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Baumgartner R, Engstrand J, Rajala P, Grip J, Ghorbani P, Sparrelid E, Gilg S. Comparing the accuracy of prediction models to detect clinically relevant post-hepatectomy liver failure early after major hepatectomy. Br J Surg 2024; 111:znad433. [PMID: 38150185 PMCID: PMC10763542 DOI: 10.1093/bjs/znad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/02/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Arterial lactate measurements were recently suggested as an early predictor of clinically relevant post-hepatectomy liver failure (PHLF). This needed to be evaluated in the subgroup of major hepatectomies only. METHOD This observational cohort study included consecutive elective major hepatectomies at Karolinska University Hospital from 2010 to 2018. Clinical risk factors for PHLF, perioperative arterial lactate measurements and routine lab values were included in uni- and multivariable regression analysis. Receiver operating characteristics and risk cut-offs were calculated. RESULTS In total, 649 patients constituted the study cohort, of which 92 developed PHLF grade B/C according to the International Study Group of Liver Surgery (ISGLS). Lactate reached significantly higher intra- and postoperative levels in PHLF grades B and C compared to grade A or no liver failure (all P < 0.002). Lactate on postoperative day (POD) 1 was superior to earlier measurement time points in predicting PHLF B/C (AUC 0.75), but was outperformed by both clinical risk factors (AUC 0.81, P = 0.031) and bilirubin POD1 (AUC 0.83, P = 0.013). A multivariable logistic regression model including clinical risk factors and bilirubin POD1 had the highest AUC of 0.87 (P = 0.006), with 56.6% sensitivity and 94.7% specificity for PHLF grade B/C (cut-off ≥0.32). The model identified 46.7% of patients with 90-day mortality and had an equally good discriminatory potential for mortality as the established ISGLS criteria for PHLF grade B/C but could be applied already on POD1. CONCLUSION The potential of lactate to predict PHLF following major hepatectomy was inferior to a prediction model consisting of clinical risk factors and bilirubin on first post-operative day.
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Affiliation(s)
- Ruth Baumgartner
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Rajala
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Grip
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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2
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Engstrand J, Stål P, Gilg S, Jansson A, Strömberg C. Hepatocellular carcinoma in cirrhotic versus non-cirrhotic liver: Treatment and survival differences in a nationwide cohort. Scand J Surg 2023:14574969231220179. [PMID: 38145321 DOI: 10.1177/14574969231220179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND AND AIMS Numerous studies have reported superior outcome for patients with hepatocellular carcinoma (HCC) in non-cirrhotic compared to cirrhotic livers. This cohort study aims to describe the clinical presentation, disease course, treatment approaches, and survival differences in a population-based setting. METHODS Data on patients diagnosed with HCC in Sweden between 2008 and 2018 were identified and extracted from the Swedish Liver registry (SweLiv). Descriptive and survival statistics were applied. RESULTS Among the 4259 identified patients, 34% had HCC in a non-cirrhotic liver. Cirrhotic patients presented at a younger age (median = 64 vs 74 years, p < 0.001) and with a poorer performance status (Eastern Cooperative Oncology Group (ECOG) = 0-1: 64% vs 69%, p = 0.024). Underlying liver disease was more prevalent among cirrhotic patients (81% vs 19%, p < 0.001). Tumors in non-cirrhotic livers were diagnosed at a more advanced stage (T3-T4: 46% vs 31%) and more frequently with metastatic disease at diagnosis (22% vs 10%, p < 0.001). Tumors were significantly larger in non-cirrhotic livers (median size of largest tumor 7.5 cm) compared to cirrhotic livers (3.5 cm) (p < 0.001). Curative interventions were more commonly intended (45% vs 37%, p < 0.001) and performed (40% vs 31%, p < 0.001) in the cirrhotic vs non-cirrhotic patients. Median survival was 19 months (95% confidence interval (CI) = 18-21 months), in patients with cirrhosis as compared to 13 months in non-cirrhotic patients (95% CI = 11-15) (p < 0.001). In the multivariable Cox regression model, cirrhosis was not an independent predictor of survival, neither among curatively nor palliatively treated patients. CONCLUSION These population-based data show that patients with HCC in a cirrhotic liver receive curative treatment to a greater extent and benefit from superior survival compared to those with HCC in a non-cirrhotic liver. The differences in survival are more attributable to patient and tumor characteristics rather than the cirrhotic status itself. CLINICAL TRIAL REGISTRATION not applicable. Patient confidentially: not applicable.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet and Karolinska University Hospital 141 86 Stockholm Sweden
| | - Per Stål
- Department of Gastroenterology and Hepatology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anders Jansson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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3
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Leduc S, De Schepper M, Richard F, Maetens M, Pabba A, Borremans K, Jaekers J, Latacz E, Zels G, Bohlok A, Van Baelen K, Nguyen HL, Geukens T, Dirix L, Larsimont D, Vankerckhove S, Santos E, Oliveira RC, Dede K, Kulka J, Borbala S, Salamon F, Madaras L, Marcell Szasz A, Lucidi V, Meyer Y, Topal B, Verhoef C, Engstrand J, Moro CF, Gerling M, Bachir I, Biganzoli E, Donckier V, Floris G, Vermeulen P, Desmedt C. Histopathological growth patterns and tumor-infiltrating lymphocytes in breast cancer liver metastases. NPJ Breast Cancer 2023; 9:100. [PMID: 38102162 PMCID: PMC10724185 DOI: 10.1038/s41523-023-00602-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
Liver is the third most common organ for breast cancer (BC) metastasis. Two main histopathological growth patterns (HGP) exist in liver metastases (LM): desmoplastic and replacement. Although a reduced immunotherapy efficacy is reported in patients with LM, tumor-infiltrating lymphocytes (TIL) have not yet been investigated in BCLM. Here, we evaluate the distribution of the HGP and TIL in BCLM, and their association with clinicopathological variables and survival. We collect samples from surgically resected BCLM (n = 133 patients, 568 H&E sections) and post-mortem derived BCLM (n = 23 patients, 97 H&E sections). HGP is assessed as the proportion of tumor liver interface and categorized as pure-replacement ('pure r-HGP') or any-desmoplastic ('any d-HGP'). We score the TIL according to LM-specific guidelines. Associations with progression-free (PFS) and overall survival (OS) are assessed using Cox regressions. We observe a higher prevalence of 'any d-HGP' (56%) in the surgical samples and a higher prevalence of 'pure r-HGP' (83%) in the post-mortem samples. In the surgical cohort, no evidence of the association between HGP and clinicopathological characteristics is observed except with the laterality of the primary tumor (p value = 0.049) and the systemic preoperative treatment before liver surgery (p value = .039). TIL is less prevalent in 'pure r-HGP' as compared to 'any d-HGP' (p value = 0.001). 'Pure r-HGP' predicts worse PFS (HR: 2.65; CI: (1.45-4.82); p value = 0.001) and OS (HR: 3.10; CI: (1.29-7.46); p value = 0.011) in the multivariable analyses. To conclude, we demonstrate that BCLM with a 'pure r-HGP' is associated with less TIL and with the worse outcome when compared with BCLM with 'any d-HGP'. These findings suggest that HGP could be considered to refine treatment approaches.
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Affiliation(s)
- Sophia Leduc
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Maxim De Schepper
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - François Richard
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Marion Maetens
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Anirudh Pabba
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Kristien Borremans
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Gynecological Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Joris Jaekers
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Emily Latacz
- Translational Cancer Research Unit, GZA Hospitals & CORE, MIPRO, University of Antwerp, Antwerp, Belgium
| | - Gitte Zels
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bohlok
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Karen Van Baelen
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Gynecological Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Ha Linh Nguyen
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Tatjana Geukens
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Luc Dirix
- Translational Cancer Research Unit, GZA Hospitals & CORE, MIPRO, University of Antwerp, Antwerp, Belgium
| | - Denis Larsimont
- Department of Anatomopathology, Institut Jules Bordet, Brussels, Belgium
| | - Sophie Vankerckhove
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Eva Santos
- General Surgery Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - Rui Caetano Oliveira
- General Surgery Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - Kristòf Dede
- Department of Surgical Oncology, Uzsoki Hospital, Budapest, Hungary
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Székely Borbala
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Ferenc Salamon
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Lilla Madaras
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
- Department of Pathology, Uzsoki Hospital, Budapest, Hungary
| | - A Marcell Szasz
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Valerio Lucidi
- Department of Abdominal Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Yannick Meyer
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Baki Topal
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Carlos Fernandez Moro
- Department of Biosciences and Nutrition, Karolinska Institute, Huddinge and Karolinska University Hospital, Solna, Sweden
| | - Marco Gerling
- Department of Biosciences and Nutrition, Karolinska Institute, Huddinge and Karolinska University Hospital, Solna, Sweden
| | - Imane Bachir
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Elia Biganzoli
- Unit of Medical Statistics, Biometry and Epidemiology, Department of Biomedical and Clinical Sciences (DIBIC) "L. Sacco" & DSRC, LITA Vialba campus, University of Milan, Milan, Italy
| | - Vincent Donckier
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Giuseppe Floris
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
- Department of Imaging and Pathology, Laboratory of Translational Cell & Tissue Research and University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Vermeulen
- Translational Cancer Research Unit, GZA Hospitals & CORE, MIPRO, University of Antwerp, Antwerp, Belgium
| | - Christine Desmedt
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Leuven, Belgium.
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Stoop TF, von Gohren A, Engstrand J, Sparrelid E, Gilg S, Del Chiaro M, Ghorbani P. Risk Factors, Management, and Outcome of Gastric Venous Congestion After Total Pancreatectomy: An Underestimated Complication Requiring Standardized Identification, Grading, and Management. Ann Surg Oncol 2023; 30:7700-7711. [PMID: 37596448 PMCID: PMC10562271 DOI: 10.1245/s10434-023-13847-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/28/2023] [Accepted: 06/19/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Gastric venous congestion (GVC) after total pancreatectomy (TP) is rarely studied despite its high 5% to 28% incidence and possible association with mortality. This study aimed to provide insight about incidence, risk factors, management, and outcome of GVC after TP. METHODS This retrospective observational single-center study included all patients undergoing elective TP from 2008 to 2021. The exclusion criteria ruled out a history of gastric resection, concomitant (sub)total gastrectomy for oncologic indication(s) or celiac axis resection, and postoperative (sub)total gastrectomy for indication(s) other than GVC. RESULTS The study enrolled 268 patients. The in-hospital major morbidity (Clavien-Dindo grade ≥IIIa) rate was 28%, and the 90-day mortality rate was 3%. GVC was identified in 21% of patients, particularly occurring during index surgery (93%). Intraoperative GVC was managed with (sub)total gastrectomy for 55% of the patients. The major morbidity rate was higher for the patients with GVC (44% vs 24%; p = 0.003), whereas the 90-day mortality did not differ significantly (5% vs 3%; p = 0.406). The predictors for major morbidity were intraoperative GVC (odds ratio [OR], 2.207; 95% confidence interval [CI], 1.142-4.268) and high TP volume (> 20 TPs/year: OR, 0.360; 95% CI, 0.175-0.738). The predictors for GVC were portomesenteric venous resection (PVR) (OR, 2.103; 95% CI, 1.034-4.278) and left coronary vein ligation (OR, 11.858; 95% CI, 5.772-24.362). CONCLUSIONS After TP, GVC is rather common (in 1 of 5 patients). GVC during index surgery is predictive for major morbidity, although not translating into higher mortality. Left coronary vein ligation and PVR are predictive for GVC, requiring vigilance during and after surgery, although gastric resection is not always necessary. More evidence on prevention, identification, classification, and management of GVC is needed.
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Affiliation(s)
- Thomas F Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - André von Gohren
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
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5
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Stoop TF, von Gohren A, Engstrand J, Sparrelid E, Gilg S, Del Chiaro M, Ghorbani P. ASO Author Reflections: Gastric Venous Congestion After Total Pancreatectomy is an Underestimated Complication. Ann Surg Oncol 2023; 30:7758-7759. [PMID: 37561344 PMCID: PMC10562292 DOI: 10.1245/s10434-023-13979-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Thomas F Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - André von Gohren
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
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6
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Stoop TF, von Gohren A, Engstrand J, Sparrelid E, Gilg S, Del Chiaro M, Ghorbani P. ASO Visual Abstract: Risk Factors, Management, and Outcome of Gastric Venous Congestion After Total Pancreatectomy: An Underestimated Complication Requiring Standardized Identification, Grading, and Management. Ann Surg Oncol 2023; 30:7768-7769. [PMID: 37543557 DOI: 10.1245/s10434-023-14038-6] [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: 08/07/2023]
Affiliation(s)
- Thomas F Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - André von Gohren
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
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7
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Fernández Moro C, Geyer N, Harrizi S, Hamidi Y, Söderqvist S, Kuznyecov D, Tidholm Qvist E, Salmonson Schaad M, Hermann L, Lindberg A, Heuchel RL, Martín-Bernabé A, Dhanjal S, Navis AC, Villard C, Del Valle AC, Bozóky L, Sparrelid E, Dirix L, Strell C, Östman A, Schmierer B, Vermeulen PB, Engstrand J, Bozóky B, Gerling M. An idiosyncratic zonated stroma encapsulates desmoplastic liver metastases and originates from injured liver. Nat Commun 2023; 14:5024. [PMID: 37596278 PMCID: PMC10439160 DOI: 10.1038/s41467-023-40688-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 07/31/2023] [Indexed: 08/20/2023] Open
Abstract
A perimetastatic capsule is a strong positive prognostic factor in liver metastases, but its origin remains unclear. Here, we systematically quantify the capsule's extent and cellular composition in 263 patients with colorectal cancer liver metastases to investigate its clinical significance and origin. We show that survival improves proportionally with increasing encapsulation and decreasing tumor-hepatocyte contact. Immunostaining reveals the gradual zonation of the capsule, transitioning from benign-like NGFRhigh stroma at the liver edge to FAPhigh stroma towards the tumor. Encapsulation correlates with decreased tumor viability and preoperative chemotherapy. In mice, chemotherapy and tumor cell ablation induce capsule formation. Our results suggest that encapsulation develops where tumor invasion into the liver plates stalls, representing a reparative process rather than tumor-induced desmoplasia. We propose a model of metastases growth, where the efficient tumor colonization of the liver parenchyma and a reparative liver injury reaction are opposing determinants of metastasis aggressiveness.
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Affiliation(s)
- Carlos Fernández Moro
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, 14186, Sweden
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, 14186, Stockholm, Sweden
| | - Natalie Geyer
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Sara Harrizi
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Yousra Hamidi
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Sara Söderqvist
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Danyil Kuznyecov
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Medicinsk Service, Skåne University Hospital, 22185, Lund, Sweden
| | - Evelina Tidholm Qvist
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, 14186, Sweden
| | | | - Laura Hermann
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Amanda Lindberg
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185, Uppsala, Sweden
| | - Rainer L Heuchel
- Pancreatic Cancer Research Laboratory, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 14183, Hudinge, Sweden
| | | | - Soniya Dhanjal
- CRISPR Functional Genomics, SciLifeLab and Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17165, Solna, Sweden
| | - Anna C Navis
- CRISPR Functional Genomics, SciLifeLab and Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17165, Solna, Sweden
| | - Christina Villard
- Department of Medicine Huddinge, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Andrea C Del Valle
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Lorand Bozóky
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, 14152, Stockholm, Sweden
| | - Luc Dirix
- Translational Cancer Research Unit (GZA Hospitals and University of Antwerp), Antwerp, Belgium
| | - Carina Strell
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185, Uppsala, Sweden
- Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway
| | - Arne Östman
- Department of Oncology-Pathology, Karolinska Institutet, 17176, Solna, Sweden
| | - Bernhard Schmierer
- CRISPR Functional Genomics, SciLifeLab and Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17165, Solna, Sweden
| | - Peter B Vermeulen
- Translational Cancer Research Unit (GZA Hospitals and University of Antwerp), Antwerp, Belgium
| | - Jennie Engstrand
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, 14152, Stockholm, Sweden
| | - Béla Bozóky
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, 14186, Sweden
| | - Marco Gerling
- Department of Biosciences and Nutrition, Karolinska Institutet, 14183, Huddinge, Sweden.
- Theme Cancer, Karolinska University Hospital, 17 176, Solna, Sweden.
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Tinguely P, Ruiter SJS, Engstrand J, de Haas RJ, Nilsson H, Candinas D, de Jong KP, Freedman J. A prospective multicentre trial on survival after Microwave Ablation VErsus Resection for Resectable Colorectal liver metastases (MAVERRIC). Eur J Cancer 2023; 187:65-76. [PMID: 37119639 DOI: 10.1016/j.ejca.2023.03.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
AIM This multi-centre prospective cohort study aimed to investigate non-inferiority in patients' overall survival when treating potentially resectable colorectal cancer liver metastasis (CRLM) with stereotactic microwave ablation (SMWA) as opposed to hepatic resection (HR). METHODS Patients with no more than 5 CRLM no larger than 30 mm, deemed eligible for both SMWA and hepatic resection at the local multidisciplinary team meetings, were deliberately treated with SMWA (study group). The contemporary control group consisted of patients with no more than 5 CRLM, none larger than 30 mm, treated with HR, extracted from a prospectively maintained nationwide Swedish database. After propensity-score matching, 3-year overall survival (OS) was compared as the primary outcome using Kaplan-Meier and Cox regression analyses. RESULTS All patients in the study group (n = 98) were matched to 158 patients from the control group (mean standardised difference in baseline covariates = 0.077). OS rates at 3 years were 78% (Confidence interval [CI] 68-85%) after SMWA versus 76% (CI 69-82%) after HR (stratified Log-rank test p = 0.861). Estimated 5-year OS rates were 56% (CI 45-66%) versus 58% (CI 50-66%). The adjusted hazard ratio for treatment type was 1.020 (CI 0.689-1.510). Overall and major complications were lower after SMWA (percentage decrease 67% and 80%, p < 0.01). Hepatic retreatments were more frequent after SMWA (percentage increase 78%, p < 0.01). CONCLUSION SMWA is a valid curative-intent treatment alternative to surgical resection for small resectable CRLM. It represents an attractive option in terms of treatment-related morbidity with potentially wider options regarding hepatic retreatments over the future course of disease.
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Affiliation(s)
- Pascale Tinguely
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden; Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland.
| | - Simeon J S Ruiter
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Robbert J de Haas
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Henrik Nilsson
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Koert P de Jong
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Tinguely P, Laurell G, Enander A, Engstrand J, Freedman J. Ablation versus resection for resectable colorectal liver metastases - Health care related cost and survival analyses from a quasi-randomised study. Eur J Surg Oncol 2023; 49:416-425. [PMID: 36123245 DOI: 10.1016/j.ejso.2022.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to compare healthcare related costs and survival in patients treated with microwave ablation (MWA) versus surgical resection for resectable colorectal liver metastases (CRLM), in patients from a quasi-randomised setting. METHODS The Swedish subset of data from a prospective multi-centre study investigating survival after percutaneous computer-assisted Microwave Ablation VErsus Resection for Resectable CRLM (MAVERRIC study) was analysed. Patients with CRLM ≤ 3 cm amenable to ablation and resection were considered for study inclusion only on even calendar weeks, while treated with gold standard resection every other week, creating a quasi-randomised setting. Survival and costs (all inpatient hospital admissions, outpatient visits, oncological treatments and radiological imaging) in the 2 years following treatment were investigated. RESULTS MWA (n = 52) and resection (n = 53) cohorts had similar baseline patient and tumour characteristics and health care consumption within 1 year prior to CRLM treatment. Treatment related morbidity and length of stay were significantly higher in the resected cohort. Overall health care related costs from decision of treatment and 2 years thereafter were lower in the MWA versus resection cohort (mean ± SD USD 80'964±59'182 versus 110'059±59'671, P < 0.01). Five-year overall survival was 50% versus 54% in MWA versus resection groups (P = 0.95). CONCLUSIONS MWA is associated with decreased morbidity, time spent in medical facilities and healthcare related costs within 2 years of initial treatment with equal overall survival, highlighting its benefits for patient and health care systems.
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Affiliation(s)
- Pascale Tinguely
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Gustaf Laurell
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Anton Enander
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Gilg S, Sparrelid E, Engstrand J, Baumgartner R, Nowak G, Stål P, D'Souza M, Jansson A, Isaksson B, Jonas E, Stromberg C. Molecular adsorbent recirculating system treatment in patients with post-hepatectomy liver failure: Long-term results of a pilot study. Scand J Surg 2022; 111:48-55. [PMID: 36000747 DOI: 10.1177/14574969221112224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is the leading cause of postoperative mortality following major liver resection. Between December 2012 and May 2015, 10 consecutive patients with PHLF (according to the Balzan criteria) following major/extended hepatectomy were included in a prospective treatment study with the molecular adsorbent recirculating system (MARS). Sixty- and 90-day mortality rates were 0% and 10%, respectively. Of the nine survivors, four still had liver dysfunction at 90 days postoperatively. One-year overall survival (OS) of the MARS-PHLF cohort was 50%. The present study aims to assess long-term outcome of this cohort compared to a historical control cohort. METHODS To compare long-term outcome of the MARS-PHLF treatment cohort with PHLF patients not treated with MARS, the present study includes all 655 patients who underwent major hepatectomy at Karolinska University Hospital between 2010 and 2018. Patients with PHLF were identified according to the Balzan criteria. RESULTS The cohort was split into three time periods: pre-MARS period (n = 192), MARS study period (n = 207), and post-MARS period (n = 256). The 90-day mortality of patients with PHLF was 55% (6/11) in the pre-MARS period, 14% during the MARS study period (2/14), and 50% (3/6) in the post-MARS period (p = 0.084). Median OS (95% confidence interval (CI)) was 37.8 months (29.3-51.7) in the pre-MARS cohort, 57 months (40.7-75.6) in the MARS cohort, and 38.8 months (31.4-51.2) in the post-MARS cohort. The 5-year OS of 10 patients included in the MARS study was 40% and the median survival 11.6 months (95% CI: 3 to not releasable). In contrast, for the remaining 21 patients fulfilling the Balzan criteria during the study period but not treated with MARS, the 5-year OS and median survival were 9.5% and 7.3 months (95% CI, 0.5-25.9), respectively (p = 0.138)). CONCLUSIONS MARS treatment may contribute to improved outcome of patients with PHLF. Further studies are needed.The initial pilot study was registered at ClinicalTrials.gov (NCT03011424).
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Affiliation(s)
- Stefan Gilg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ruth Baumgartner
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Per Stål
- Department of Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Melroy D'Souza
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Jansson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Eduard Jonas
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cecilia Stromberg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Baumgartner R, Gilg S, Björnsson B, Hasselgren K, Ghorbani P, Sauter C, Stål P, Sandstöm P, Sparrelid E, Engstrand J. Impact of post-hepatectomy liver failure on morbidity and short- and long-term survival after major hepatectomy. BJS Open 2022; 6:6645280. [PMID: 35849062 PMCID: PMC9291378 DOI: 10.1093/bjsopen/zrac097] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 01/31/2022] [Revised: 06/15/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Post-hepatectomy liver failure (PHLF) is one of the most serious postoperative complications after hepatectomy. The aim of this study was to assess the impact of the International Study Group of Liver Surgery (ISGLS) definition of PHLF on morbidity and short- and long-term survival after major hepatectomy. Methods This was a retrospective review of all patients who underwent major hepatectomy (three or more liver segments) for various liver tumours between 2010 and 2018 at two Swedish tertiary centres for hepatopancreatobiliary surgery. Descriptive statistics, regression models, and survival analyses were used. Results A total of 799 patients underwent major hepatectomy, of which 218 patients (27 per cent) developed ISGLS-defined PHLF, including 115 patients (14 per cent) with ISGLS grade A, 76 patients (10 per cent) with grade B, and 27 patients (3 per cent) with grade C. The presence of cirrhosis, perihilar cholangiocarcinoma, and gallbladder cancer, right-sided hemihepatectomy and trisectionectomy all significantly increased the risk of clinically relevant PHLF (grades B and C). Clinically relevant PHLF increased the risk of 90-day mortality and was associated with impaired long-term survival. ISGLS grade A had more major postoperative complications compared with no PHLF but failed to be an independent predictor of both 90-day mortality and long-term survival. The impact of PHLF grade B/C on long-term survival was no longer present in patients surviving the first 90 days after surgery. Conclusions The presently used ISGLS definition for PHLF should be reconsidered regarding mortality as only PHLF grade B/C was associated with a negative impact on short-term survival; however, even ISGLS grade A had clinical implications.
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Affiliation(s)
- Ruth Baumgartner
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bergthor Björnsson
- Department of Biomedical and Clinical Sciences, Division of Surgery, Linköping University, Linköping, Sweden
| | - Kristina Hasselgren
- Department of Biomedical and Clinical Sciences, Division of Surgery, Linköping University, Linköping, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Sauter
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Per Stål
- Division of Hepatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Per Sandstöm
- Department of Biomedical and Clinical Sciences, Division of Surgery, Linköping University, Linköping, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Linder S, Holmberg M, Engstrand J, Ghorbani P, Sparrelid E. Prognostic impact of para-aortic lymph node status in resected pancreatic ductal adenocarcinoma and invasive intraductal papillary mucinous neoplasm - Time to consider a reclassification? Surg Oncol 2022; 41:101735. [PMID: 35287096 DOI: 10.1016/j.suronc.2022.101735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 03/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Para-aortic lymph node (PALN) metastases in pancreatic ductal adenocarcinoma (PDAC) correlates with poor prognosis. The role of PALN in invasive intraductal papillary mucinous neoplasms (inv-IPMN) has not been well explored. The present study investigated the rate of metastatic PALN, lymph node ratio (LNR) and the overall nodal (N) status as prognostic factors in PDAC and inv-IPMN. METHODS This consecutive single-center series included patients with PDAC or inv-IPMN in the pancreatic head who underwent pancreatoduodenectomy or total pancreatectomy, including PALN resection between 2009 and 2018. Median overall survival (mOS) and impact of clinicopathological factors, including PALN status on survival, were evaluated. RESULTS 403 patients were included, 314 had PDAC and 89 inv-IPMN. PALN were metastatic in 16% of PDAC and 17% of inv-IPMN. N0 status was present in 6% of the patients with PDAC and 16% of inv-IPMN patients (p = 0.007). LNR >15% was more common in PDAC (52%) than in inv-IPMN (34%) (p = 0.004). mOS was 12.7 months in the presence of PALN metastases and 22.7 months without (p < 0.0001). Age >70 years, CA19-9 >200 U/mL, PDAC and N2 status were significantly associated with worse survival in a multivariable analysis. PALN status and LNR were not independent prognostic factors. In N2 status mOS was similar regardless the presence of PALN metastases. CONCLUSION The frequency of PALN metastases was similar in PDAC and inv-IPMN. Although PALN positive status entailed a shorter mOS, it was not an independent risk factor for death, and did not influence survival in N2-staged disease. The M1-status for PALN positivity may need reconsideration.
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Affiliation(s)
- Stefan Linder
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
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Sturesson C, Engstrand J, Strömberg C. Reply to: The cohort data in the full pulmonary Metastasectomy in colorectal cancer study: Comment on Engstrand et al. Eur J Surg Oncol 2022; 48:1874. [DOI: 10.1016/j.ejso.2022.05.021] [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] [Received: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
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Engstrand J, Sterner J, Hasselgren K, Stromberg C, Sturesson C. Treatment intention and outcome in patients with simultaneously diagnosed liver and lung metastases from colorectal cancer. European Journal of Surgical Oncology 2022; 48:1799-1806. [DOI: 10.1016/j.ejso.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 12/13/2022]
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Ruiter SJS, Tinguely P, Paolucci I, Engstrand J, Candinas D, Weber S, de Haas RJ, de Jong KP, Freedman J. 3D Quantitative Ablation Margins for Prediction of Ablation Site Recurrence After Stereotactic Image-Guided Microwave Ablation of Colorectal Liver Metastases: A Multicenter Study. Front Oncol 2021; 11:757167. [PMID: 34868968 PMCID: PMC8634106 DOI: 10.3389/fonc.2021.757167] [Citation(s) in RCA: 1] [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: 08/11/2021] [Accepted: 10/15/2021] [Indexed: 01/29/2023] Open
Abstract
Background Three-dimensional (3D) volumetric ablation margin assessment after thermal ablation of liver tumors using software has been described, but its predictive value on treatment efficacy when accounting for other factors known to correlate ablation site recurrence (ASR) remains unknown. Purpose To investigate 3D quantitative ablation margins (3D-QAMs) as an algorithm to predict ASR within 1 year after stereotactic microwave ablation (SMWA) for colorectal liver metastases (CRLM). Materials and Methods Sixty-five tumors in 47 patients from a prospective multicenter study of patients undergoing SMWA for CRLM were included in this retrospective 3D-QAM analysis. Using a previously developed algorithm, 3D-QAM defined as the distribution of tumor to ablation surface distances was assessed in co-registered pre- and post-ablation CT scans. The discriminatory power and optimal cutoff values for 3D-QAM were assessed using receiver operating characteristic (ROC) curves. Multivariable logistic regression analysis using generalized estimating equations was applied to investigate the impact of various 3D-QAM outputs on 1-year ASR while accounting for other known influencing factors. Results Ten of the 65 (15.4%) tumors included for 3D-QAM analysis developed ASR. ROC analyses identified i) 3D-QAM <1 mm for >23% of the tumor surface, ii) 3D-QAM <5 mm for >45%, and iii) the minimal ablation margin (MAM) as the 3D-QAM outputs with optimal discriminatory qualities. The multivariable regression model without 3D-QAM yielded tumor diameter and KRAS mutation as 1-year ASR predictors. When adding 3D-QAM, this factor became the main predictor of 1-year ASR [odds ratio (OR) 21.67 (CI 2.48, 165.21) if defined as >23% <1 mm; OR 0.52 (CI 0.29, 0.95) if defined as MAM]. Conclusions 3D-QAM allows objectifiable and standardized assessment of tumor coverage by the ablation zone after SMWA. Our data shows that 3D-QAM represents the most important factor predicting ASR within 1 year after SMWA of CRLM.
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Affiliation(s)
- Simeon J S Ruiter
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pascale Tinguely
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden.,Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Iwan Paolucci
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Robbert J de Haas
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Koert P de Jong
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Tinguely P, Paolucci I, Ruiter SJS, Weber S, de Jong KP, Candinas D, Freedman J, Engstrand J. Stereotactic and Robotic Minimally Invasive Thermal Ablation of Malignant Liver Tumors: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:713685. [PMID: 34631539 PMCID: PMC8495244 DOI: 10.3389/fonc.2021.713685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/23/2021] [Accepted: 09/06/2021] [Indexed: 01/17/2023] Open
Abstract
Background Stereotactic navigation techniques aim to enhance treatment precision and safety in minimally invasive thermal ablation of liver tumors. We qualitatively reviewed and quantitatively summarized the available literature on procedural and clinical outcomes after stereotactic navigated ablation of malignant liver tumors. Methods A systematic literature search was performed on procedural and clinical outcomes when using stereotactic or robotic navigation for laparoscopic or percutaneous thermal ablation. The online databases Medline, Embase, and Cochrane Library were searched. Endpoints included targeting accuracy, procedural efficiency, and treatment efficacy outcomes. Meta-analysis including subgroup analyses was performed. Results Thirty-four studies (two randomized controlled trials, three prospective cohort studies, 29 case series) were qualitatively analyzed, and 22 studies were included for meta-analysis. Weighted average lateral targeting error was 3.7 mm (CI 3.2, 4.2), with all four comparative studies showing enhanced targeting accuracy compared to free-hand targeting. Weighted average overall complications, major complications, and mortality were 11.4% (6.7, 16.1), 3.4% (2.1, 5.1), and 0.8% (0.5, 1.3). Pooled estimates of primary technique efficacy were 94% (89, 97) if assessed at 1–6 weeks and 90% (87, 93) if assessed at 6–12 weeks post ablation, with remaining between-study heterogeneity. Primary technique efficacy was significantly enhanced in stereotactic vs. free-hand targeting, with odds ratio (OR) of 1.9 (1.2, 3.2) (n = 6 studies). Conclusions Advances in stereotactic navigation technologies allow highly precise and safe tumor targeting, leading to enhanced primary treatment efficacy. The use of varying definitions and terminology of safety and efficacy limits comparability among studies, highlighting the crucial need for further standardization of follow-up definitions.
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Affiliation(s)
- Pascale Tinguely
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden.,Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Iwan Paolucci
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Simeon J S Ruiter
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Koert P de Jong
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Zenlander R, Havervall S, Magnusson M, Engstrand J, Ågren A, Thålin C, Stål P. Neutrophil extracellular traps in patients with liver cirrhosis and hepatocellular carcinoma. Sci Rep 2021; 11:18025. [PMID: 34504150 PMCID: PMC8429678 DOI: 10.1038/s41598-021-97233-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 05/08/2021] [Accepted: 08/20/2021] [Indexed: 12/20/2022] Open
Abstract
Neutrophil extracellular traps (NETs) are web-like structures consisting of DNA, histones and granule proteins, released from neutrophils in thrombus formation, inflammation, and cancer. We asked if plasma levels of the NET markers myeloperoxidase (MPO)-DNA and citrullinated histone H3 (H3Cit)-DNA, are elevated in liver cirrhosis and hepatocellular carcinoma (HCC) and if the levels correlate with clinical parameters. MPO-DNA, H3Cit-DNA, and thrombin–antithrombin (TAT) complex, as a marker of coagulation activity, were measured using ELISA in plasma from 82 patients with HCC, 95 patients with cirrhosis and 50 healthy controls. Correlations were made to clinical parameters and laboratory data and patients were followed for a median of 22.5 months regarding thrombosis development. H3Cit-DNA was significantly (p < 0.01) elevated in plasma from cirrhosis (66.4 ng/mL) and HCC (63.8 ng/mL) patients compared to healthy controls (31.8 ng/mL). TAT levels showed similar pattern (3.1, 3.7, and 0.0 µg/mL respectively, p < 0.01). MPO-DNA was significantly (p < 0.01) elevated in cirrhosis patients (0.53 O.D.) as compared to controls (0.33 O.D.). Levels of MPO-DNA and H3Cit-DNA correlated positively with Child–Pugh and MELD score. TAT was increased in all Child–Pugh and MELD groups. In multivariable logistic regression, Child B and C liver cirrhosis were independent predictors of elevated H3Cit-DNA in plasma. Levels of MPO-DNA and H3Cit-DNA were similar in patients with or without history of thrombosis, or thrombus formation during follow-up. In conclusion, plasma markers of NET formation are elevated in liver cirrhosis and correlate to the degree of liver dysfunction in patients with liver cirrhosis and/or HCC. The presence of HCC did not further increase the plasma levels of NET markers as compared to patients with cirrhosis only.
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Affiliation(s)
- Robin Zenlander
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden. .,Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden. .,Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden.
| | - Sebastian Havervall
- Division of Gastroenterology, Department of Specialized Medicine, Danderyd Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Maria Magnusson
- Division of Pediatrics, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Ågren
- Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Charlotte Thålin
- Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.,Department of Internal Medicine and Infectious Diseases, Danderyd Hospital, Stockholm, Sweden
| | - Per Stål
- Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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18
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Engstrand J, Abreu de Carvalho LF, Aghayan D, Balakrishnan A, Belli A, Björnsson B, Dasari BVM, Detry O, Di Martino M, Edwin B, Erdmann J, Fristedt R, Fusai G, Gimenez-Maurel T, Hemmingsson O, Hidalgo Salinas C, Isaksson B, Ivanecz A, Izzo F, Knoefel WT, Kron P, Lehwald-Tywuschik N, Lesurtel M, Lodge JPA, Machairas N, Marino MV, Martin V, Paterson A, Rystedt J, Sandström P, Serrablo A, Siriwardena AK, Taflin H, van Gulik TM, Yaqub S, Özden I, Ramia JM, Sturesson C. Liver resection and ablation for squamous cell carcinoma liver metastases. BJS Open 2021; 5:6356812. [PMID: 34426830 PMCID: PMC8382975 DOI: 10.1093/bjsopen/zrab060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/22/2021] [Accepted: 05/17/2021] [Indexed: 12/30/2022] Open
Abstract
Background Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS). Method Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS. Results Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30). Conclusion Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.
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Affiliation(s)
- J Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - L F Abreu de Carvalho
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - D Aghayan
- The Intervention Centre, Oslo University Hospital, Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
| | - A Balakrishnan
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Belli
- Department of Abdominal Oncology, HPB Surgical Oncology Unit, National Cancer Institute, Fondazione G. Pascale-IRCCS, Naples, Italy
| | - B Björnsson
- Department of Surgery in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - B V M Dasari
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - O Detry
- Department of Abdominal Surgery and Transplantation, CHU Liège, Liège, Belgium
| | - M Di Martino
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - B Edwin
- The Intervention Centre, Oslo University Hospital, Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - J Erdmann
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - R Fristedt
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - G Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London, UK
| | - T Gimenez-Maurel
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - O Hemmingsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - C Hidalgo Salinas
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London, UK
| | - B Isaksson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - A Ivanecz
- Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - F Izzo
- Department of Abdominal Oncology, HPB Surgical Oncology Unit, National Cancer Institute, Fondazione G. Pascale-IRCCS, Naples, Italy
| | - W T Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - P Kron
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - N Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - M Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - J P A Lodge
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - N Machairas
- 3rd Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - M V Marino
- General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo (PA), Abano, Italy.,General Surgery Department, Policlinico Abano Terme, Abano, Italy
| | - V Martin
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - A Paterson
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Rystedt
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - P Sandström
- Department of Surgery in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - A K Siriwardena
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | - H Taflin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Sweden
| | - T M van Gulik
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - S Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - I Özden
- Department of General Surgery, Istanbul University School of Medicine, Istanbul, Turkey
| | - J M Ramia
- Hospital General Universitario de Alicante. ISABIAL Alicante, Spain
| | - C Sturesson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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19
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Tinguely P, Dal G, Bottai M, Nilsson H, Freedman J, Engstrand J. Microwave ablation versus resection for colorectal cancer liver metastases – A propensity score analysis from a population-based nationwide registry. Eur J Surg Oncol 2020; 46:476-485. [DOI: 10.1016/j.ejso.2019.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/15/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
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20
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Engstrand J, Strömberg C, Nilsson H, Freedman J, Jonas E. Synchronous and metachronous liver metastases in patients with colorectal cancer-towards a clinically relevant definition. World J Surg Oncol 2019; 17:228. [PMID: 31878952 PMCID: PMC6933908 DOI: 10.1186/s12957-019-1771-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [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: 09/16/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
Background Approximately 25% of patients with colorectal cancer (CRC) will have liver metastases classified as synchronous or metachronous. There is no consensus on the defining time point for synchronous/metachronous, and the prognostic implications thereof remain unclear. The aim of the study was to assess the prognostic value of differential detection at various defining time points in a population-based patient cohort and conduct a literature review of the topic. Methods All patients diagnosed with CRC in the counties of Stockholm and Gotland, Sweden, during 2008 were included in the study and followed for 5 years or until death to identify patients diagnosed with liver metastases. Patients with liver metastases were followed from time of diagnosis of liver metastases for at least 5 years or until death. Different time points defining synchronous/metachronous detection, as reported in the literature and identified in a literature search of databases (PubMed, Embase, Cochrane library), were applied to the cohort, and overall survival was calculated using Kaplan-Meier curves and compared with log-rank test. The influence of synchronously or metachronously detected liver metastases on disease-free and overall survival as reported in articles forthcoming from the literature search was also assessed. Results Liver metastases were diagnosed in 272/1026 patients with CRC (26.5%). No statistically significant difference in overall survival for synchronous vs. metachronous detection at any of the defining time points (CRC diagnosis/surgery and 3, 6 and 12 months post-diagnosis/surgery) was demonstrated for operated or non-operated patients. In the literature search, 41 publications met the inclusion criteria. No clear pattern emerged regarding the prognostic significance of synchronous vs. metachronous detection. Conclusion Synchronous vs. metachronous detection of CRC liver metastases lacks prognostic value. Using primary tumour diagnosis/operation as standardized cut-off point to define synchronous/metachronous detection is semantically correct. In synchronous detection, it defines a clinically relevant group of patients where individualized multimodality treatment protocols will apply.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden.
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Nilsson
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 182 88, Stockholm, Sweden
| | - Eduard Jonas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
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21
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Beermann M, Lindeberg J, Engstrand J, Galmén K, Karlgren S, Stillström D, Nilsson H, Harbut P, Freedman J. 1000 consecutive ablation sessions in the era of computer assisted image guidance - Lessons learned. Eur J Radiol Open 2018; 6:1-8. [PMID: 30547062 PMCID: PMC6282637 DOI: 10.1016/j.ejro.2018.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 10/16/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022] Open
Abstract
Computer assisted targeting techniques are simple to use and improve results in ablative tumour treatments. The indications for ablative soft tissue tumour ablation are increasing. Treatments are superior to resective surgery in terms of complications and hospitalization, oncological non-inferiority remains to be proven. An incomplete ablation can be retreated without negative effects on survival. Jet ventilation is an effective technique to minimize organ displacement during percutaneous or laparoscopic ablation.
Background Ablation therapies for tumours are becoming more used as ablation modalities evolve and targeting solutions are getting better. There is an increasing body of long-term results challenging resection and proving lower morbidities and costs. The aim of this paper is to share the experiences from a high-volume centre in introducing computer assisted targeting solutions and efficient ablation modalities like microwave generators and irreversible electroporation. Material and methods One thousand consecutive treatments in one high-volume centre were evaluated retrospectively from prospectively collected data. Results The purpose of this paper is to present the benefits of going into computer assisted targeting techniques and microwave technology; pitfalls and overview of outcomes. The main target organ was the liver and the main indications were ablation of hepatocellular carcinomas and colorectal liver metastases. With the assistance of computer assisted targeting the local recurrence rate within 6 months has dropped from 30 to near 10%. The survival of patients with hepatocellular carcinoma and colorectal liver metastases is not worse if the tumour can be retreated after a local recurrence. Multiple colorectal liver metastases can be treated successfully. Discussion The incorporation of computer assisted targeting technologies for ultrasound-, ct guided- and laparoscopic tumour ablation has been very successful and without a noticeable learning curve. The same is true for switching from radiofrequency energies to microwave generators and irreversible electroporation. Conclusion It is well worthwhile upgrading ablation and targeting technologies to achieve excellent and reproducible results and minimizing operator dependency.
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Key Words
- Ablation
- CAS, computer assisted surgery
- Colorectal liver metastases
- Fused ultrasound
- HFJV, high frequency jet ventilation
- HIFU, high intensity focused ultrasound
- Hepatocellular carcinoma
- IRE
- IRE, irreversible electroporation
- Jet ventilation
- Kidney
- Liver
- Lung
- MWA, microwave ablation
- Microwave
- Pancreas
- RF
- RFA, radio-frequency ablation
- Renal cell carcinoma
- SBRT, stereotactic body radiation therapy
- Stereotactic navigation
- TAE, TACE, trans-arterial embolization or chemo-embolization
- TIVA, total intravenous anaesthesia
- Ultrasound
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Affiliation(s)
- Marie Beermann
- Dept of Radiology, Danderyd University Hospital, Stockholm, Sweden
| | - Johan Lindeberg
- Dept of Radiology, Danderyd University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Dept of Surgery and Urology, Danderyd University Hospital, Stockholm, Sweden
| | - Karolina Galmén
- Dept of Anaesthesiology, Danderyd University Hospital, Stockholm, Sweden
| | - Silja Karlgren
- Dept of Surgery and Urology, Danderyd University Hospital, Stockholm, Sweden
| | - David Stillström
- Dept of Surgery and Urology, Danderyd University Hospital, Stockholm, Sweden
| | - Henrik Nilsson
- Dept of Surgery and Urology, Danderyd University Hospital, Stockholm, Sweden
| | - Piotr Harbut
- Dept of Anaesthesiology, Danderyd University Hospital, Stockholm, Sweden
| | - Jacob Freedman
- Dept of Surgery and Urology, Danderyd University Hospital, Stockholm, Sweden
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22
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Engstrand J, Nilsson H, Strömberg C, Jonas E, Freedman J. Colorectal cancer liver metastases - a population-based study on incidence, management and survival. BMC Cancer 2018; 18:78. [PMID: 29334918 PMCID: PMC5769309 DOI: 10.1186/s12885-017-3925-x] [Citation(s) in RCA: 455] [Impact Index Per Article: 75.8] [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: 04/19/2017] [Accepted: 12/14/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer-associated deaths with liver metastases developing in 25-30% of those affected. Previous data suggest a survival difference between right- and left-sided liver metastatic CRC, even though left-sided cancer has a higher incidence of liver metastases. The aim of the study was to describe the liver metastatic patterns and survival as a function of the characteristics of the primary tumour and different combinations of metastatic disease. METHODS A retrospective population-based study was performed on a cohort of patients diagnosed with CRC in the region of Stockholm, Sweden during 2008. Patients were identified through the Swedish National Quality Registry for Colorectal Cancer Treatment (SCRCR) and additional information on intra- and extra-hepatic metastatic pattern and treatment were retrieved from electronic patient records. Patients were followed for 5 years or until death. Factors influencing overall survival (OS) were investigated by means of Cox regression. OS was compared using Kaplan-Meier estimations and the log-rank test. RESULTS Liver metastases were diagnosed in 272/1026 (26.5%) patients within five years of diagnosis of the primary. Liver and lung metastases were more often diagnosed in left-sided colon cancer compared to right-sided cancer (28.4% versus 22.1%, p = 0.029 and 19.7% versus 13.2%, p = 0.010, respectively) but the extent of liver metastases were more extensive for right-sided cancer as compared to left-sided (p = 0.001). Liver metastatic left-sided cancer, including rectal cancer, was associated with a 44% decreased mortality risk compared to right-sided cancer (HR = 0.56, 95% CI: 0.39-0.79) with a 5-year OS of 16.6% versus 4.3% (p < 0.001). In liver metastatic CRC, the presence of lung metastases did not significantly influence OS as assessed by multivariate analysis (HR = 1.11, 95% CI: 0.80-1.53). CONCLUSION The worse survival in liver metastatic right-sided colon cancer could possibly be explained by the higher number of metastases, as well as more extensive segmental involvement compared with left-sided colon and rectal cancer, even though the latter had a higher incidence of liver metastases. Detailed population-based data on the metastatic pattern of CRC and survival could assist in more structured and individualized guidelines for follow-up of patients with CRC.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, 182 88, Stockholm, Sweden.
| | - Henrik Nilsson
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, 182 88, Stockholm, Sweden
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, 171 77, Stockholm, Sweden
| | - Eduard Jonas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, 171 77, Stockholm, Sweden.,Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town Health Sciences Faculty, Cape Town, 7925, South Africa
| | - Jacob Freedman
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, 182 88, Stockholm, Sweden
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Engstrand J, Kartalis N, Strömberg C, Broberg M, Stillström A, Lekberg T, Jonas E, Freedman J, Nilsson H. The Impact of a Hepatobiliary Multidisciplinary Team Assessment in Patients with Colorectal Cancer Liver Metastases: A Population-Based Study. Oncologist 2017; 22:1067-1074. [PMID: 28550028 PMCID: PMC5599196 DOI: 10.1634/theoncologist.2017-0028] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Assessing patients with colorectal cancer liver metastases (CRCLM) by a liver multidisciplinary team (MDT) results in higher resection rates and improved survival. The aim of this study was to evaluate the potentially improved resection rate in a defined cohort if all patients with CRCLM were evaluated by a liver MDT. PATIENTS AND METHODS A retrospective analysis of patients diagnosed with colorectal cancer during 2008 in the greater Stockholm region was conducted. All patients with liver metastases (LM), detected during 5-year follow-up, were re-evaluated at a fictive liver MDT in which previous imaging studies, tumor characteristics, medical history, and patients' own treatment preferences were presented. Treatment decisions for each patient were compared to the original management. Odds ratios (ORs) and 95% confidence intervals were estimated for factors associated with referral to the liver MDT. RESULTS Of 272 patients diagnosed with LM, 102 patients were discussed at an original liver MDT and 69 patients were eventually resected. At the fictive liver MDT, a further 22 patients were considered as resectable/potentially resectable, none previously assessed by a hepatobiliary surgeon. Factors influencing referral to liver MDT were age (OR 3.12, 1.72-5.65), American Society of Anaesthesiologists (ASA) score (OR 0.34, 0.18-0.63; ASA 2 vs. ASA 3), and number of LM (OR 0.10, 0.04-0.22; 1-5 LM vs. >10 LM), while gender (p = .194) and treatment at a teaching hospital (p = .838) were not. CONCLUSION A meaningful number of patients with liver metastases are not managed according to best available evidence and the potential for higher resection rates is substantial. IMPLICATIONS FOR PRACTICE Patients with liver metastatic colorectal cancer who are assessed at a hepatobiliary multidisciplinary meeting achieve higher resection rates and improved survival. Unfortunately, patients who may benefit from resection are not always properly referred. In this study, the potential improved resection rate was assessed by re-evaluating all patients with liver metastases from a population-based cohort, including patients with extrahepatic metastases and accounting for comorbidity and patients' own preferences towards treatment. An additional 12.9% of the patients were found to be potentially resectable. The results highlight the importance of all patients being evaluated in the setting of a hepatobiliary multidisciplinary meeting.
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Affiliation(s)
- Jennie Engstrand
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Nikolaos Kartalis
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Strömberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Mats Broberg
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Anna Stillström
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Jonas
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
| | - Jacob Freedman
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Henrik Nilsson
- Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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Engstrand J, Nilsson H, Jansson A, Jonas E, Freedman J. Fate of necrotic volume after microwave ablation of multiple liver metastases. Hepatogastroenterology 2015; 62:108-110. [PMID: 25911878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS The aim of this study was to find the rate of shrinkage of necrosis and time of peak ablation volume after multiple microwave ablations in the treatment of multiple liver metastases of colorectal cancer. These factors are not known and are important in evaluation of treatment and identification of local recurrence, as microwave treatment is becoming more used thanks to improved technology in diagnostics and interventional therapy. METHODOLOGY A retrospective analysis of non-cirrhotic patients with multiple liver only metastases of colorectal cancer, not suited for resection for this reason. Patients were selected for palliative microwave treatment at a liver multidisciplinary team conference. 68 ablations were made in six patients. Ablation volume was analysed with repeated imaging and computer analyses. RESULTS The ablation volume peeks after 5-7 days where after reduction of the necrosis in the liver occurs logarithmically with a 60% reduction of ablation volume after 100 days and 80% after a year. DISCUSSION Liver regeneration after microwave ablations occurs at a constant logarithmic rate after an initial expansion of the ablation volume during the first five days. Evaluation of ablation volume in comparison to tumour volume must take this into account so that follow-up imaging is properly timed.
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