBeirut, Lebanon
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Schwarz RE, Abdalla EK, Aloia TA, Vauthey JN. AHPBA/SSO/SSAT sponsored consensus conference on the multidisciplinary treatment of colorectal cancer metastases. HPB (Oxford) 2013; 15:89-90. [PMID: 23297718 PMCID: PMC3719913 DOI: 10.1111/j.1477-2574.2012.00569.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Roderich E Schwarz
- Division of Surgical Oncology, UT Southwestern Medical CenterDallas, TX, USA
| | - Eddie K Abdalla
- Department of Surgery, Lebanese American University HospitalBeirut, Lebanon
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer CenterHouston, TX, USA
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7
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Abdalla EK, Bauer TW, Chun YS, D'Angelica M, Kooby DA, Jarnagin WR. Locoregional surgical and interventional therapies for advanced colorectal cancer liver metastases: expert consensus statements. HPB (Oxford) 2013; 15:119-30. [PMID: 23297723 PMCID: PMC3719918 DOI: 10.1111/j.1477-2574.2012.00597.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/20/2012] [Indexed: 12/12/2022]
Abstract
Selection of the optimal surgical and interventional therapies for advanced colorectal cancer liver metastases (CRLM) requires multidisciplinary discussion of treatment strategies early in the trajectory of the individual patient's care. This paper reports on expert consensus on locoregional and interventional therapies for the treatment of advanced CRLM. Resection remains the reference treatment for patients with bilateral CRLM and synchronous presentation of primary and metastatic cancer. Patients with oligonodular bilateral CRLM may be candidates for one-stage multiple segmentectomies; two-stage resection with or without portal vein embolization may allow complete resection in patients with more advanced disease. After downsizing with preoperative systemic and/or regional therapy, curative-intent hepatectomy requires resection of all initial and currently known sites of disease; debulking procedures are not recommended. Many patients with synchronous primary disease and CRLM can safely undergo simultaneous resection of all disease. Staged resections should be considered for patients in whom the volume of the future liver remnant is anticipated to be marginal or inadequate, who have significant medical comorbid condition(s), or in whom extensive resections are required for the primary cancer and/or CRLM. Priority for liver-first or primary-first resection should depend on primary tumour-related symptoms or concern for the progression of marginally resectable CRLM during treatment of the primary disease. Chemotherapy delivered by hepatic arterial infusion represents a valid option in patients with liver-only disease, although it is best delivered in experienced centres. Ablation strategies are not recommended as first-line treatments for resectable CRLM alone or in combination with resection because of high local failure rates and limitations related to tumour size, multiplicity and intrahepatic location.
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Affiliation(s)
- Eddie K Abdalla
- Department of Surgery, Lebanese American UniversityBeirut, Lebanon
| | - Todd W Bauer
- Department of Surgery, University of Virginia Health SystemCharlottesville, VA, USA
| | - Yun S Chun
- Department of Surgical Oncology, Fox Chase Cancer CenterPhiladelphia, PA, USA
| | - Michael D'Angelica
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - David A Kooby
- Department of Surgery, Emory University School of MedicineAtlanta, GA, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
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8
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Shen Y, Sahin IH, Hassan M, Kee BK, Feig BW, Ellis LM, Aloia TA, Abdalla EK, Curley SA, Vauthey JN, Garrett CR. Impact of smoking history on patient outcome following hepatic metastasectomy for colorectal cancer. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.4_suppl.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
517 Background: Although it is clear that smoking increases perioperative risks associated with liver resection, there are also oncologic concerns associated with smoking. For example, nicotine induces CRC cell proliferation in vitro. We undertook a single institution retrospective analysis of pts outcome based on prior smoking history. Methods: Under an IRB-approved protocol, pts who underwent hepatic metastasectomy for treatment for CRC liver metastasis with curative intent at a single institution, from 2005 to 2009, were retrospectively evaluated for smoking history, time to progression (TTP), and overall survival (OS). Pts were analyzed as never smokers (A), ex-smokers (B), or current smokers and those who discontinued at the time of cancer diagnosis (C). Results: 350 pts outcomes were analyzed; their data is demonstrated in the table below. There were no difference in TTP or OS between group A and B (p = 0.346, p = 0.453 respectively). Pts in group A had a superior TTP and OS when compared to group C (p =0.002, p = 0.021 respectively). Patients in group B had a superior TTP when compared to group C (p =0.044), while a difference of OS was not found between the two groups (p =0.153). Conclusions: Smoking history is a negative prognostic factor for TTP in patients undergoing hepatic metastasecomy for CRC. Further studies are necessary to validate these preliminary findings. Active smokers who are candidates for hepatic metastasectomy for CRC should undergo nicotine cessation counseling and treatment. [Table: see text]
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Affiliation(s)
- Yehua Shen
- Fudan University Shanghai Cancer Center, Shanghai, China
| | | | - Manal Hassan
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bryan K. Kee
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barry W. Feig
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lee M. Ellis
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Aloia
- The University of Texas MD Anderson Cancer Center, Houston, TX
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9
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Tzeng CWD, Aloia TA, Vauthey JN, Chang GJ, Ellis LM, Feig BW, Curley SA, Skibber JM, Abdalla EK, You YN, Rodriguez-Bigas MA. Morbidity of Staged Proctectomy After Hepatectomy for Colorectal Cancer: A Matched Case–Control Analysis. Ann Surg Oncol 2012; 20:482-90. [DOI: 10.1245/s10434-012-2620-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Indexed: 12/20/2022]
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10
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Tzeng CWD, Katz MHG, Fleming JB, Pisters PWT, Lee JE, Abdalla EK, Curley SA, Vauthey JN, Aloia TA. Risk of venous thromboembolism outweighs post-hepatectomy bleeding complications: analysis of 5651 National Surgical Quality Improvement Program patients. HPB (Oxford) 2012; 14:506-13. [PMID: 22762398 PMCID: PMC3406347 DOI: 10.1111/j.1477-2574.2012.00479.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Historically, liver surgeons have withheld venous thromboembolism (VTE) chemoprophylaxis due to perceived postoperative bleeding risk and theorized protective anticoagulation effects of a hepatectomy. The relationships between extent of hepatectomy, postoperative VTE and bleeding events were evaluated using the National Surgical Quality Improvement Program (NSQIP) database. METHODS From 2005 to 2009, all elective open hepatectomies were identified. Factors associated with 30-day rates of VTE, postoperative transfusions and returns to the operating room (ROR), were analysed. RESULTS The analysis included 5651 hepatectomies with 3376 (59.7%) partial, 585 (10.4%) left, 1134 (20.1%) right, and 556 (9.8%) extended. Complications included deep vein thrombosis (DVT) (1.93%), pulmonary embolism (PE) (1.31%), venous thromboembolism (VTE) (2.88%), postoperative transfusion (0.76%) and ROR with transfusion (0.44%). VTE increased with magnitude of hepatectomy (partial 2.13%, left 2.05%, right 4.15%, extended 5.76%; P < 0.001) and outnumbered bleeding events (P < 0.001). Other factors independently associated with VTE were aspartate aminotransferase (AST) ≥27 (P= 0.022), American Society of Anesthesiologists (ASA) class ≥3 (P < 0.001), operative time >222 min (P= 0.043), organ space infection (P < 0.001) and length of hospital stay ≥7 days (P= 0.004). VTE resulted in 30-day mortality of 7.4% vs. 2.3% with no VTE (P= 0.001). CONCLUSIONS Contrary to the belief that transient postoperative liver insufficiency is protective, VTE increases with extent of hepatectomy. VTE exceeds major bleeding events and is strongly associated with mortality. These data support routine post-hepatectomy VTE chemoprophylaxis.
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Affiliation(s)
- Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA
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11
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Tzeng CWD, Fleming JB, Lee JE, Xiao L, Pisters PWT, Vauthey JN, Abdalla EK, Wolff RA, Varadhachary GR, Fogelman DR, Crane CH, Balachandran A, Katz MHG. Defined clinical classifications are associated with outcome of patients with anatomically resectable pancreatic adenocarcinoma treated with neoadjuvant therapy. Ann Surg Oncol 2012; 19:2045-53. [PMID: 22258816 DOI: 10.1245/s10434-011-2211-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND We previously introduced a classification system for patients with localized pancreatic adenocarcinoma that integrates assessments of tumor anatomy, cancer biology, and patient physiology. By means of this system, we sought to analyze outcomes of patients with resectable anatomy but heterogeneous biology and physiology who were treated with neoadjuvant therapy. METHODS We evaluated consecutive patients (2002-2007) with anatomically potentially resectable cancers treated with chemotherapy or chemoradiation before potential pancreatectomy. We compared clinical factors and outcomes of patients classified as having disease that was clinically resectable (CR; no extrapancreatic disease, preserved performance status); suspicion for extrapancreatic disease (BR-B); or marginal performance status or significant comorbidity (BR-C). Patients with borderline resectable anatomy (BR-A) were excluded. RESULTS Resection rates for 138 CR, 41 BR-B, and 38 BR-C patients were 75, 46, and 37%, respectively (P < 0.001). Metastases, detected during treatment in 23% of patients, were the most common contraindication to resection among CR (15%) and BR-B (46%) patients. Performance status rarely precluded surgery except among BR-C (32%) patients. Factors associated with selection against surgery were older age, poor performance status, pain, and therapeutic complications (P < 0.05). The median overall survival of all patients was 21 months. Resected and unresected BR-B and BR-C patients had median overall survival durations similar to those of resected and unresected CR patients, respectively (P > 0.22). CONCLUSIONS This system describes discrete clinical subgroups of patients with pancreatic cancer who have similar, potentially resectable tumor anatomy but heterogeneous physiology and cancer biology. It may be used with neoadjuvant therapy to predict outcomes, individualize treatment algorithms, and optimize survival.
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Affiliation(s)
- Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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12
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Abbott DE, Brouquet A, Mittendorf EA, Andreou A, Meric-Bernstam F, Valero V, Green MC, Kuerer HM, Curley SA, Abdalla EK, Hunt KK, Vauthey JN. Resection of liver metastases from breast cancer: estrogen receptor status and response to chemotherapy before metastasectomy define outcome. Surgery 2012; 151:710-6. [PMID: 22285778 PMCID: PMC3628698 DOI: 10.1016/j.surg.2011.12.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 12/22/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND The oncologic benefit of resecting liver metastases in patients with breast cancer is unclear. This study was performed to identify predictors of survival after hepatectomy. METHODS Between 1997 and 2010, 86 patients underwent resection of breast cancer liver metastases. Clinicopathologic characteristics of the primary breast neoplasm, timing of metastasis development, and treatment were recorded. Response to prehepatectomy chemotherapy was evaluated according to Response Criteria in Solid Tumors criteria, and the best response to chemotherapy during treatment and the response immediately before hepatectomy were noted. Univariate and multivariate analyses were performed to identify predictors of disease-free survival and overall survival. RESULTS Fifty-nine patients (69%) had estrogen receptor- or progesterone receptor- positive primary breast neoplasms. Fifty-three patients (62%) had a solitary breast cancer liver metastasis, and 73 (85%) had breast cancer liver metastases ≤5 cm. Sixty-five patients (76%) received prehepatectomy hormonal and/or chemotherapy. Four patients (6%) had progressive disease as the best response, and 19 patients (30%) had progressive disease before hepatectomy (P < .001). Seventy percent of patients who received preoperative chemotherapy or hormonal therapy had either response or stable disease immediately before hepatectomy. No postoperative deaths were observed. At a 62-month median follow-up, the disease-free survival and overall survival were 14 and 57 months, respectively. On univariate analysis, estrogen receptor/progesterone receptor status of the primary breast neoplasm, best radiographic response, and preoperative radiographic response were associated with overall survival. On multivariate analysis, estrogen receptor-negative primary breast disease (P = .009; hazard ratio, 3.3; 95% confidence interval, 1.4-8.2) and preoperative progressive disease (P = .003; hazard ratio, 3.8; 95% confidence interval, 1.6-9.2) were associated with decreased overall survival. CONCLUSION Resection of breast cancer liver metastases in patients with estrogen receptor-positive disease that is responding to chemotherapy is associated with improved survival. The timing of operative intervention may be critical; resection before progression is associated with a better outcome.
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MESH Headings
- Adult
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/metabolism
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Chemotherapy, Adjuvant
- Female
- Follow-Up Studies
- Hepatectomy
- Humans
- Liver Neoplasms/mortality
- Liver Neoplasms/secondary
- Liver Neoplasms/surgery
- Mastectomy
- Middle Aged
- Multivariate Analysis
- Neoadjuvant Therapy
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Retrospective Studies
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Daniel E Abbott
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-4095, USA
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13
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Tzeng CWD, Fleming JB, Lee JE, Xiao L, Pisters PWT, Vauthey JN, Abdalla EK, Wolff RA, Varadhachary GR, Fogelman DR, Crane CH, Balachandran A, Katz MH. Use of operability classifications to predict outcome of patients with anatomically resectable pancreatic adenocarcinoma treated with neoadjuvant therapy. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
293 Background: We previously introduced a novel classification system for assessing “operability” in patients with localized pancreatic adenocarcinoma (PDAC) that integrates cancer biology, patient physiology, and tumor anatomy. We sought to analyze resection rates, reasons for no resection, and outcomes after neoadjuvant therapy (NT) of patients with both resectable anatomy and either “operable” or “borderline” biology/physiology. Methods: We evaluated consecutive patients (2002-2007) with radiographically resectable cancers treated with NT prior to potential resection. Borderline resectable anatomy (BR-A) was excluded. We compared clinical factors and outcomes of 217 patients classified by established criteria as “potentially resectable-operable” (PR-OP, no evidence of extrapancreatic disease, performance status [PS] ≤1); “borderline resectable-B” (BR-B, findings suspicious for extrapancreatic disease); or “borderline resectable-C” (BR-C, severe but reversible comorbidities or marginal PS ≥2). Results: 138 PR-OP, 41 BR-B, and 38 BR-C patients began NT. 62.7% of all patients underwent subsequent pancreatectomy. Resection rates after NT for PR-OP, BR-B, and BR-C were 74.6%, 46.3%, and 36.8%, respectively (p<0.001). Metastases were detected during NT in 23.0% of all patients and were the most common contraindication to resection in PR-OP (15.2%) and BR-B (46.3%) patients. PS rarely precluded surgery except in BR-C patients (31.6%). Factors independently predicting not utilizing surgery after NT were older age, poor PS, new pain medications, and complications on NT (p<0.05). Median OS of all patients was 20.9 (95% CI, 17.1-27.1) mo. Resected and unresected BR-B and BR-C patients had OS similar to that of PR-OP patients (resected medians 33.0, 39.8, 36.0 mo, respectively; unresected medians, 10.1, 12.6, 12.9 mo; p<0.001). Conclusions: Our operability classification system describes discrete clinical subgroups among PDAC patients with similar, resectable tumor anatomy but vastly heterogeneous physiology and cancer biology. It can be used with NT to predict outcomes, individualize treatment, and optimize survival rates.
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Affiliation(s)
| | | | | | - Lianchun Xiao
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | | | | | - Robert A. Wolff
- University of Texas M. D. Anderson Cancer Center, Houston, TX
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14
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Tzeng CWD, Chang GJ, Curley SA, Vauthey JN, Ellis LM, Skibber JM, Feig BW, Abdalla EK, Aloia TA, You YN, Rodriguez-Bigas MA. Morbidity of staged proctectomy after hepatectomy for colorectal cancer: A matched case-control analysis. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
629 Background: Proctectomy after hepatectomy, or the “reverse approach,” is an alternative to traditional sequencing for advanced liver metastases with asymptomatic colorectal primaries. However, perioperative morbidity from staged proctectomy remains uncharacterized. We sought to identify risk factors for morbidity in these patients. Methods: A single-institution colorectal database was queried for patients treated with proctectomy after previous hepatectomy from 2003-2011. Reverse approach patients (31) were matched 1:2 with a cohort of standard proctectomy patients (62), using operation, age, sex, and surgeon. Perioperative factors were analyzed by univariate/multivariate models for associations with complications graded by Dindo-Clavien criteria. Results: 31 patients with adenocarcinoma ≤20 cm from the anal verge underwent proctectomy after hepatectomy. Median time from hepatectomy to proctectomy was 5.1 mo. Median tumor distance was 8.5 cm from the anal verge. No patients with primary tumors in situ recurred in the liver while awaiting proctectomy after hepatectomy. Prior to proctectomy, there were 28 (90%) major hepatectomies and 7 (22%) portal vein embolizations. Grade ≥2 complications developed in 42% of reverse approach and 27% of standard proctectomies (p=0.17). Grade 3 complications developed in 10% and 8%, respectively (p=1.00). There were no perioperative deaths. Reverse approach patients did not differ from the control cohort in operation, demographics, body mass index (BMI), comorbidities, tumor distance, operative time, estimated blood loss (EBL), length of stay, or complication rates (p>0.05). Independent predictors of Grade ≥2 complications were BMI ≥30 (p=0.007), operative time ≥300 min (p=0.012), intraoperative transfusion (p=0.044), concurrent procedures (p=0.024), and age ≥50 (p=0.030). Independent factors for Grade 3 complications were operative time ≥300 min (p=0.015), intraoperative transfusion (p=0.011), and EBL ≥300 ml (p=0.047). Conclusions: Risk factors for morbidity of staged proctectomy are similar to those for standard proctectomy. When applied to selected patients, the reverse approach is safe with acceptable morbidity.
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Affiliation(s)
| | - George J. Chang
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | | | - Lee M. Ellis
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Barry W. Feig
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Thomas A. Aloia
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Y. Nancy You
- University of Texas M. D. Anderson Cancer Center, Houston, TX
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15
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Katz MHG, Wang H, Balachandran A, Bhosale P, Crane CH, Wang X, Pisters PWT, Lee JE, Vauthey JN, Abdalla EK, Wolff R, Abbruzzese J, Varadhachary G, Chopin-Laly X, Charnsangavej C, Fleming JB. Effect of neoadjuvant chemoradiation and surgical technique on recurrence of localized pancreatic cancer. J Gastrointest Surg 2012; 16:68-78; discussion 78-9. [PMID: 22065318 DOI: 10.1007/s11605-011-1748-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 10/13/2011] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the influence of neoadjuvant chemoradiation and standardized dissection of the superior mesenteric artery upon the oncologic outcome of patients with localized pancreatic adenocarcinoma. METHODS One hundred ninety-four patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy between 2004 and 2008 were evaluated. The retroperitoneal dissection was performed directly along the superior mesenteric artery in all cases. A standard histopathologic protocol that measured the "superior mesenteric artery (SMA) margin distance" between cancer cells and the superior mesenteric artery was employed. RESULTS Seventy-six percent of patients received neoadjuvant chemoradiation. The SMA margin was positive in 4% of patients but an additional 22% of patients with a negative margin had a SMA margin distance of ≤1 mm. Preoperative CT images overestimated the SMA margin distance in 73% of cases. Patients who received chemoradiation had longer SMA margin distances than those who did not. Patients who received chemoradiation and had a SMA margin of >1 mm had the lowest recurrence rates. Administration of neoadjuvant chemoradiation and lower estimated blood loss were independently associated with longer progression-free survival on multivariate analysis. CONCLUSIONS Preoperative chemoradiation and meticulous dissection of the superior mesenteric artery maximize the distance between cancer cells and the SMA margin and may influence locoregional control.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA.
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16
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Estrella JS, Rashid A, Fleming JB, Katz MH, Lee JE, Wolf RA, Varadhachary GR, Pisters PWT, Abdalla EK, Vauthey JN, Wang H, Gomez HF, Evans DB, Abbruzzese JL, Wang H. Post-therapy pathologic stage and survival in patients with pancreatic ductal adenocarcinoma treated with neoadjuvant chemoradiation. Cancer 2012; 118:268-77. [PMID: 21735446 DOI: 10.1002/cncr.26243] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/23/2011] [Accepted: 04/13/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation before surgery is an emerging treatment modality for pancreatic ductal adenocarcinoma (PDAC). However, analysis of prognostic factors is limited for patients with PDAC treated with neoadjuvant chemoradiation and pancreaticoduodenectomy (PD). METHODS The study population was comprised of 240 consecutive patients with PDAC who received neoadjuvant chemoradiation and PD and was compared with 60 patients who had no neoadjuvant therapy between 1999 and 2007. Clinicopathologic features were correlated with disease-free survival (DFS) and overall survival (OS). RESULTS Among the 240 treated patients, the 1-year and 3-year DFS rates were 52% and 32%, with a median DFS of 15.1 months. The 1-year and 3-year OS rates were 95% and 47%, with a median OS of 33.5 months. By univariate analysis, DFS was associated with age, post-therapy tumor stage (ypT), lymph node status (ypN), number of positive lymph nodes, and American Joint Committee on Cancer (AJCC) stage, whereas OS was associated with intraoperative blood loss, margin status, ypT, ypN, number of positive lymph nodes, and AJCC stage. By multivariate analysis, DFS was independently associated with age, number of positive lymph nodes, and AJCC stage, and OS was independently associated with differentiation, margin status, number of positive lymph nodes, and AJCC stage. In addition, the treated patients had better OS and lower frequency of lymph node metastasis than those who had no neoadjuvant therapy. CONCLUSIONS In patients with PDAC who received neoadjuvant chemoradiation and subsequent PD, post-therapy pathologic AJCC stage and number of positive lymph nodes are independent prognostic factors.
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Affiliation(s)
- Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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17
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Abstract
BACKGROUND The outcome after a repeat hepatectomy for recurrent colorectal liver metastases (CLM) is not well defined. The present study examined the morbidity, mortality and long-term survivals after a repeat hepatectomy for recurrent CLM. METHODS Data on patients who underwent surgery for recurrent CLM between 1993 and 2009 were retrospectively evaluated. Patients who underwent radiofrequency ablation at the time of first treatment or at recurrence of CLM were excluded. RESULTS Forty-three patients underwent a repeat hepatectomy for recurrent CLM. At the time of recurrence, patients had a median of 1 (1-3) lesions and the median tumour size was 2 (0.5-8.7) cm. The post-operative morbidity and mortality rates were 12% and 0%, respectively. After a median follow-up of 33 months from a repeat hepatectomy, 5-year overall and progression-free survival rates were 73% and 22%, respectively. Using multivariate analysis, the largest initial CLM ≥5 cm and positive surgical margins at initial resection were independently associated with a worse survival after surgery for recurrent CLM. Positive surgical margins at repeat hepatectomy were a predictive factor for an increased risk of further recurrence. DISCUSSION A repeat hepatectomy for recurrent CLM was associated with excellent survival, low morbidity and no mortality. Surgeon-controlled variables, including margin-negative resection at first and repeat hepatectomy, contribute to good oncological outcome.
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Affiliation(s)
- Andreas Andreou
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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18
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Gaur P, Sceusi EL, Samuel S, Xia L, Fan F, Zhou Y, Lu J, Tozzi F, Lopez-Berestein G, Vivas-Mejia P, Rashid A, Fleming JB, Abdalla EK, Curley SA, Vauthey JN, Sood AK, Yao JC, Ellis LM. Identification of cancer stem cells in human gastrointestinal carcinoid and neuroendocrine tumors. Gastroenterology 2011; 141:1728-37. [PMID: 21806944 PMCID: PMC3202668 DOI: 10.1053/j.gastro.2011.07.037] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 06/16/2011] [Accepted: 07/26/2011] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Metastatic gastrointestinal neuroendocrine tumors (NETs) frequently are refractory to chemotherapy. Chemoresistance in various malignancies has been attributed to cancer stem cells (CSCs). We sought to identify gastrointestinal neuroendocrine CSCs (N-CSCs) in surgical specimens and a NET cell line and to characterize novel N-CSC therapeutic targets. METHODS Human gastrointestinal NETs were evaluated for CSCs using the Aldefluor (Stemcell Technologies, Vancouver, Canada) assay. An in vitro, sphere-forming assay was performed on primary NET cells. CNDT2.5, a human midgut carcinoid cell line, was used for in vitro (sphere-formation) and in vivo (tumorigenicity assays) CSC studies. N-CSC protein expression was characterized using Western blotting. In vivo, systemic short interfering RNA administration targeted Src. RESULTS By using the Aldefluor assay, aldehyde dehydrogenase-positive (ALDH+) cells comprised 5.8% ± 1.4% (mean ± standard error of the mean) of cells from 19 patient samples. Although many primary cell lines failed to grow, CNDT96 ALDH+ cells formed spheres in anchorage-independent conditions, whereas ALDH- cells did not. CNDT2.5 ALDH+ cells formed spheres, whereas ALDH- cells did not. In vivo, ALDH+ CNDT2.5 cells generated more tumors, with shorter latency than ALDH- or sham-sorted cells. Compared with non-CSCs, ALDH+ cells demonstrated increased expression of activated Src, Erk, Akt, and mammalian target of rapamycin (mTOR). In vivo, anti-Src short interfering RNA treatment of ALDH+ tumors reduced tumor mass by 91%. CONCLUSIONS CSCs are present in NETs, as shown by in vitro sphere formation and in vivo tumorigenicity assays. Src was activated in N-CSCs and represents a potential therapeutic target in gastrointestinal NETs.
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Affiliation(s)
- Puja Gaur
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric L. Sceusi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shaija Samuel
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ling Xia
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fan Fan
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yunfei Zhou
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jia Lu
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Federico Tozzi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriel Lopez-Berestein
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pablo Vivas-Mejia
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason B. Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eddie K. Abdalla
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven A. Curley
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anil K. Sood
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James C. Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lee M. Ellis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas,Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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19
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Skinner HD, Sharp HJ, Kaseb AO, Javle MM, Vauthey JN, Abdalla EK, Delclos ME, Das P, Crane CH, Krishnan S. Radiation treatment outcomes for unresectable hepatocellular carcinoma. Acta Oncol 2011; 50:1191-8. [PMID: 21793641 DOI: 10.3109/0284186x.2011.592147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatocellular carcinoma is one of the most common cancers worldwide. Data regarding the use of radiotherapy is limited in patients from populations without endemic viral hepatitis. We examine the outcomes for patients treated with radiotherapy in the modern era at a single institution. MATERIAL AND METHODS A total of 29 patients with localized hepatocellular carcinoma treated from 2000-2010 were reviewed. Patients with metastatic disease at the time of radiation were excluded. Median radiation dose was 50 Gy (range 30 to 75 Gy) with a median biologically effective dose of 80.6 (range 60 to 138.6). Median tumor size at the time of radiation was 5.2 cm (range 2 to 25 cm). RESULTS Eighty three percent of all patients had either stable disease or a partial response to radiation, based on RECIST criteria. Median change in tumor size following radiation was -17% (range -73.5 to 177.8%). Estimated one-year overall survival and in-field progression-free survival rates for the study population were 56% and 79%, respectively. One-year overall survival in patients treated to a biologically effective dose <75 was significantly lower than in patients treated to a biologically effective dose ≥75 (18% vs. 69%). One-year in-field progression-free survival rate (60% vs. 88%) and biochemical progression-free survival duration (median 6.5 vs. 1.6 months) were also significantly improved in patients treated to a biologically effective dose ≥75. Grade 3 toxicity was seen in 13.8% of patients. DISCUSSION In a population without endemic viral hepatitis, unresectable hepatocellular carcinoma demonstrates significant response to radiotherapy with minimal toxicity. Furthermore, our findings suggest that increased biologically effective dose is associated with improved survival and local tumor control.
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Affiliation(s)
- Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA
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20
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Kaseb AO, Morris JS, Hassan MM, Siddiqui AM, Lin E, Xiao L, Abdalla EK, Vauthey JN, Aloia TA, Krishnan S, Abbruzzese JL. Clinical and prognostic implications of plasma insulin-like growth factor-1 and vascular endothelial growth factor in patients with hepatocellular carcinoma. J Clin Oncol 2011; 29:3892-9. [PMID: 21911725 DOI: 10.1200/jco.2011.36.0636] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Cirrhosis and hepatocellular carcinoma (HCC) together form a two-disease state that affects survival of patients with HCC and dictates treatment decisions and prognostic stratification of patients in clinical trials. The study objective was to improve prognostic stratification of patients with HCC. PATIENTS AND METHODS We prospectively collected plasma samples and baseline clinicopathologic features from 288 new patients with HCC, and plasma insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) levels were tested. We applied Cox regression and log-rank tests to assess association of IGF-1 and VEGF with overall survival (OS), Kaplan-Meier curves to estimate OS, and recursive partitioning to determine optimal cutoff points for IGF-1 and VEGF. Prognostic ability of conventional and molecular Barcelona Clinic Liver Cancer classifications was compared using the c-index. RESULTS Lower plasma IGF-1 and higher plasma VEGF levels significantly correlated with advanced clinicopathologic parameters and poor OS, with optimal cut points of 26 ng/mL and 450 pg/mL, respectively. The combination of low IGF-1 and high VEGF predicted median OS of 2.7 months compared with 19 months for patients with high IGF-1 and low VEGF (P < .001), further refining the prognostic ability of conventional HCC staging (P < .001). CONCLUSION Baseline levels of plasma IGF-1 and VEGF correlated significantly with survival in patients with HCC. Integrating IGF-1 and VEGF into HCC staging significantly enhanced prognostic stratification of patients. If validated, these results may prove to be useful in designing strategies to personalize management approaches among these patients.
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Affiliation(s)
- Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, Unit 426, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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21
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Abstract
The Americas Hepato-Pancreato Biliary Association (AHPBA) Annual 2011 Meeting provided a forum for discussion of multidisciplinary advances surrounding six tracks including the liver, biliary system, liver transplantation, pancreas, imaging and biomedical engineering and general hepato-pancreato biliary (HPB) surgical disease. The meeting and postgraduate courses attracted the largest ever attendance and participation in the AHPBA annual meeting, including field leaders and participants from across North, Central and South America who interchanged clinical and scientific knowledge, and discussed advances in technology, care and outcomes for treatment of HPB diseases. The AHPBA Foundation, established in 2010, announced progress toward support of meritorious research in HPB disease and enrichment of educational programs. HPB fellowship graduates were recognized, marking successful establishment of the AHPBA as an important body guiding HPB education and training in the USA and the Americas.
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Affiliation(s)
- Eddie K Abdalla
- The University of Texas MD Anderson Cancer Center, 1400 Hermann Pressler Drive, Houston, TX 77030-4008, USA.
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22
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Kaseb AO, Abbruzzese JL, Vauthey JN, Aloia TA, Abdalla EK, Hassan MM, Lin E, Xiao L, El-Deeb AS, Rashid A, Morris JS. I-CLIP: improved stratification of advanced hepatocellular carcinoma patients by integrating plasma IGF-1 into CLIP score. Oncology 2011; 80:373-81. [PMID: 21822028 PMCID: PMC3171278 DOI: 10.1159/000329040] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 04/05/2011] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Improving the prognostic stratification of unresectable hepatocellular carcinoma (HCC) patients is critically needed. Since patients' survival is closely linked to the severity of the underlying liver disease, and insulin-like growth factor-1 (IGF-1) is produced predominantly in the liver, we hypothesized that IGF-1 may correlate with patients' survival and hence improve the prognostic ability of the Cancer of the Liver Italian Program (CLIP) score. METHODS Baseline plasma IGF-1 and clinicopathologic parameters were available from 288 patients. Multivariate Cox regression models, Kaplan-Meier curves, and the log-rank test were applied. Recursive partitioning was used to determine the optimal cut point for IGF-1 using training/validation samples. Prognostic ability of the I-CLIP (I = IGF) was compared to CLIP using C-index. RESULTS IGF-1 significantly correlated with the clinicopathologic features. With an optimal IGF-1 cut point of 26 ng/ml, the overall survival of patients with IGF-1 >26 was 17.7 months (95% CI 13.6-22.8), and with IGF-1 ≤26 was 5.8 months (95% CI 4.0-12.5), p < 0.0001. The concordance probabilities for CLIP and I-CLIP were 0.7037 and 0.7096, respectively (p < 0.0001). CONCLUSIONS Our preliminary results indicate that I-CLIP significantly improved prognostic stratification of patients with advanced HCC. However, independent validation of our study is warranted.
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Affiliation(s)
- Ahmed O. Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA,*Ahmed O. Kaseb, MD, Department of Gastrointestinal Medical Oncology, Unit 426, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030 (USA), Tel. +1 713 792 2828, E-Mail
| | - James L. Abbruzzese
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Thomas A. Aloia
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Eddie K. Abdalla
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Manal M. Hassan
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - E. Lin
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Lianchun Xiao
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Adel S. El-Deeb
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Asif Rashid
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
| | - Jeffrey S. Morris
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Tex., USA
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Anaya DA, Blazer DG, Abdalla EK. Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma. Semin Intervent Radiol 2011; 25:110-22. [PMID: 21326552 DOI: 10.1055/s-2008-1076684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.
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Affiliation(s)
- Daniel A Anaya
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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24
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Brouquet A, Vauthey JN, Contreras CM, Walsh GL, Vaporciyan AA, Swisher SG, Curley SA, Mehran RJ, Abdalla EK. Improved survival after resection of liver and lung colorectal metastases compared with liver-only metastases: a study of 112 patients with limited lung metastatic disease. J Am Coll Surg 2011; 213:62-9; discussion 69-71. [PMID: 21700179 DOI: 10.1016/j.jamcollsurg.2011.05.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 04/14/2011] [Accepted: 05/04/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Lung metastases are considered a poor prognostic factor in patients with resectable colorectal liver metastases. STUDY DESIGN We reviewed records of 1,260 consecutive patients with liver-only or liver-plus-lung (L+L) metastases from colorectal cancer who underwent resection with curative intent (1995 to 2009). Survival and prognostic factors were analyzed. RESULTS There were 112 patients who underwent resection of L+L (mean 2 liver, 2 lung metastases). Mean tumor sizes were 3 cm and 1 cm, respectively. Thirty-four (31%) had bilateral lung metastases. Ten (9%) had synchronous L+L metastases, 60 (54%) had diagnosis of lung metastases within 1 year of liver resection. Most (108 of 112, 96%) had resection of liver before or at the same time as lung. Preoperative chemotherapy was used in 77 (69%) before liver resection and 56 (50%) before lung resection. Among L+L patients, no postoperative deaths occurred; postoperative morbidity rates were 26% after liver resection and 4% after lung resection. After a median of 49 months follow-up, L+L patients (n = 112) had better survival than liver only (n = 1,148) (5-year overall survival, L+L, 50% vs liver only, 40%; p = 0.01). CEA level > 5 ng/dL (hazard ratio [HR] 2.1, 95% CI 1.1 to 4.4, p = 0.04) and rectal primary (HR 2.9, 95% CI 1.4 to 6, p = 0.004) were associated with worse survival in L+L patients. CONCLUSIONS The survival rate for patients who undergo resection of L+L metastases from colorectal cancer is greater than the survival rate of the general population of patients who undergo resection of liver metastases only. The presence of resectable lung metastases is neither a poor prognostic factor nor a contraindication to resection of liver metastases.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-4008, USA
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Abdalla EK. Who Benefits from Portal Vein Embolization Prior to Major Hepatectomy for Colorectal Cancer Liver Metastases? Curr Colorectal Cancer Rep 2011. [DOI: 10.1007/s11888-011-0094-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Brouquet A, Vauthey JN, Badgwell BD, Loyer EM, Kaur H, Curley SA, Abdalla EK. Hepatectomy for recurrent colorectal liver metastases after radiofrequency ablation. Br J Surg 2011; 98:1003-9. [PMID: 21541936 DOI: 10.1002/bjs.7506] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND The results of surgery for recurrent colorectal liver metastases (CLM) after radiofrequency ablation (RFA) have not been evaluated. METHODS From 1993 to 2009, data on patients who underwent resection or RFA for recurrent CLM were collected prospectively. Inclusion criteria for this study were RFA as initial treatment for CLM and resection of recurrent CLM after RFA. Postoperative results and oncological outcomes were analysed. RESULTS Twenty-eight patients (median number of tumours 1 (1-3), median size 2·8 (2·0-4·0) cm) met the inclusion criteria. Of these, 22 had recurrence at the site of RFA only, two developed new lesions, whereas four had both recurrent and de novo metastases. At the time of resection, patients had a median of 1 (1-13) CLM with a median maximum tumour diameter of 5·0 (1·8-11·0) cm, significantly larger than at the time of RFA (P = 0·021). Ninety-day postoperative morbidity and mortality rates were 46 per cent (13 of 28) and 7 per cent (2 of 28) respectively. After a median follow-up of 35 (0-70) months, 3-year overall and disease-free survival rates calculated by Kaplan-Meier analysis were 60 and 29 per cent respectively. Plasma carcinoembryonic antigen level over 5 ng/ml at the time of resection and a rectal primary tumour were associated with worse survival (P = 0·041 and P = 0·021 respectively). CONCLUSION Resection for recurrence after RFA is associated with significant morbidity and modest long-term benefit.
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Affiliation(s)
- A Brouquet
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Brouquet A, Overman MJ, Kopetz S, Maru DM, Loyer EM, Andreou A, Cooper A, Curley SA, Garrett CR, Abdalla EK, Vauthey JN. Is resection of colorectal liver metastases after a second-line chemotherapy regimen justified? Cancer 2011; 117:4484-92. [PMID: 21446046 DOI: 10.1002/cncr.26036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 11/22/2010] [Accepted: 01/03/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patient outcomes following resection of colorectal liver metastases (CLM) after second-line chemotherapy regimen is unknown. METHODS From August 1998 to June 2009, data from 1099 patients with CLM were collected prospectively. We retrospectively analyzed outcomes of patients who underwent resection of CLM after second-line (2 or more) chemotherapy regimens. RESULTS Sixty patients underwent resection of CLM after 2 or more chemotherapy regimens. Patients had advanced CLM (mean number of CLM ± standard deviation, 4 ± 3.5; mean maximum size of CLM, 5 ± 3.2 cm) and had received 17 ± 8 cycles of preoperative chemotherapy. In 54 (90%) patients, the switch from the first regimen to another regimen was motivated by tumor progression or suboptimal radiographic response. All patients received irinotecan or oxaliplatin, and the majority (42/60 [70%]) received a monoclonal antibody (bevacizumab or cetuximab) as part of the last preoperative regimen. Postoperative morbidity and mortality rates were 33% and 3%, respectively. At a median follow-up of 32 months, 1-year, 3-year, and 5-year overall survival rates were 83%, 41%, and 22%, respectively. Median chemotherapy-free survival after resection or completion of additional chemotherapy administered after resection was 9 months (95% confidence interval, 4-14 months). Synchronous (vs metachronous) CLM and minor (vs major) pathologic response were independently associated with worse survival. CONCLUSIONS Resection of CLM after a second-line chemotherapy regimen was found to be safe and was associated with a modest hope for definitive cure. This approach represents a viable option in patients with advanced CLM.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Brouquet A, Abdalla EK, Kopetz S, Garrett CR, Overman MJ, Eng C, Andreou A, Loyer EM, Madoff DC, Curley SA, Vauthey JN. High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol 2011; 29:1083-90. [PMID: 21263087 DOI: 10.1200/jco.2010.32.6132] [Citation(s) in RCA: 303] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Prolonged survival after two-stage resection (TSR) of advanced colorectal liver metastases (CLM) may be the result of selection of best responders to chemotherapy. The impact of complete resection in this well-selected group is controversial. PATIENTS AND METHODS Data on 890 patients undergoing resection and 879 patients who received only chemotherapy for CLM were collected prospectively. We used intent-to-treat analysis to evaluate the survival of patients who underwent TSR. Additionally, we evaluated a cohort of nonsurgically treated patients selected to mirror the TSR population: colorectal metastases with liver-only disease, objective response to chemotherapy, and alive 1 year after chemotherapy initiation. RESULTS Sixty-five patients underwent the first stage of TSR; 62 patients fulfilled the inclusion criteria for the medical group. TSR patients had a mean of 6.7 ± 3.4 CLM with mean size of 4.5 ± 3.1 cm. Nonsurgical patients had a mean of 5.9 ± 2.9 CLM with mean size of 5.4 ± 3.4 cm (not significant). Forty-seven TSR patients (72%) completed the second stage. Progression between stages was the main cause of noncompletion of the second stage (61%). After 50 months median follow-up, the 5-year survival rate was 51% in the TSR group and 15% in the medical group (P = .005). In patients who underwent TSR, noncompletion of TSR and major postoperative complications were independently associated with worse survival. CONCLUSION TSR is associated with excellent outcome in patients with advanced CLM as a result of both selection by chemotherapy and complete resection of metastatic disease.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 444, Houston, TX 77030, USA
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Abstract
Portal vein embolization (PVE) is used to increase the volume and function of the liver that will remain after extensive liver resection. Operative outcomes are improved in properly selected patients who undergo PVE and experience adequate future liver remnant (FLR) hypertrophy. Absolute volume and volume change of the FLR after PVE (interpreted in context of liver disease) predict adequate liver function postresection. Oncologic outcomes following resection in patients with appropriately applied PVE are excellent.
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Affiliation(s)
- Eddie K Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1400 Holcombe Boulevard-Unit 444, Houston, Texas 77030, USA.
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Kishi Y, Zorzi D, Contreras CM, Maru DM, Kopetz S, Ribero D, Motta M, Ravarino N, Risio M, Curley SA, Abdalla EK, Capussotti L, Vauthey JN. Extended preoperative chemotherapy does not improve pathologic response and increases postoperative liver insufficiency after hepatic resection for colorectal liver metastases. Ann Surg Oncol 2010; 17:2870-6. [PMID: 20567921 DOI: 10.1245/s10434-010-1166-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND The optimal duration, safety, and benefit of preoperative chemotherapy in patients with colorectal liver metastases (CLM) are unclear. We evaluated the association between the duration of preoperative chemotherapy with 5-fluorouracil (5-FU), leucovorin, oxaliplatin (FOLFOX) ± bevacizumab, pathologic response, and hepatotoxicity after hepatic resection for CLM. METHODS A total of 219 patients underwent hepatic resection following FOLFOX with or without bevacizumab and were divided into 2 groups according to the chemotherapy duration: 1-8 cycles (short duration [SD]; N = 157) and ≥9 cycles (long duration [LD]; N = 62). The frequency of complete or major pathologic response, sinusoidal injury, and major postoperative morbidity were compared. RESULTS Treatment consisting of ≥9 cycles was not associated with an increase in complete or major pathologic response (SD vs. LD, 57% vs. 55%; P = .74). The incidence of sinusoidal injury was higher in the LD group (26% vs. 42%; P = .017). The incidence of liver insufficiency was higher in the LD group (4% vs. 11%; P = .035). Sinusoidal injury did not predict postoperative liver insufficiency; multivariate analysis revealed ≥9 cycles was the only independent predictor of postoperative liver insufficiency (P = .031; odds ratio = 3.90). Chemotherapy including bevacizumab was associated with a significantly higher frequency of complete or major response in both SD and LD groups. CONCLUSIONS Extended preoperative chemotherapy increases the risk of hepatotoxicity in CLM without improving the pathologic response. The type of chemotherapy (FOLFOX with bevacizumab) has more impact on pathologic response than the duration of chemotherapy.
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Affiliation(s)
- Yoji Kishi
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Glazer ES, Tseng JF, Al-Refaie W, Solorzano CC, Liu P, Willborn KA, Abdalla EK, Vauthey JN, Curley SA. Long-term survival after surgical management of neuroendocrine hepatic metastases. HPB (Oxford) 2010; 12:427-33. [PMID: 20662794 PMCID: PMC3028584 DOI: 10.1111/j.1477-2574.2010.00198.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical cytoreduction and endocrine blockade are important options for care for neuroendocrine liver metastases. We investigated the long-term survival of patients surgically treated for hepatic neuroendocrine metastases. METHODS Patients (n= 172) undergoing operations for neuroendocrine liver metastases from any primary were identified from a prospective liver database. Recorded data and medical record review were used to analyse the type of procedure, length of hospital stay, peri-operative morbidity, tumour recurrence, progression,and survival. RESULTS The median age was 56.8 years (range 11.5-80.7 years). 48.3% of patients were female. Median overall survival was 9.6 years (range 89 days to 22 years). On multivariate analysis, lung/thymic primaries were associated with worse survival [hazard ratio (HR): 15.6, confidence interval (CI): 4.3-56.8, P= 0.002]. Severe post-operative complications were also associated with worse long-term survival (P < 0.001). A positive resection margin status (R1) was not associated with a worse overall survival probability (P approximately 0.8). DISCUSSION Early and aggressive surgical management of hepatic metastases from neuroendocrine tumours is associated with significant long-term survival rates. Radiofrequency ablation is a reasonable option if a lesion is unresectable. R1 resections, unlike many other cancers, are not associated with a worse overall survival.
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Affiliation(s)
- Evan S Glazer
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
| | - Jennifer F Tseng
- Department of Surgery, University of Massachusetts Medical SchoolWorcester, MA
| | - Waddah Al-Refaie
- Department of Surgery, University of Massachusetts Medical SchoolWorcester, MA
| | - Carmen C Solorzano
- Department of Surgery, University of Minnesota Medical SchoolMinneapolis, MN
| | - Ping Liu
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
| | - Katherine A Willborn
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
| | - Eddie K Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
| | - Steven A Curley
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX
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Abstract
Staging of hepatocellular carcinoma (HCC) is complex and relies on multiple factors including tumor extent and hepatic function. No single staging system is applicable to all patients with HCC. The staging of the American Joint Committee on Cancer / International Union for Cancer Control should be used to predict outcome following resection or liver transplantation. The Barcelona Clinic Liver Cancer scheme is appropriate in patients with advanced HCC not candidate for surgery. Dual phase computed tomography or magnetic resonance imaging can be used for pretreatment assessment of tumor extent but the accuracy of these methods remains poor to characterize < 1 cm lesions. Assessment of tumor response should not rely only on tumor size and new imaging methods are available to evaluate response to therapy in HCC patients. Liver volumetry is part of the preoperative assessment of patients with HCC candidate for resection as it reflects liver function. Preoperative portal vein embolization is indicated in patients with small future liver remnant (≤ 20% in normal liver; ≤ 40% in fibrotic or cirrhotic liver). Tumor size is not a contraindication to liver resection. Liver resection can be proposed in selected patients with multifocal HCC. Besides tumor extent, surgical resection of HCC may be performed in selected patients with chronic liver disease.
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Affiliation(s)
- Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX, USA
| | - Elijah Dixon
- Department of Surgery, University of CalgaryCalgary, Canada
| | - Eddie K Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX, USA
| | - W Scott Helton
- Department of Surgery, Hospital of Saint RaphaelNew Haven, CT
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD
| | - Bachir Taouli
- Department of Radiology, Mount Sinai School of MedicineNew York, NY
| | - Antoine Brouquet
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer CenterHouston, TX, USA
| | - Reid B Adams
- Department of Surgery, University of Virginia Health SystemCharlottesville, VA, USA
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Brouquet A, Mortenson MM, Vauthey JN, Rodriguez-Bigas MA, Overman MJ, Chang GJ, Kopetz S, Garrett C, Curley SA, Abdalla EK. Surgical strategies for synchronous colorectal liver metastases in 156 consecutive patients: classic, combined or reverse strategy? J Am Coll Surg 2010; 210:934-41. [PMID: 20510802 DOI: 10.1016/j.jamcollsurg.2010.02.039] [Citation(s) in RCA: 201] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 02/06/2010] [Accepted: 02/10/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND An increasing number of patients with synchronous colorectal liver metastases (CLM) are candidates for resection. The optimal treatment sequence in these patients has not been defined. STUDY DESIGN Data on 156 consecutive patients with synchronous resectable CLM and intact primary were reviewed. Surgical strategies were defined as combined (combined resection of primary and liver), classic (primary before liver), and reverse (liver before primary) after preoperative chemotherapy. Postoperative morbidity and mortality rates and overall survival were analyzed. RESULTS One hundred forty-two patients (83%) had resection of all disease. Seventy-two patients underwent classic, 43 combined, and 27 reverse strategies. Median numbers of CLMs per patient were 1 in the combined, 3 in the classic, and 4 in the reverse strategy group (p = 0.01 classic vs reverse; p < 0.001 reverse vs combined). Postoperative mortality rates in the combined, classic, and reverse strategies were 5%, 3%, and 0%, respectively (p = NS), and postoperative cumulative morbidity rates were 47%, 51%, and 31%, respectively (p = NS). Three-year and 5-year overall survival rates were, respectively, 65% and 55% in the combined, 58% and 48% in the classic, and 79% and 39% in the reverse strategy (NS). On multivariate analysis, liver tumor size >3 cm (hazard ratio [HR] 2.72, 95% CI 1.52 to 4.88) and cumulative postoperative morbidity (HR 1.8, 95% CI 1.03 to 3.19) were independently associated with overall survival after surgery. CONCLUSIONS The classic, combined, or reverse surgical strategies in patients with synchronous presentation of CLM are associated with similar outcomes. The reverse strategy can be considered as an alternative option in patients with advanced CLM and an asymptomatic primary.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Hassan MM, Curley SA, Li D, Kaseb A, Davila M, Abdalla EK, Javle M, Moghazy DM, Lozano RD, Abbruzzese JL, Vauthey JN. Association of diabetes duration and diabetes treatment with the risk of hepatocellular carcinoma. Cancer 2010; 116:1938-46. [PMID: 20166205 DOI: 10.1002/cncr.24982] [Citation(s) in RCA: 231] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the observed association between diabetes mellitus and hepatocellular carcinoma (HCC), little is known about the effect of diabetes duration before HCC diagnosis and whether some diabetes medications reduced the risk of HCC development. This objective of the current study was to determine the association between HCC risk and diabetes duration and type of diabetes treatment. METHODS A total of 420 patients with HCC and 1104 healthy controls were enrolled in an ongoing hospital-based case-control study. Multivariate logistic regression models were used to adjust for HCC risk factors. RESULTS The prevalence of diabetes mellitus was 33.3% in patients with HCC and 10.4% in the control group, yielding an adjusted odds ratio (AOR) of 4.2 (95% confidence interval [95% CI], 3.0-5.9). In 87% of cases, diabetes was present before the diagnosis of HCC, yielding an AOR of 4.4 (95% CI, 3.0-6.3). Compared with patients with a diabetes duration of 2 to 5 years, the estimated AORs for those with a diabetes duration of 6 to 10 years and those with a diabetes duration >10 years were 1.8 (95% CI, 0.8-4.1) and 2.2 (95% CI, 1.2-4.8), respectively. With respect to diabetes treatment, the AORs were 0.3 (95% CI, 0.2-0.6), 0.3 (95% CI, 0.1-0.7), 7.1 (95% CI, 2.9-16.9), 1.9 (95% CI, 0.8-4.6), and 7.8 (95% CI, 1.5-40.0) for those treated with biguanides, thiazolidinediones, sulfonylureas, insulin, and dietary control, respectively. CONCLUSIONS Diabetes appears to increase the risk of HCC, and such risk is correlated with a long duration of diabetes. Relying on dietary control and treatment with sulfonylureas or insulin were found to confer the highest magnitude of HCC risk, whereas treatment with biguanides or thiazolidinediones was associated with a 70% HCC risk reduction among diabetics.
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Affiliation(s)
- Manal M Hassan
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Glazer ES, Beaty K, Abdalla EK, Vauthey JN, Curley SA. Effectiveness of positron emission tomography for predicting chemotherapy response in colorectal cancer liver metastases. Arch Surg 2010; 145:340-5; discussion 345. [PMID: 20404283 DOI: 10.1001/archsurg.2010.41] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
HYPOTHESIS Chemotherapeutic agents may be able to convert unresectable colorectal hepatic metastasis to resectable disease, therefore changing the surgical options. The role of positron emission tomography (PET) for patients undergoing chemotherapy remains unclear. We hypothesize that recent chemotherapy treatment could result in false-negative PET results. DESIGN Case-control study evaluating PET findings. SETTING The University of Texas M. D. Anderson Cancer Center. PATIENTS From May 1, 2006, through August 31, 2008, data for 224 consecutive patients were entered into a prospective database for evaluation of hepatic metastasis of colorectal carcinoma. One hundred thirty-eight patients underwent PET and conventional imaging (a combination of computed tomography, magnetic resonance imaging, and ultrasonography). All had oncologically sound colorectal operations. INTERVENTIONS Liver resection or ablation for colorectal liver metastases. MAIN OUTCOME MEASURES To determine the accuracy of PET scans to detect residual viable colorectal cancer liver metastases after a significant response to systemic chemotherapy. RESULTS Patients with biopsy-proven disease underwent hepatic resection (120 patients [87.0%]), radiofrequency ablation (2 [1.4%]), or resection with radiofrequency ablation (7 [5.1%]). Nine patients (6.5%) had inoperable disease that was found intraoperatively. When performed within 4 weeks of chemotherapy, PET had a negative predictive value of 13.3% and a positive predictive value of 94.3%. The sensitivity was 89.9%, the specificity was 22.2%, and the accuracy was 85.5%. CONCLUSIONS Positron emission tomography within 4 weeks of chemotherapy is not a useful test for evaluation of colorectal hepatic metastases. The high rate of false-negative results is likely due to metabolic inhibition caused by chemotherapeutic drugs. We recommend that physicians not use PET in patients recently completing chemotherapy; they should undergo the appropriate oncologic hepatic operation based on the high probability of viable malignant disease.
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Affiliation(s)
- Evan S Glazer
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA
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Contreras CM, Abdalla EK. Metastasectomy of Combined Liver and Lung Colorectal Cancer Metastases. Curr Colorectal Cancer Rep 2010. [DOI: 10.1007/s11888-010-0047-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rubbia-Brandt L, Lauwers GY, Wang H, Majno PE, Tanabe K, Zhu AX, Brezault C, Soubrane O, Abdalla EK, Vauthey JN, Mentha G, Terris B. Sinusoidal obstruction syndrome and nodular regenerative hyperplasia are frequent oxaliplatin-associated liver lesions and partially prevented by bevacizumab in patients with hepatic colorectal metastasis. Histopathology 2010; 56:430-9. [PMID: 20459550 DOI: 10.1111/j.1365-2559.2010.03511.x] [Citation(s) in RCA: 212] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS Because of its efficacy, oxaliplatin (OX) is increasingly used as a chemotherapeutic agent in the treatment of colorectal liver metastases (CRLM). Oxaliplatin-associated liver toxicity has been reported and can affect clinical practice, but studies on its prevalence and a full pathological description are lacking. The aims of this study were to fill this gap by providing, from a pathologist's perspective, a detailed assessment of the spectrum of hepatic lesions associated with OX, to suggest a scoring system to quantify them, and to investigate the protective effect of bevacizumab against OX-associated damage. METHODS AND RESULTS The spectrum of oxaliplatin-associated liver lesions was investigated in a multi-institutional series of surgically resected CRLM (n = 385). Among 274 patients treated by OX, 54% had moderate/severe sinusoidal obstruction syndrome (SOS). Peliosis, centrilobular perisinusoidal/venular fibrosis and nodular regenerative hyperplasia (NRH) developed in 10.6%, 47% and 24.5%, respectively. The 111 patients treated by surgery alone had no lesions. Hepatic lesions were less severe in patients treated with OX/bevacizumab (n = 70) compared with the group treated by OX alone (n = 204), with an incidence of moderate/severe SOS (31.4% versus 62.2%), peliosis (4.3% versus 14.6%), NRH (11.4% versus 28.9%, respectively) and centrilobular/venular fibrosis (31.4% versus 52%, respectively) (P < 0.001). CONCLUSIONS Pathologists should be aware of the distinctive lesions associated with OX and of their high prevalence. OX-related lesions are less frequent in patients treated with bevacizumab, suggesting that this drug has a preventive effect. Uniform criteria for diagnosis and grading of OX-associated lesions should help to include histological data in the optimal multidisciplinary management of CRLM.
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Katz MHG, Varadhachary GR, Fleming JB, Wolff RA, Lee JE, Pisters PWT, Vauthey JN, Abdalla EK, Sun CC, Wang H, Crane CH, Lee JH, Tamm EP, Abbruzzese JL, Evans DB. Serum CA 19-9 as a marker of resectability and survival in patients with potentially resectable pancreatic cancer treated with neoadjuvant chemoradiation. Ann Surg Oncol 2010; 17:1794-801. [PMID: 20162463 PMCID: PMC2889288 DOI: 10.1245/s10434-010-0943-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Indexed: 12/14/2022]
Abstract
Purpose The role of carbohydrate antigen (CA) 19-9 in the evaluation of patients with resectable pancreatic cancer treated with neoadjuvant therapy prior to planned surgical resection is unknown. We evaluated CA 19-9 as a marker of therapeutic response, completion of therapy, and survival in patients enrolled on two recently reported clinical trials. Patients and Methods We analyzed patients with radiographically resectable adenocarcinoma of the head/uncinate process treated on two phase II trials of neoadjuvant chemoradiation. Patients without evidence of disease progression following chemoradiation underwent pancreaticoduodenectomy (PD). CA 19-9 was evaluated in patients with a normal bilirubin level. Results We enrolled 174 patients, and 119 (68%) completed all therapy including PD. Pretreatment CA 19-9 <37 U/ml had a positive predictive value (PPV) for completing PD of 86% but a negative predictive value (NPV) of 33%. Among patients without evidence of disease at last follow-up, the highest pretreatment CA 19-9 was 1,125 U/ml. Restaging CA 19-9 <61 U/ml had a PPV of 93% and a NPV of 28% for completing PD among resectable patients. The area under the receiver-operating characteristics curve of pretreatment and restaging CA 19-9 levels for completing PD was 0.59 and 0.74, respectively. We identified no association between change in CA 19-9 and histopathologic response (P = 0.74). Conclusions Although the PPV of CA 19-9 for completing neoadjuvant therapy and undergoing PD was high, its clinical utility was compromised by a low NPV. Decision-making for patients with resectable PC should remain based on clinical assessment and radiographic staging.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgery, The University of California, Orange, CA, USA.
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Palavecino M, Kishi Y, Chun YS, Brown DL, Gottumukkala VNR, Lichtiger B, Curley SA, Abdalla EK, Vauthey JN. Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557 consecutive liver resections. Surgery 2010; 147:40-8. [PMID: 19733879 DOI: 10.1016/j.surg.2009.06.027] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Accepted: 06/25/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND Blood transfusions are an independent risk factor for adverse outcomes after hepatectomy. In-hospital transfusions are still reported in one third of patients in major series. Data on factors affecting blood transfusions in large series of liver resection are limited. The aim of this study was to evaluate factors predictive of blood transfusion in hepatectomies performed at a tertiary referral center. METHODS Records of 1,477 patients who underwent 1,557 liver resections between 1998 and 2007 were reviewed. Multivariate analysis of risk factors for red cell transfusion was performed. RESULTS Median intra-operative blood loss was 250 cc, and 30-day peri-operative red cell transfusion rate was 27%. On multivariate analysis, factors that significantly predicted increased red cell transfusion rates were female sex, pre-operative hematocrit<30%, platelet count<100,000/mm3, simultaneous resection of other organs, major hepatic resection, use of the Pringle maneuver, and tumors>10 cm. Parenchymal transection technique was an independent risk factor for perioperative red cell transfusion; the usage of the 2-surgeon technique (combined saline-linked cautery and ultrasonic dissection) was associated with a lower transfusion rate than other techniques, including ultrasonic dissection alone, finger fracture, and stapling (P<.001). CONCLUSION Although most factors that affect the red cell transfusion rate for liver resection are patient- or tumor-related, the parenchymal transection technique is under the surgeon's control. The decrease in transfusion rate associated with the use of the 2-surgeon technique emphasizes the important role of the hepatobiliary surgeon in determining outcomes after liver resection.
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Affiliation(s)
- Martin Palavecino
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Chun YS, Vauthey JN, Boonsirikamchai P, Maru DM, Kopetz S, Palavecino M, Curley SA, Abdalla EK, Kaur H, Charnsangavej C, Loyer EM. Association of computed tomography morphologic criteria with pathologic response and survival in patients treated with bevacizumab for colorectal liver metastases. JAMA 2009; 302:2338-44. [PMID: 19952320 PMCID: PMC4139149 DOI: 10.1001/jama.2009.1755] [Citation(s) in RCA: 399] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT The standard criteria used to evaluate tumor response, the Response Evaluation Criteria in Solid Tumors (RECIST), were developed to assess tumor shrinkage after cytotoxic chemotherapy and may be limited in assessing response to biologic agents, which have a cytostatic mechanism of action. OBJECTIVE To validate novel tumor response criteria based on morphologic changes observed on computed tomography (CT) in patients with colorectal liver metastases treated with bevacizumab-containing chemotherapy regimens. DESIGN, SETTING, AND PATIENTS A total of 234 colorectal liver metastases were analyzed from 50 patients who underwent hepatic resection after preoperative chemotherapy that included bevacizumab at a comprehensive US cancer center from 2004 to 2007; date of last follow-up was March 2008. All patients underwent routine contrast-enhanced CT at the start and end of preoperative therapy. Three blinded, independent radiologists evaluated images for morphologic response, based on metastases changing from heterogeneous masses with ill-defined margins into homogeneous hypoattenuating lesions with sharp borders. These criteria were validated with a separate cohort of 82 patients with unresectable colorectal liver metastases treated with bevacizumab-containing chemotherapy. MAIN OUTCOME MEASURES Response determined using morphologic criteria and RECIST was correlated with pathologic response in resected liver specimens and with patient survival. RESULTS Interobserver agreement for scoring morphologic changes was good among 3 radiologists (kappa, 0.68-0.78; 95% confidence interval [CI], 0.51-0.93). In resected tumor specimens, the median (interquartile range [IQR]) percentages of residual tumor cells for optimal morphologic response was 20% (10%-30%); for incomplete response, 50% (30%-60%); and no response, 70% (60%-70%; P < .001). With RECIST, the median (IQR) percentages of residual tumor cells were for partial response 30% (10%-60%); for stable disease, 50% (20%-70%); and for progressive disease, 70% (65%-70%; P = .04). Among patients who underwent hepatic resection, median overall survival was not yet reached with optimal morphologic response and 25 months (95% CI, 20.2-29.8 months) with incomplete or no morphologic response (P = .03). In the validation cohort, patients with optimal morphologic response had median overall survival of 31 months (95% CI, 26.8-35.2 months) compared with 19 months (95% CI, 14.6-23.4 months) with incomplete or no morphologic response (P = .009). RECIST did not correlate with survival in either the surgical or validation cohort. CONCLUSION Among patients with colorectal liver metastases treated with bevacizumab-containing chemotherapy, CT-based morphologic criteria had a statistically significant association with pathologic response and overall survival.
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Affiliation(s)
- Yun Shin Chun
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Piyaporn Boonsirikamchai
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Dipen M. Maru
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Martin Palavecino
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Steven A. Curley
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Eddie K. Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Harmeet Kaur
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Chusilp Charnsangavej
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Evelyne M. Loyer
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Kishi Y, Abdalla EK, Chun YS, Zorzi D, Madoff DC, Wallace MJ, Curley SA, Vauthey JN. Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry. Ann Surg 2009; 250:540-8. [PMID: 19730239 DOI: 10.1097/sla.0b013e3181b674df] [Citation(s) in RCA: 336] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE(S) This study aimed to determine the effect of preoperative liver volumetry on postoperative outcomes after extended right hepatectomy. Primary end point was to evaluate whether future liver remnant (FLR)/standardized liver volume ratio (sFLR) >20% is sufficient for a safe hepatic resection. Secondary end point was to assess whether preoperative portal vein embolization (PVE) is associated with improved outcome in patients with initial sFLR ≤ 20%. BACKGROUND DATA An sFLR >20% of the total liver volume has been proposed as sufficient for safe hepatic resection, but this concept has not been validated in a large series. In addition, recent reports suggest preoperative PVE is indicated for sFLR <30%. METHODS The impact of sFLR and PVE on short-term outcomes (postoperative complications, liver insufficiency, and 90-day mortality) was analyzed in 301 consecutive patients after extended right hepatectomy. Liver volumetry accounted for partial resection of segment IV. Liver insufficiency was defined as peak postoperative serum bilirubin >7 mg/dL. Predictors of liver insufficiency were identified by multivariate logistic regression. RESULTS Postoperative liver insufficiency occurred in 45 patients (15%) and accounted for 61% of deaths. Among 290 patients who underwent liver volumetry, sFLR was <20% in 38 patients, 20.1% to 30% in 144, and ≥ 30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with sFLR 20.1% to 30% and sFLR ≥ 30% but higher in patients with sFLR ≤ 20% (P 0.05). Postoperative outcomes were similar between patients with increase in sFLR from ≤ 20% to >20% after PVE and patients with initial sFLR >20%. Multivariate analysis revealed that body mass index >25 kg/m2, intraoperative blood transfusion, and sFLR ≤ 20% (odds ratio = 3.18; 95% CI, 1.34-7.54) independently predicted postoperative liver insufficiency. CONCLUSIONS Systematic measurement of FLR volume is important to select patients for PVE and extended right hepatectomy. A sFLR >20% is sufficient for safe hepatic resection and sFLR 20.1% to 30% is not an indication for preoperative PVE.
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Affiliation(s)
- Yoji Kishi
- Department of Surgical Oncology, Unit 444, The University of Texas MD Anderson Cancer Center, Houston, TX 77030–4009, USA
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Abstract
"Cure" for patients with stage IV colorectal cancer remains elusive, but for a growing subset of patients with colorectal liver metastases (CLMs), cure (ie, > 10-year survival without evidence of disease) is achieved in at least 17% of resected patients. Candidates for resection include those with limited and in some cases extensive hepatic disease, and in highly selected cases, patients with extrahepatic disease. Number, size, and bilaterality of CLMs no longer stand as absolute contraindications to surgery. Chemotherapy has further advanced the field of surgery for CLMs, enabling an additional group of patients who present with unresectable disease to undergo surgery after downsizing with chemotherapy. Modern surgical techniques and liver preparation allow resection after chemotherapy, with excellent results. This article summarizes the current multidisciplinary approach to treatment of CLMs. The definition of resectability, conversion of unresectable CLMs to resectable ones, advances in surgical techniques, advances in chemotherapy, and predictors of outcome are detailed.
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Affiliation(s)
- Richard N Berri
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Suite 12.2016, Houston, TX 77030, USA
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Vauthey JN, Zorzi D, Kopetz S, Abdalla EK, Kishi Y, Blazer DG. Reply to D.J. Gallagher et al. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.22.5698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Daria Zorzi
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Eddie K. Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Yoji Kishi
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Dan G. Blazer
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Reddy SK, Zorzi D, Lum YW, Barbas AS, Pawlik TM, Ribero D, Abdalla EK, Choti MA, Kemp C, Vauthey JN, Morse MA, White RR, Clary BM. Timing of multimodality therapy for resectable synchronous colorectal liver metastases: a retrospective multi-institutional analysis. Ann Surg Oncol 2009; 16:1809-19. [PMID: 18979139 DOI: 10.1245/s10434-008-0181-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 09/10/2008] [Accepted: 09/10/2008] [Indexed: 02/03/2023]
Abstract
The optimal timing of chemotherapy relative to resection of synchronous colorectal liver metastases (SCRLM) is not known. The objective of this retrospective multi-institutional study was to assess the influence of chemotherapy administered before and after hepatic resection on long-term outcomes among patients with initially resectable SCRLM treated from 1995 to 2005. Clinicopathologic data, treatments, and long-term outcomes from patients with initially resectable SCRLM who underwent partial hepatectomy at three hepatobiliary centers were reviewed. Four hundred ninety-nine consecutive patients underwent resection; 297 (59.5%) and 264 (52.9%) were treated with chemotherapy before and after resection. Chemotherapy strategies included pre-hepatectomy alone (n = 148, 24.7%), post-hepatectomy alone (n = 115, 23.0%), perioperative (n = 149, 29.0%), and no chemotherapy (n = 87, 17.4%). Male gender (p = 0.0029, HR = 1.41 [1.12-1.77]), node-positive primary tumor (p = 0.0046, HR = 1.40 [1.11-1.77]), four or more SCRLM (p = 0.0005, HR = 1.65 [1.24-2.18]), and post-hepatectomy chemotherapy treatment for 6 months or longer (p = 0.039, HR = 0.75 [0.57-0.99]) were associated with recurrence-free survival after discovery of SCRLM. Carcinoembryonic antigen >200 ng/ml (p = 0.0003, HR = 2.33 [1.48-3.69]), extrahepatic metastatic disease (p = 0.0025, HR = 2.34 [1.35-4.05]), four or more SCRLM (p = 0.033, HR = 1.43 [1.03-2.00]), and post-hepatectomy chemotherapy treatment for 2 months or longer (p < 0.0001, HR = 0.59 [0.45-0.76]) were associated with overall survival. Pre-hepatectomy chemotherapy was not associated with recurrence-free or overall survival. Patients treated with perioperative chemotherapy had similar outcomes as patients treated with post-hepatectomy chemotherapy only. We conclude that chemotherapy administered after but not before resection of SCRLM was associated with improved recurrence-free and overall survival. However, prospective randomized trials are needed to determine the optimal timing of chemotherapy.
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Affiliation(s)
- Srinevas K Reddy
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Hassan MM, Kaseb A, Li D, Part YZ, Vauthey JN, Thomas MB, Curley SA, Spitz MR, Sherman SI, Abdalla EK, Davila M, Lozano RD, Hassan DM, Chan W, Brown TD, Abbruzzese JL. Association between hypothyroidism and hepatocellular carcinoma: a case-control study in the United States. Hepatology 2009; 49:1563-70. [PMID: 19399911 PMCID: PMC3715879 DOI: 10.1002/hep.22793] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Thyroid hormones play an essential role in lipid mobilization, lipid degradation, and fatty acid oxidation. Hypothyroidism has been associated with nonalcoholic steatohepatitis; however, the association between thyroid diseases and hepatocellular carcinoma (HCC) in men and women has not been well established. We investigated the association between hypothyroidism and HCC risk in men and women in a case-control study, which included 420 eligible patients with HCC and 1104 healthy controls. We used multivariate unconditional logistic regression models to control for the confounding effects of established HCC risk factors. A long-term history of hypothyroidism (>10 years) was associated with a statistically significant high risk of HCC in women; after adjusting for demographic factors, diabetes, hepatitis, alcohol consumption, cigarette smoking, and family history of cancer, the odds ratio (OR) was 2.9 (95% confidence interval [CI], 1.3-6.3). Restricted analyses among hepatitis virus-negative subjects, nondrinkers, nondiabetics, nonsmokers, and nonobese individuals indicated a significant association between hypothyroidism and HCC, with an approximate two-fold to three-fold increased risk of HCC development. We observed risk modification among women with diabetes mellitus (OR = 9.4; 95% CI = 2.7-32.7) and chronic hepatitis virus infection (OR = 31.2; 95% CI = 6.3-153.2). A history of hyperthyroidism was not significantly related to HCC (OR = 1.7; CI = 0.6-5.1). We noted significant elevated risk association between hypothyroidism and HCC in women that was independent of established HCC risk factors. Experimental investigations are necessary for thorough assessment of the relationship between thyroid disorders and HCC.
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Affiliation(s)
- Manal M. Hassan
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Donghui Li
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Yehuda Z. Part
- Division of Hematology and Oncology, University of New Mexico Cancer Center, Albuquerque, NM
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Melanie B. Thomas
- Division of Hematology and Oncology, Hollings Cancer Center, Charleston, South Carolina
| | - Steven A. Curley
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Margaret R. Spitz
- Department of Epidemiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Steven I. Sherman
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Eddie K. Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Marta Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Richard D. Lozano
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Deena M. Hassan
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Wenyaw Chan
- Department of Biostatistics, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX
| | - Thomas D. Brown
- Division of Hematology and Oncology, Arizona Cancer Center, Tucson, AZ
| | - James L. Abbruzzese
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Abstract
Liver resection is the preferred treatment for gastrointestinal stromal tumor liver metastases (GIST LMs) when complete resection can be achieved. Major and extended hepatic resections can be safely performed, and using modern techniques, an increasing proportion of patients with GIST LMs are candidates for potentially curative therapy. The combination of tyrosine kinase inhibitor therapy (eg, imatinib) with surgery seems to improve outcome, and although prospective data are lacking, a short neoadjuvant course (6 months) of imatinib therapy followed by resection may improve patient selection for surgery and outcome from treatment. Postoperative therapy with imatinib is generally advised, although the duration of such therapy is not yet clearly defined. These questions may formulate the basis for future prospective studies of imatinib with complete resection of GIST LMs.
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Affiliation(s)
- Stephane Zalinski
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA
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Palavecino M, Chun YS, Madoff DC, Zorzi D, Kishi Y, Kaseb AO, Curley SA, Abdalla EK, Vauthey JN. Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: Perioperative outcome and survival. Surgery 2009; 145:399-405. [PMID: 19303988 DOI: 10.1016/j.surg.2008.10.009] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 10/16/2008] [Indexed: 02/03/2023]
Abstract
BACKGROUND Preoperative portal vein embolization (PVE) is performed to minimize perioperative risks of major hepatic resection for hepatocellular carcinoma (HCC), but its effects on tumor growth are ill defined. Perioperative outcome and survival after major hepatic resection for HCC, with and without PVE, were investigated. METHODS Patients that underwent major hepatic resection (> or =3 segments) for HCC between January 1998 and May 2007 were analyzed retrospectively. Preoperative PVE was performed when the remnant liver volume was predicted to be insufficient. RESULTS A total of 54 patients underwent major hepatic resection for HCC: 21 patients with PVE before resection (PVE group) and 33 patients without PVE (non-PVE group). PVE and non-PVE groups had similar rates of fibrosis or cirrhosis, hepatitis C virus, hepatitis B virus, American Joint Committee on Cancer stage, preoperative transarterial chemoembolization, overall postoperative complications, and positive margin (P = nonsignificant for all rates). There were no perioperative deaths in the PVE group and 6 (18%) deaths in the non-PVE group (P = .038). Median follow-up was 21 months. Excluding perioperative deaths, overall survival rates at 1, 3, and 5 years were 94%, 82%, and 72%, respectively, in the PVE group and 93%, 63%, and 54%, respectively, in the non-PVE group (P = .35). Similarly, disease-free survival (DFS) rates were not significantly different between the groups, with 1-, 3-, and 5-year DFS rates of 84%, 56%, and 56%, respectively, in the PVE group and 66%, 49%, and 49%, respectively, in the non-PVE group (P = .38). CONCLUSION PVE before major hepatic resection for HCC is associated with improved perioperative outcome. Excluding perioperative mortality, overall survival and DFS rates were similar between patients with and without preoperative PVE.
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Affiliation(s)
- Martin Palavecino
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Abstract
In patients with hilar cholangiocarcinoma, extended hepatectomy and caudate lobe resection are often performed to achieve an R0 resection. In patients whose standardized future liver remnant is less than or equal to 20% of total liver volume, portal vein embolization (PVE) should be performed. In patients with biliary dilatation of the future liver remnant, a biliary drainage catheter should be placed before PVE. If the planned surgery is an extended right hepatectomy, segment 4 branch embolization improves the hypertrophy of segments 2 and 3. In high-volume centers, PVE can be safely performed; it increases the resectability rate and results in the same survival rates as those in patients who undergo resection without PVE.
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Affiliation(s)
- Martin Palavecino
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA
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Kishi Y, Kopetz S, Chun YS, Palavecino M, Abdalla EK, Vauthey JN. Blood neutrophil-to-lymphocyte ratio predicts survival in patients with colorectal liver metastases treated with systemic chemotherapy. Ann Surg Oncol 2009; 16:614-22. [PMID: 19130139 DOI: 10.1245/s10434-008-0267-6] [Citation(s) in RCA: 261] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 10/23/2008] [Accepted: 10/24/2008] [Indexed: 02/03/2023]
Abstract
BACKGROUND Whether neutrophil-to-lymphocyte ratio (NLR) predicts survival of patients with colorectal liver metastases (CLM) treated with systemic chemotherapy remains unclear. METHODS Clinicopathologic data were reviewed for patients with CLM treated with chemotherapy and resection (n=200) or chemotherapy only (n=90). Univariate and multivariate analyses for prognostic factors were performed. In the resection group, whether chemotherapy normalizes high NLR and the effect of NLR normalization on survival were evaluated. RESULTS In the resection group, patients with preoperative NLR>5 had a worse 5-year survival rate than patients with NLR <or= 5 (19% vs. 43%; P=0.009), and NLR>5 was the only independent preoperative predictor of worse survival (P=0.016; hazard ratio [HR]=2.22; 95% confidence interval [95% CI], 1.16-4.25). In the nonresection group, patients with prechemotherapy NLR>5 had a worse 3-year survival rate than patients with NLR <or= 5 (0% vs. 23%; P=0.0002), and NLR>5 was the only independent predictor of worse survival (P=0.001; HR = 2.91; 95% CI, 1.54-5.50). In the resection group, chemotherapy normalized high NLR in 17 of 25 patients, and these 17 patients had better survival than the 8 patients with high NLR both before chemotherapy and before surgery (P=0.021). CONCLUSION NLR independently predicts survival in patients with CLM treated with chemotherapy followed by resection or chemotherapy only. When chemotherapy normalizes high NLR, improved survival is expected.
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Affiliation(s)
- Yoji Kishi
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030-4009, USA
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Abstract
BACKGROUND Improved efficacy of chemotherapy for treatment of colorectal liver metastases (CLM) has renewed interest in the use of systemic treatment as part of a 'potentially curative' treatment plan for patients with CLM. Controversy exists regarding potential hepatotoxicity of therapy delivered before liver resection. METHODS Medline reports of pathologic changes in liver and tumor, specific chemotherapy types and clinical outcomes were examined. RESULTS Hepatic steatosis without inflammation (simple steatosis) may occur with chemotherapy treatment, but hepatic resection can be performed safely even in patients with severe (>30%) steatosis. Steatohepatitis is associated with irinotecan therapy and an increased risk for liver failure and death after hepatic resection. Hepatic sinusoidal obstruction can occur with oxaliplatin treatment and appears to increase in severity with prolonged treatment (>6 cycles). Bevacizumab can be used safely when discontinued >5 weeks before liver resection. Importantly, bevacizumab decreases the incidence and severity of sinusoidal injury with oxaliplatin therapy. Pathologic response is improved with the addition of bevacizumab and is evolving as an independent predictor of long-term survival. CONCLUSIONS Chemotherapy-related liver injuries are regimen-specific. Targeted therapy combined with cytotoxic therapy is safe and most effective. With the use of limited chemotherapy combining appropriately selected agents, the risk of surgical complications can be minimized and the overall effect and benefits of treatment optimized.
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Affiliation(s)
- Eddie K Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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