Complete Blood Count Alterations Prior to the Diagnosis of Colorectal Cancer May Help in the Detection of Synchronous Liver Metastases

Background and Aims: Colorectal cancer (CRC) represents 10% of all cancers worldwide with the highest incidence in developed countries; its incidence is also increasing in middle- and low-income countries. Population screening programs facilitate early diagnosis of the disease. When the diagnosis is carried out in advanced stages, approximately 80% of patients with liver metastases (LM) are considered unresectable at the time of diagnosis. In our study, variations in blood counts prior to CRC diagnosis were analyzed to assess whether they could be useful in identifying smaller, more manageable metastases at earlier stages for more effective treatment. Methods: A study was carried out using complete blood counts (CBCs) from CRC patients, obtained from primary health centers and the La Ribera University Hospital within La Ribera Health Department, Valencian Community, Spain, between July 2012 and September 2020. Data from CRC patients who presented synchronous liver metastasis (CRLM) were compared with those with CRC without LM at diagnosis (CRC patients). Results: Our analysis shows that at least 15 months before CRC diagnosis, a progressive alteration was observed in CBC parameters in both groups. A higher incidence of anemia (p < 0.001) was observed among CRLM patients in the three months prior to CRC diagnosis than in CRC patients showing no LM. Conclusions: A statistically significant deterioration of CBC was observed in patients with advanced-stage CRC and synchronous or early LM (CRLM) in the three months prior to diagnosis. The primary goal of incorporating CBC variations into predictive models is to identify individuals who are at a greater risk of developing metastatic colon cancer, leading to early diagnosis. Our research improves these models by highlighting a more pronounced and rapid decline in hemoglobin levels among CRLM patients. Identification of metastases at an earlier stage when they are smaller, more manageable, and more amenable to treatment may be a valuable tool to prevent their further progression.

[Laparoscopic downstaging surgery for colorectal cancer with synchronous liver metastases: what value in two-stage hepatectomies?]

Bilobar hepatic metastases from colorectal cancer pose a problem in terms of management, with curative surgery often requiring several stages. The purpose of our study was to evaluate laparoscopic approach with portal vein ligation in the first step of two-stage hepatectomy in the treatment of patients with synchronous liver metastases from colorectal cancers (SLMCRC). We conducted a single-center retrospective study from August 2016 to January 2020. It included patients with SLMCRC requiring two-stage curative surgery due to insufficient future liver remnant volume (FRL). The primary endpoint was to evaluate postoperative morbidity and mortality following first step laparoscopy at 30 days. The secondary endpoints were to evaluate conversion rate, FRL hypertrophy following laparoscopic portal vein ligation, postoperative morbidity and mortality of 2nd step of two-stage hepatectomy and finally treatment completion rate. We included six patients (4 men and 2 women) with a mean age of 64 (44-72) years. The first step of surgery consisted of a laparoscopic colonic resection associated with right portal vein ligation in 5 patients and left portal vein ligation in one patient. The postoperative morbimortality was zero. The conversion rate was zero. After portal vein ligation, 5 of the 6 patients had significantly enlarged FRL, with a mean gain in FRL volume of 59.48% (31.02%-68.71%). Two of the six patients had severe morbidity after 2nd step hepatectomy (Clavien IIIb). All patients completed the treatment.

The Effect of Induction Chemotherapy with VEGF Inhibition on Tumor Response in Synchronously Metastasized Potentially Resectable Colorectal Cancer

(1) Background: The pathological tumor response of the primary tumor to induction chemotherapy in synchronously metastasized colorectal cancer (mCRC) patients has not been investigated. The aim of this study was to compare patients treated with induction chemotherapy combined with vascular endothelial growth factor (VEGF) or with epidermal growth factor receptor (EGFR) antibodies. (2) Methods: We present a retrospective analysis, where we included 60 consecutive patients with potentially resectable synchronous mCRC who received induction chemotherapy combined with either VEGF or EGFR antibodies. The primary endpoint of this study was the regression of the primary tumor, which was assessed by the application of the histological regression score according to Rödel. The secondary endpoints were recurrence-free survival (RFS) and overall survival (OS). (3) Results: A significantly better pathological response and a longer RFS for patients treated with the VEGF antibody therapy compared to those treated with the EGFR antibodies was demonstrated (p = 0.005 for the primary tumor and log-rank = 0.047 for RFS). The overall survival did not differ. The trial was registered with clinicaltrial.gov, number NCT05172635. (4) Conclusion: Induction chemotherapy combined with a VEGF antibody revealed a better pathological response of the primary tumor, leading to a better RFS compared to that with EGFR therapy; this has clinical relevance in patients with potentially resectable synchronously mCRC.

Real-Life Experience of the Prognostic Significance of the Primary Tumor Location on the Timing of Colorectal Liver Metastases: A Retrospective Analysis

Background Numerous research studies have looked into how the primary tumor location (PTL) affects patients' prognosis for colorectal cancer (CRC). Our research aimed to investigate the prognostic effects of PTL in patients with synchronous (SM) and metachronous (MM) colorectal cancer liver metastases (CRCLM). Material and methods From 2016 to 2021, we looked back at the records of patients at our institute who were affected by CRCLM. Results 109 patients were included, of whom 21.1% received CRCLM resection (R0=73.9%), with 57.7% having left-sided colon cancer (LCC) and 42.2% having right-sided colon cancer (RCC). SM predominated (69.7%). The median duration of follow-up was 21,3 months (95%CI=15,4-25,2). ≥5 hepatic metastases prevailed in the SM group (N=61; 83.5%). 21% of all patients underwent CRCLM resection (R0=78.2%). We observed a double rate of patients unresponsive to standard systemic antineoplastic treatments in the SM group (35.8% vs. 17.9% of the MM group) (p=0.27). We found a significantly longer median overall survival (OS) in patients with MM-LCC compared with the other groups (27.7 months; HR=0.3797; 95%CI=0.19-0.74; p=0.0205). The median OS, regardless of PTL, was higher in the MM group (16,5 months vs. 16,1 months; HR=0,29; 95%CI=0,13-0,67; p=0.0038) as well as progression-free survival (PFS) (11 months vs. 10,2 months; HR=0,61; 95%CI=0,33-1,12; p=0.11). Finally, in patients undergoing liver surgery, a noteworthy median OS was shown to be significantly in favor of patients with metachronous liver metastases from the primary left tumor (37.0 months; HR=0.47; 95%CI=0.11-1.96; p=0.0041). Conclusions Our real-life study demonstrated that patients with LCC, particularly MM-LCC, have the highest survival and that the timing of CRCLM should be a prognostic factor.

Minimally Invasive Concepts in Treating Synchronous Liver Metastases Rectal Cancer Patients: Six Cases Report

BACKGROUND

Rectal cancer patients with synchronous liver metastases (SLM) is common in clinical practice. However, the application of conventional natural orifice specimen extraction surgery (NOSES) and NOSES with specimen extraction via stoma/hepatectomy incision in the special population is rarely explored.

CASE REPORT

Six SLM rectal cancer patients were treated with simultaneous surgical resection and the specimens were extracted via anal/stoma/hepatectomy incision. Respectively, intraoperative and postoperative data, anal function 3 months after surgery and long-term prognosis were reviewed.

RESULTS

Intraoperative and postoperative data and anal function were reliable for the six cases. Only one patient died of brain and bone metastases at 84 months after surgery and the other five patients were alive at their last follow-up.

CONCLUSIONS

Simultaneous surgical resection with the concept of conventional NOSES and NOSES with specimen extraction via stoma/hepatectomy incision is safety for SLM rectal patients.

Outcomes of Laparoscopic Combined Surgery for Colorectal Cancer with Synchronous Liver Metastases: A Prospective Comparative Study

AIM

Combined surgery for colorectal cancer with synchronous liver metastases (CRCSLM) is addressed to selected patients. Technically, by conventional surgery this simultaneous approach raises a problem of adequate access. The purpose of this study is to assess the feasibility and safety of the laparoscopic approach in combined surgery.

METHODS

From August 2016 to January 2020 a monocentric prospective comparative study was conducted. Short and long-term outcomes of simultaneous laparoscopic surgery (SLS) were evaluated. Short-term outcomes of SLS were compared to those of laparoscopic colorectal surgery alone (LCRS).

RESULTS

Forty patients were included in each arm. In SLS group, the median age was 62.5 years. Hybrid surgery was performed for 60% of patients, down staging laparoscopic surgery for 22.5% of patients and totally laparoscopic surgery for 10% of patients. The conversion rate was 7.5%. Mean operating time was 323 minutes. Overall morbidity rate was 27.5%. Multivariate analysis showed that anemia (p = 0.046) and number of liver resections (p = 0.018) were independent factors of morbidity. Ninety-five percent of colorectal resections were R0, 90% of liver resections were R0. The mean length of hospital stay was 5.1 ± 2.58 days. The recurrence rate was 22.5%. Median diseasefree survival was 27 months. There was no difference in short-term outcomes between the two arms except for operating time which was longer in SLS arm (p < 0.0005).

CONCLUSION

Laparoscopy is feasible in combined surgery in selected patients. Minor liver resection may be associated with laparoscopic colorectal surgery without increasing morbidity.

Incidence and predictors of textbook outcome after simultaneous liver and rectal surgeries for Stage IV rectal cancer

AIM

Textbook outcome (TO) is a new surgical quality measure that combines structure, process and surgical outcomes into a single element. Our study aimed to determine the incidence of TO after simultaneous rectal and liver surgery and to use the achievement of TO as a tool to identify the best candidates for these complex procedures.

METHODS

In total, 256 patients who underwent simultaneous liver and rectal surgery for Stage IV rectal cancer between January 2004 and August 2019 at five tertiary centres were enrolled. TO was defined as a lack of complication, prolonged length of stay, readmission and death.

RESULTS

Mortality rate at 90 days and major morbidity rate were 2.3% and 15.6%, respectively. An overall TO was achieved in 59% of the patients, which is associated with significantly improved overall (median TO 86.3 months vs. no TO 37.4 months) and disease-free (median TO 70.6 months vs. no TO 24.9 months) survival. On multivariate analysis the presence of multi-comorbidities (OR 3.073) was associated with a reduced likelihood of achieving TO. Left lateral sectionectomy/limited resection was a protective factor (OR 0.416).

CONCLUSION

TO was achieved in six of 10 patients undergoing simultaneous resections for rectal cancer and liver metastases. Achieving a TO is strongly associated with improved long-term survival. The best candidates for these procedures were patients without multiple comorbidities and those treated with left lateral sectionectomy/limited resection.

Differences in management and outcome for colon and rectal carcinoma with synchronous liver metastases: a population-based cohort study

AIM

Surgical treatment of colorectal cancer with synchronous colorectal liver metastases (SCRLM) can follow three different strategies with regard to the timing of liver resection. The aim of this study was to describe the selection of surgical strategy, focusing on differences between colon and rectal cancer with SCRLM, postoperative morbidity/mortality and survival.

METHOD

This was a retrospective population-based study of patients with SCRLM registered in the Swedish Colorectal Cancer Registry in the Stockholm/Gotland region during 2010-2017 and treated with surgical resection of the primary tumour and liver metastases (LM). Patients were followed for 5 years or censored at 22 November 2018.

RESULTS

A total of 238 patients met the inclusion criteria during the study period. Patients with rectal cancer were treated with the 'liver first' strategy in 70% of cases, whereas the main treatment strategies for colonic tumours were 'simultaneous resection' (44%) and 'primary first' (37%). Rectal cancer had a superior 5-year survival rate compared with colon tumours with SCRLM (62 vs. 47%; p = 0.033). There was no difference in survival between treatment strategies irrespective of primary tumour location. Postoperative complications occurred most commonly among rectal tumours treated with simultaneous resection (p = 0.024).

CONCLUSION

Patients with rectal cancer and SCRLM were more often treated with the 'liver first' strategy than patients with colon cancer. Patients with rectal cancer and SCRLM where both primary tumour and LM were operated on had significantly better survival than corresponding patients with colon cancer.

The safety and feasibility of a single incision in simultaneous resection for patients with colorectal cancer liver metastases

Background

The approach of performing a simultaneous resection for patients with colorectal cancer liver metastases has been lauded universally, but the operation procedures have differences. In general, colorectal lesions are removed laparoscopically; however, some liver metastases cannot be resected under laparoscopy. For these patients, the traditional approach of performing a simultaneous resection which utilizes the inferior abdominal midline incision and the right subcostal incision is preferred. In this study, we assessed the safety and feasibility of the single right subcostal incision approach for patients with either rectal or sigmoid colon cancer and liver metastasis who underwent simultaneous resection.

Methods

A total of 85 patients with rectal or sigmoid colon cancer and liver metastases who underwent simultaneous resection from January 2012 to December 2016 in the Cancer Hospital Chinese Academy of Medical Sciences were identified. Clinicopathological data, as well as operative and perioperative outcomes, were collected and analyzed retrospectively.

Results

Overall, 42 patients were included in this study, 26 (61.9%) patients underwent simultaneous resection with a single surgical incision (right subcostal incision), and 16 (38.1%) underwent simultaneous resection with dual surgical incisions (inferior abdominal midline incision and right subcostal incision). Compared to the dual-incision approach, the single-incision approach had a shorter operation time (328.0 vs. 420.0 min, P=0.006) but had no significant differences in total hospitalization time, postoperative hospitalization time, intraoperative blood loss, time of postoperative drainage tube extraction, time to the first postoperative bowel movement, and postoperative complications (P>0.05).

Conclusions

The single-incision approach (right subcostal incision) is feasible and safe for patients with either sigmoid colon or rectal cancer and liver metastases.

Effect of treatment sequence on survival in stage IV rectal cancer with synchronous and potentially resectable liver metastases

BACKGROUND AND OBJECTIVES

The optimal treatment sequence in stage IV rectal cancer (RC) with synchronous liver metastases (SLM) remains undefined. Here, we compared outcomes between patients treated with the bowel-first approach (BFA) or the liver-first approach (LFA).

METHODS

Consecutive patients diagnosed with stage IV RC with SLM and who underwent complete resection were included. Both groups were matched using propensity scores. Differences in postoperative outcome, local control, and long-term survival were studied. In addition, a decision analysis (DA) model was built using TreeAge Pro to define the approach that results in the highest treatment completion rate.

RESULTS

During a 12-year period, 52 patients were identified, 21 and 31 of whom underwent the BFA and the LFA, respectively. Twenty-eight patients were matched; patients treated with the BFA experienced a longer median OS (50.0 vs 33.0 months; P = .40) and higher 5-year OS (42.9% vs 28.6%). The DA defined the BFA to be superior when the failure threshold (ie, no R0 resection, treatment discontinuation regardless of cause) for colectomy is less than 28.6%.

CONCLUSIONS

In stage IV rectal cancer with SLM, either the BFA or the LFA result in similar long-term outcomes. Treatment should be tailored according to clinicopathological variables.

Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.

Simultaneous Pure Laparoscopic Resection of Primary Colorectal Cancer and Synchronous Liver Metastases: A Single Institution Experience with Propensity Score Matching Analysis

Background

The aim of the study was to compare the outcome of pure laparoscopic and open simultaneous resection of both the primary colorectal cancer and synchronous colorectal liver metastases (SCLM).

Patients and methods

From 2000 to 2016 all patients treated by simultaneous resection were assessed for entry in this single center, clinically nonrandomized trial. A propensity score matching was used to compare the laparoscopic group (LAP) to open surgery group (OPEN). Primary endpoints were perioperative and oncologic outcomes. Secondary endpoints were overall survival (OS) and disease-free survival (DFS).

Results

Of the 82 patients identified who underwent simultaneous liver resection for SCLM, 10 patients underwent LAP. All these consecutive patients from LAP were matched to 10 comparable OPEN. LAP reduced the length of hospital stay (P = 0.044) and solid food oral intake was faster (P = 0.006) in this group. No patient undergoing the laparoscopic procedure experienced conversion to the open technique. No difference was observed in operative time, blood loss, transfusion rate, narcotics requirement, clinical risk score, resection margin, R0 resections rate, morbidity, mortality and incisional hernias rate. The two groups did not differ significantly in terms of the 3-year OS rate (90 vs. 75%; P = 0.842) and DFS rate (60 vs. 57%; P = 0.724).

Conclusions

LAP reduced the length of hospital stay and offers faster solid food oral intake. Comparable oncologic and survival outcomes can be achieved. LAP is beneficial for well selected patients in high volume centers with appropriate expertise.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

Simultaneous hepatic resection benefits patients with synchronous colorectal cancer liver metastases

Objective

The safety of the simultaneous resection of synchronous colorectal cancer liver metastases (SCRLM) is still being debated. However, this simultaneous operative approach is more commonly adopted at present than in the past. Therefore, we compared simultaneous hepatic resection with delayed hepatic resection in this study.

Methods

All patients with SCRLM diagnosed before initial treatment between January 2009 and September 2013 were retrospectively included in our study. Short-term and long-term outcomes were compared in patients who underwent simultaneous colorectal and hepatic resection and those treated by delayed hepatectomy.

Results

Among the 73 patients diagnosed with SCRLM, simultaneous colorectal and hepatic resection was performed in 60 patients (82.2%), while delayed hepatic resection was performed in 13 patients (17.8%). The mortality rate was zero. The postoperative complication rate after delayed resection was higher than, but not significantly different from, that after simultaneous resection (46% vs. 23%, P=0.166). The duration of operating time (240 vs. 420 min, P<0.05) and postoperative hospital stay time (11 vs. 18 days, P<0.05) were shorter in the simultaneous resection group. After the initial treatments were given, the 1-, 2-, and 3-year survival rates in the simultaneous resection group were 77%, 59%, and 53%, respectively, whereas those in the delayed resection group were 67%, 42%, and 10%, respectively. The 5-year survival rate in the simultaneous resection group was 23%; overall survival differed significantly between the two groups (P=0.037). Median disease-free survival (DFS) times were 19.1 months in the simultaneous resection group and 8.8 months in the delayed resection group. DFS differed significantly between the two groups.

Conclusions

Simultaneous colorectal and hepatic resection is safe and exhibits advantages in the long-time survival of patients.

Initial hepatic artery infusion and systemic chemotherapy for asymptomatic colorectal cancer with un-resectable liver metastasis

PURPOSE

Hepatic arterial infusion (HAI) has been proved to be an effective strategy to increase the chances of resection for colorectal cancer patients with liver metastasis (CRCLM). Herein, we aimed to evaluate the benefits and risks of initial treatment with HAI floxuridine (FUDR) and systemic XELOX in un-resectable synchronous CRCLM.

MATERIALS AND METHODS

HAI catheter systems were implanted radiologically in 54 patients with un-resectable synchronous CRCLM. Upfront HAI FUDR and systemic XELOX were delivered without primary cancer resection. Patients underwent deferred surgery when the metastatic diseases were converted to resectability, or any serious colorectal cancer-related complications occurred.

RESULTS

Thirty-eight patients (70.4%) were converted to resectability and underwent staged or synchronous resection of the primary tumor and metastatic disease, with an estimated 3-year survival rate of 76% compared with 15% in un-resected patients. Uni-variate analysis showed that hepatic involvement, number of lesion, and the location of primary cancer did not affect resectability rate. Only 3 patients (5.6%) required palliative surgery to treat complications related to primary cancer.

CONCLUSIONS

Initial HAI FUDR and systemic XELOX are effective to help patients with CRCLM to obtain a high resection rate for asymptomatic colorectal cancer and un-resectable liver metastases, and associated with a low rate of complications related to the intact primary cancer.

Neoadjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases

AIM

Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neoadjuvant chemotherapy with or without chemoradiotherapy followed by resection of the primary tumour and then liver metastases.

METHOD

Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with peri-operative systemic chemotherapy as the first line of treatment. Responders to chemotherapy underwent resection of the primary tumour with or without preoperative chemoradiotherapy followed by hepatic resection.

RESULTS

Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival was 59.0% at 3 years and 39.0% at 5 years.

CONCLUSION

Rectal resection before hepatic resection combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows downstaging of liver lesions and removal of the primary tumour before the progression of further micrometastases. Furthermore, patients who do not respond to chemotherapy can be identified and may avoid major surgical intervention.