Pulmonary Metastasectomy in Colorectal Cancer: A Population-Based Retrospective Cohort Study Using the Korean National Health Insurance Database

PURPOSE

The study aimed to investigate the current status and prognostic factors for overall survival in patients who had undergone pulmonary metastasectomy for colorectal cancer.

MATERIALS AND METHODS

The data of 2,573 patients who had undergone pulmonary metastasectomy after surgery for colorectal cancer between January 2009 and December 2014 were extracted from the Korean National Health Insurance Service claims database. Patient-, colorectal cancer-, pulmonary metastasis-, and hospital-related factors were analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis to identify prognostic factors for overall survival after pulmonary metastasectomy.

RESULTS

The mean age of the patients was 60.9±10.5 years; 66.2% and 79.1% of the participants were male and had distally located colorectal cancer, respectively. Wedge resection (71.7%) was the most frequent extent of pulmonary resection; 21.8% of the patients underwent repeated pulmonary metastasectomies; 73% of pulmonary metastasectomy cases were performed in tertiary hospitals; 53.9% of patients were treated in Seoul area; 82% of patients received chemotherapy in conjunction with pulmonary metastasectomy. The median survival duration was 51.8 months. The 3- and 5-year overall survival rates were 67.7% and 39.4%, respectively. In multivariate analysis, female sex, distally located colorectal cancer, pulmonary metastasectomy-only treatment, and high hospital volume (> 10 pulmonary metastasectomy cases/yr) were positive prognostic factors for survival.

CONCLUSION

Pulmonary metastasectomy seemed to provide long-term survival of patients with colorectal cancer. The female sex, presence of distally located colorectal cancer, and performance of pulmonary metastasectomy in high-volume centers were positive prognostic factors for survival.

The role of local therapy in the treatment of solitary melanoma progression on immune checkpoint inhibition: A multicentre retrospective analysis

INTRODUCTION

In patients with metastatic melanoma, progression of a single tumour lesion (solitary progression) after response to immune checkpoint inhibition (ICI) is increasingly treated with local therapy. We evaluated the role of local therapy for solitary progression in melanoma.

PATIENTS AND METHODS

Patients with metastatic melanoma treated with ICI between 2010 and 2019 with solitary progression as first progressive event were included from 17 centres in 9 countries. Follow-up and survival are reported from ICI initiation.

RESULTS

We identified 294 patients with solitary progression after stable disease in 15%, partial response in 55% and complete response in 30%. The median follow-up was 43 months; the median time to solitary progression was 13 months, and the median time to subsequent progression after treatment of solitary progression (TTSP) was 33 months. The estimated 3-year overall survival (OS) was 79%; median OS was not reached. Treatment consisted of systemic therapy (18%), local therapy (36%), both combined (42%) or active surveillance (4%). In 44% of patients treated for solitary progression, no subsequent progression occurred. For solitary progression during ICI (n = 143), the median TTSP was 29 months. Both TTSP and OS were similar for local therapy, ICI continuation and both combined. For solitary progression post ICI (n = 151), the median TTSP was 35 months. TTSP was higher for ICI recommencement plus local therapy than local therapy or ICI recommencement alone (p = 0.006), without OS differences.

CONCLUSION

Almost half of patients with melanoma treated for solitary progression after initial response to ICI had no subsequent progression. This study suggests that local therapy can benefit patients and is associated with favourable long-term outcomes.

Proposal of a Useful Surrogate Endpoint of the Overall Survival in Patients Undergoing Pulmonary Metastasectomy: The Time to Local Therapy Failure

BACKGROUND

A recent study demonstrated remarkable discrepancy between the relapse-free survival (RFS) and overall survival (OS) after pulmonary metastasectomy (PM) in the current era. As the RFS may not be a suitable parameter after PM, a more suitable parameter is needed for PM as a surrogate marker for OS.

METHODS

A total of 134 consecutive patients who underwent PM were retrospectively analyzed. In the present study, we introduced a new endpoint, time to local treatment failure (TLTF). This endpoint was defined as the time interval between the first PM and the first untreatable recurrence by local treatment with curative intent or death due to any cause. We analyzed the correlation between the RFS and OS and between the TLTF and OS to validate whether or not the TLTF is a better parameter than the RFS after PM.

RESULTS

Thus far, 78 patients have experienced relapse. Of these, 37 patients (47%) underwent local therapy with curative intent, 29 of whom are alive without local treatment failure. The 5-year OS, RFS and TLTF were 70.9%, 36.5%, and 57.6%, respectively. The concordance proportions for the RFS and OS and for the TLTF and OS were 0.634 and 0.851 for all patients, respectively. The Spearman's rank correlation coefficient for the RFS and OS was 0.639, while that for the TLTF and OS was 0.875.

CONCLUSIONS

The TLTF may be a good surrogate parameter for the OS after PM in the current era.

Factors affecting survival in patients with isolated liver-metastatic colorectal cancer treated with local ablative or surgical treatments for liver metastasis

PURPOSE

Local treatments for isolated synchronous or metachronous liver metastases in colorectal cancer (CRC) have been shown to improve overall survival (OS). The aim of this study was to investigate the factors affecting OS in CRC patients with isolated liver metastasis in whom the primary tumor and corresponding liver metastasis were treated with curative intent using local ablative or surgical methods.

METHODS

A total 47 surgical operated CRC patients presenting with an initial or subsequent isolated liver metastasis, who were treated with local surgical or ablative treatment for liver metastasis with curative intent, were enrolled in this study between 2007 and 2017. The possible factors affecting OS were analyzed.

RESULTS

Of the 47 patients, 35 (74.5%) were male. The median age was 61 (25 - 80) years. Thirty-four (72.3%) patients underwent liver metastasectomy, while 13 (27.7%) patients were treated with non-surgical local ablative therapies (NSLAT) for liver metastasis. Median OS (mOS) could not be reached in patients who underwent metastasectomy at the time of diagnosis compared to 55 months in those undergoing metastasectomy following a chemotherapy period (p = 0.03). Patients treated with NSLAT had a mOS of 60 months compared to ''not reached'' in those who underwent liver metastasectomy (p = 0.45). mOS was higher in patients with pT4 stage vs. with <pT4 stages (28 months vs. not reached, p = 0.02, respectively). Multivariate regression analysis revealed that undergoing liver metastasectomy at the time of diagnosis (HR 0.10; 95%Cl: 0.01 - 0.82) and pT4 stage (HR 4.365; 95%Cl: 1.27 - 14.98) were the most important independent factors affecting OS.

CONCLUSION

This study demonstrated that CRC patients with isolated liver metastasis, <pT4 stage and curative liver metastasectomy achieved the best survival outcomes.

Surgery for gastrointestinal metastases of malignant melanoma - a retrospective exploratory study

BACKGROUND

Cutaneous melanoma has a rapidly increasing incidence in Sweden, and it has more than doubled in the last two decades. In recent years, new systemic treatments for patients with metastatic disease have increased overall survival. The role of surgery in the metastatic setting has been unclear, and no randomized data exist. Many surgeons still perform metastasectomies; however, the exact role probably has to be redefined. The aim of this single-institution study was to retrospectively examine the safety and efficacy of surgery in abdominal melanoma metastases and to identify prognostic and predictive factors.

METHODS

Retrospective analysis of a consecutive series of all patients with stage IV melanoma with gastrointestinal metastases that underwent abdominal surgery at a single center between January 2010 and December 2018. Fifteen patients who underwent in total 18 abdominal procedures, both acute and elective, were identified and included in the study.

RESULTS

Out of 18 laparotomies, six (33%) were emergency procedures due to ileus (n = 4), small bowel perforation (n = 1), and abdominal abscess (n = 1). Twelve procedures (66%) were elective with the most common indication being persistent anemia (58%, n = 7), abdominal pain and anemia (33%, n = 4), and abdominal pain (8%, n = 1). All procedures were performed by laparotomy. There were 19 small bowel resections, 3 partial colon resections, and 2 omental resections. Radical resection was possible in 56% (n = 10) of cases and 67% (n = 8) when only considering elective procedures. In 17 of 18 procedures (94%), there were mild or no surgical complications (Clavien-Dindo grades 0-I). The median overall survival was 14 months with a 5-year survival of 23%.

CONCLUSIONS

Patients with abdominal melanoma metastases can safely undergo resection with a high grade of radical procedures when performed in the elective setting.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03879395 . Registered 15 March 2019.

Metastasectomy of pancreatic and periampullary adenocarcinoma to solid organ: The current evidence

PURPOSE

Pancreatic and periampullary adenocarcinoma have not generally been included in the tumour types considered for metastasectomy. However, there is an increasing interest that metastasectomy in well-selected patients can prolong survival. This review aims to establish the recent evidence on the surgical management of oligometastatic disease and survival outcome in patients who underwent metastasectomy focusing on isolated hepatic and pulmonary metastases.

METHODS

A systematic search was performed in the PubMed database to identify all original articles on the role of metastasectomy for oligometastasis of pancreatic and periampullary adenocarcinoma. Data on methodologies used, 1,3,5 - year survival and median overall survival were summarized, and used to address relevant clinical questions related to the survival outcome in patients who underwent metastasectomy.

RESULTS

Sixteen studies were included in this review. All the studies included were retrospective and heterogenous in nature and did not have a uniform reporting on survival outcomes.

CONCLUSION

There is insufficient evidence to support a change of current practice in managing metastatic pancreatic and periampullary cancer. However, patients with ampullary cancer as the primary and any patients with first recurrence as isolated pulmonary metastases had better prognosis than patients with synchronous metastasis or metastases to the liver. This need to be explored in future studies.

Survival Outcome of Pulmonary Metastasectomy Among Patients with Sarcoma and Colorectal Primary Cancers: A Single Institute Experience

BACKGROUND

One of the most common organs targeted by metastatic malignancies are the lungs. In the field of surgical oncology, pulmonary metastasectomy (PM) is frequently performed for patients with pulmonary metastatic nodules secondary to specific primary tumors. This study aimed to evaluate survival and its predictors among patients with primary sarcoma or colorectal cancer who underwent PM at the Princess Norah Oncology Center, Jeddah, between 2007 and 2016.

PATIENTS AND METHODS

Sarcoma and colorectal cancer patients with isolated lung metastasis and who underwent PM in our institution between 2007 and 2016 were identified. Overall survival and possible survival predictors were assessed using log-rank test and multivariate analysis was implemented using Cox regression.

RESULTS

Thirty-eight patients (16 with colorectal cancer and 22 with sarcoma) were identified. The median follow-up duration was 26 months (range 0-88). A total of 11 patients (28.9%) died during the follow-up period. The 5-year survival rates for patients who underwent PM with primary colorectal and sarcoma were 89% and 41%, respectively. Univariate analysis indicated that PM in patients with primary colorectal cancer was associated with longer overall survival (p value = 0.023) compared with PM with sarcoma. In the multivariate analysis, a metastatic lesion with size = 15 mm and having primary colorectal cancer were the factors significantly associated with prolonged survival.

CONCLUSION

Our experience has shown a substantial 5-year survival benefit for patients with primary tumors of sarcomas and colorectal cancer who underwent a PM. A primary tumor of the colorectum and larger pulmonary metastases were associated with a better outcome. We recommend PM, following careful selection, for patients with pulmonary deposits secondary to a primary tumor of Colorectum or sarcoma.

Prognostic value of distant metastasis sites and surgery in stage IV colorectal cancer: a population-based study

PURPOSE

We investigated the prognostic value of distant metastasis sites among patients with metastatic colorectal cancer (CRC) and the significance of metastasectomy and resection of the primary CRC.

METHODS

Between 2010 and 2014, patients diagnosed with metastatic colorectal adenocarcinoma were selected using the surveillance, epidemiology, and end results (SEER) database. The prognosis of these patients was compared according to the site of metastasis (liver, lung, bone, and brain). A total of 15,133 patients suffered from isolated organ involvement, while 5135 patients experienced multiple organ metastases.

RESULTS

In the isolated organ metastasis cohort, median overall survival (OS) for patients with liver, lung, bone, and brain metastases was 16, 20, 7, and 5 months, respectively. Patients with isolated lung metastases had better cancer-specific survival (CSS) and OS as compared to patients with metastases at any other sites (p < 0.0001 for both CSS and OS). Patients with isolated liver metastases had better prognosis as compared to patients with isolated bone or brain metastases (p < 0.0001 for both CSS and OS). Moreover, patients with a single metastatic site had better prognosis than patients with multiple organs involved (p < 0.0001 for both CSS and OS). Multivariate analysis in patients with isolated organ metastases demonstrated that age ≤ 60 years, rectal cancer, being married, non-black race, N0 stage, and surgery of the primary and distant lesions showed more favorable prognosis.

CONCLUSIONS

The metastatic site was an independent prognostic factor in stage IV colorectal cancer. Also, carefully chosen patients may benefit from surgery.

Impact of Metastasectomy in the Multimodality Approach for BRAF V600E Metastatic Colorectal Cancer: The Mayo Clinic Experience

BACKGROUND

BRAF V600E mutations are present in 8%-10% of patients with metastatic colorectal cancer (mCRC) and portend poor prognosis. This study investigated the impact of metastasectomy for patients with BRAF V600E mCRC.

SUBJECTS, MATERIALS, AND METHODS

Using prospective clinical and molecular data, patients with BRAF V600E mCRC were analyzed for clinical characteristics and survival. Statistical analyses utilized the Kaplan-Meier method, log-rank test, and Cox proportional hazard models.

RESULTS

Fifty-two patients were identified between July 1, 2008, and January 4, 2016. Patient characteristics included median age 65 years, 61% female, Eastern Cooperative Oncology Group performance status ≤1, 71% with right-sided tumors, and 28% with liver-limited metastasis. In the first-line setting, 7% (4/52) received fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI)/bevacizumab (BEV) and 81% were treated with doublet chemotherapy consisting of fluoropyrimidine, oxaliplatin, and BEV. Median overall survival (OS) for all 52 patients was 25 months with median progression-free survival (PFS) of 9.3 months. With median follow-up of 18.3 months, 21 patients underwent metastasectomy with longer OS (29.1 months vs. 22.7 months, hazard ratio [HR] = 0.33; confidence interval [CI], 0.12-0.78; p = .01) and PFS (13.6 months vs. 6.2 months, HR = 0.53, CI, 0.28-0.97; p = .03) compared with the non-metastasectomy cohort. In multivariate analysis, metastasectomy remained significant for improved survival outcomes (HR = 0.52; 95% CI, 0.07-1.02; p = .02). Median disease-free survival after metastasectomy was 9.7 months (95% CI, 5.5-19.5). Two patients remain disease-free at the time of last follow-up, with one patient without relapse for greater than 2 years (28.9 months).

CONCLUSION

Multimodality therapy incorporating metastasectomy for BRAF V600E mCRC should be considered and might be associated with improved overall survival in select patients.

IMPLICATIONS FOR PRACTICE

BRAF V600E metastatic colorectal cancer (mCRC) represents an extremely difficult molecular subset of colorectal cancer to treat. To date, this subset remains refractory to standard chemotherapies, prompting extensive clinical investigation regarding novel treatment approaches and targeted modalities. While the use of metastasectomy for expanded RAS wild-type and RAS mutated mCRC has resulted in improved overall survival for select patients, utilization of metastasectomy in patients with BRAF V600E mCRC remains controversial. This article explores the authors' experience with BRAF V600E mCRC to ascertain whether a multidisciplinary approach incorporating metastasectomy for well-selected patients improves overall survival.

Bladder Metastases from Breast Cancer: Managing the Unexpected. A Systematic Review

Breast cancer (BrC) has the highest incidence among females world over and it is one of the most common causes of death from cancer overall. Its high mortality is mostly due to its propensity to rapidly spread to other organs through lymphatic and blood vessels in spite of proper treatment. Bladder metastases from BrC are rare, with 50 cases having been reported in the last 60 years. This review aims to discuss some critical points regarding this uncommon condition. First, we performed a systematic review of the literature in order to draw a clinical and pathological profile of this entity. On this basis, its features in terms of diagnostic issues, imaging techniques, and survival are critically examined. Most bladder metastases from BrC are secondary lobular carcinoma, which mimic very closely the rare variant of urothelial cancer with lobular carcinoma-like features (uniform cells with an uncohesive single-cell, diffusely invasive growth pattern); thus, immunohistochemistry is mandatory to arrive at a correct diagnosis. This article summarizes the current knowledge regarding the incidence, clinical presentation, diagnosis, prognosis, and treatment of bladder metastases in patients with BrC.

Validation of clinical risk score for colorectal liver metastases resected in a contemporary multicenter cohort

BACKGROUND

Recent advances in care for colorectal liver metastases (CRLM) have lengthened 5-year survival. In this new era, prognostic tools such as the clinical risk score (CRS) for colorectal liver metastases require reevaluation.

METHODS

Patients undergoing resection for CRLM between 2008 and 2012 at 4 specialty hepatobiliary centers in Canada (N = 740) were stratified by CRS and analyzed in Kaplan-Meier survival curves. Primary outcome of overall survival (OS) and secondary outcome of recurrence-free survival (RFS). Multivariate Cox regression compared CRS to patient factors.

RESULTS

Median OS not reached (>60 months), median RFS 16 months. Original CRS strata was a significant (p < 0.001) predictor of both OS (5-year OS: 0; 75%, 1; 71%, 2; 57%, 3; 57%, 4; 46%) and RFS (5-year RFS: 0; 39%, 1; 33%, 2; 21%, 3; 21%, 4; 8%). The presence of extrahepatic colorectal metastatic disease increased recurrence risk (RFS hazard ratio of 1.32 (1.06-1.65)), and the use of intraoperative portal pedicle clamping reduced recurrence risk (RFS hazard ratio of 0.78 (0.61-0.99)).

CONCLUSIONS

The CRS remains a relevant tool for predicting long-term outcomes for patients undergoing resection of CRLM. Additional factors such as the presence of extrahepatic colorectal metastatic disease and the use of intraoperative portal pedicle clamping may improve the prognostic power of the CRS.

Combined hepatectomy and hepatic pedicle lymphadenectomy in colorectal liver metastases is justified

BACKGROUND

The aim of this study was to describe the outcome of patients with colorectal liver metastases (CRLM) and radiological or clinical evidence of metastatic hepatic lymph node involvement who underwent combined hepatectomy and hepatic pedicle lymphadenectomy.

METHODS

Retrospective analysis of a prospectively maintained audit of 2082 patients undergoing liver resection for CRLM between 1994 and 2014. Age, type of resection, CT/MRI/PET detection, location, disease recurrence and survival were analysed.

RESULTS

Combined hepatectomy and hepatic pedicle lymphadenopathy was performed on 76 patients who met the inclusion criteria. 46% of enlarged lymph nodes were located in the hepatic ligament, with 38% retroportal, 38% common hepatic and 33% coeliac nodes. 50% of lymph node resections were positive for metastatic tumour. Pre-operative CT, MRI and CT/PET failed to detect histologically proven lymph node disease in 25/38 patients. Patients with negative nodal histology had a significant overall (44 vs 20 months, p = 0.008) and disease free (20 vs 11 months, p < 0.001) survival advantage.

CONCLUSION

Combined hepatectomy and lymph node resection for CRLM in the setting of enlarged or suspicious lymphadenopathy is justified as imaging and operative findings are poor guides in determining positive lymph node disease.

A systematic review and meta-analysis of the utility of repeated versus single hepatic resection for colorectal cancer liver metastases

BACKGROUND

Recurrence of colorectal liver metastases after a first hepatectomy is common (4-48% of patients). This review investigates the utility of repeated hepatic resection of colorectal liver metastases.

METHODS

A systematic search of the literature was performed in the Cochrane Library, MEDLINE, EMBASE, and trial registers. All studies comparing repeated hepatic resection for colorectal liver metastases with patients who underwent only one hepatectomy were eligible. Outcome criteria were safety parameters and survival rates. Data were analyzed using the random-effects model.

RESULTS

In eight observational clinical studies, 450 patients with repeated hepatic resection were compared with 2669 single hepatic resections. Morbidity such as hepatic insufficiency (OR [95% CI] 1.46 [0.69; 3.08], p = 0.32) and biliary leakage and fistula (OR [95% CI] 1.22 [0.80; 1.85], p = 0.35) was comparable between the two groups. Mortality (OR [95% CI] 1.13 [0.46; 2.74], p = 0.79) and overall survival (HR [95% CI] 1.00 [0.63; 1.60], p = 0.99) were not significantly different between the two groups.

DISCUSSION

Repeated hepatic resection for colorectal liver metastases is safe in selected patients. A prospective, multicenter high-quality trial or register study of repeated hepatic resection will be required to clarify patient-oriented outcomes such as overall survival and quality of life.

Thermal ablation in colorectal liver metastases: Lack of evidence or lack of capability to prove the evidence?

Many studies suggest that combined multimodality treatments including ablative therapies may achieve better outcomes than systemic chemotherapy alone in patients with colorectal liver metastases. Nevertheless, ablative therapies are not yet considered as effective options because their efficacy has never been proved by randomized controlled trials (RCT). However, there are in literature no trials that failed in demonstrating the effectiveness of ablative treatments: what are lacking, are the trials. All the attempts to organize phase III studies on this topic failed as a result of non accrual. Just one prospective RCT comparing radiofrequency ablation combined with systemic chemotherapy vs chemotherapy alone has been published. It was designed as a phase III study, but it was closed early because of slow accrual, and was downscaled to phase II study, with the consequent limits in drawing definite conclusions on the benefit of combined treatment. However, the combination treatment met the primary end point of the study and obtained a significantly higher 3-year progression-free survival than systemic chemotherapy alone. It is very unlikely that ultimate efficacy of ablation treatments will ever be tested again, and the best available evidence points toward a benefit for the combination strategy using ablative treatments and chemotherapy.

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

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

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

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

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

Adjuvant chemotherapy for resected colorectal cancer metastases: Literature review and meta-analysis

Surgical resection is the only option of cure for patients with metastatic colorectal cancer (CRC). However, the risk of recurrence within 18 mo after metastasectomy is around 75% and the liver is the most frequent site of relapse. The current international guidelines recommend an adjuvant therapy after surgical resection of CRC metastases despite the lower level of evidence (based on the quality of studies in this setting). However, there is still no standard treatment and the effective role of an adjuvant therapy remains controversial. The aim of this review is to report the state-of-art of systemic chemotherapy and regional chemotherapy with hepatic arterial infusion in the management of patients after resection of metastases from CRC, with a literature review and meta-analysis of the relevant randomized controlled trials.

Factors Affecting Survival in Patients with Lung Metastases from Colorectal Cancer. A Short Meta-analysis

Liver and pulmonary metastases (PMs) are relatively common in patients with colorectal cancer. The majority of metastases are suitable for surgical resection, and the effectiveness of metastasectomy is usually assessed based on overall survival (OS). Metastasectomy provides a mean 5-year OS rate of approximately 50%, but the results are better in patients with liver metastases compared to those with PMs. Unfortunately, the presence of bilateral or multiple PMs represents a relative contraindication to surgical metastasectomy. Unresectable PMs can be safely treated with percutaneous radiofrequency ablation or radiotherapy, but the reported results vary widely. Several clinical prognostic factors affecting OS after metastasectomy have been reported, such as number of PMs, hilar or mediastinal lymph node involvement, disease-free interval, age and gender, resection margins, size of the metastases, neoadjuvant chemotherapy administration, and histological type of the primary cancer. The accurate evaluation of all clinical prognostic factors, circulating and immunohistochemical markers, and the study of gene mutational status will lead to a more accurate selection of patients scheduled to metastasectomy, with the aim of improving outcome.

Long-Term Outcomes Of Surgical Resection for Liver Metastasis from Breast Cancer

BACKGROUND/AIMS

The aim of the present study was to define the prognostic factors for survival after hepatic metastasectomy from breast cancer.

METHODOLOGY

Between October 2003 and December 2013, 28 patients with hepatic metastases from breast cancer underwent liver resection with curative intent. All patients had obtained locoregional control of their primary breast tumors. Various perioperative variables were investigated retrospectively to confirm the role of pulmonary metastasectomy and to identify possible prognostic factors for survival after hepatic metastasectomy.

RESULTS

Overall survival after liver resection was 53% and 23% at 5 and 10 years, respectively. Disease-free survival after hepatic metastasectomy was 20% and 0% at 5 and 10 years. On multivariate analysis, disease-free interval longer than 36 months (P = 0.003), no tumor recurrence before hepatic metastasectomy (P = 0.020) and complete resection (P = 0.008) provided a significantly favorable overall survival.

CONCLUSION

Hepatic metastasectomy for breast cancer can be associated with prolonged survival. Complete resection, longer disease-free interval and no tumor recurrence before liver resection are the most predictive factors for prolonged survival. However, the accumulation of more cases is necessary to evaluate the prognostic factors properly and to determine the selection criteria for liver resection.

Clinical Features of Surgical Resection for Liver Metastasis from Extremity Soft Tissue Sarcoma

BACKGROUND/AIMS

The aim of the present study was to define the prognostic factors for survival after hepatic metastasectomy from extremity soft tissue sarcoma.

METHODOLOGY

Between January 2000 and January 2009, 27 patients with hepatic metastases from extremity soft tissue sarcomas underwent liver resection with radical intent. Various clinicopathologic variables were investigated retrospectively to identify possible prognostic factors for survival after hepatic metastasectomy.

RESULTS

Overall survival was 46% and 24% at 5 and 10 years after liver resection, respectively. Disease-free survival was 13% at 1 year after hepatic metastasectomy. On multivariate analysis, disease-free interval longer than 24 months (P = 0.010), no tumor recurrence before hepatic metastasectomy (P = 0.040) and negative margin resection (P = 0.002) provided a significantly favorable overall survival. Repeated hepatic metastasectomy for recurrent hepatic metastases (P = 0.007) also provided a favorable overall survival.

CONCLUSION

Hepatic metastasectomy for extremity soft tissue sarcoma can be associated with prolonged survival. Complete resection, longer disease-free interval, no tumor recurrence before liver resection and repeated resection for recurrent liver metastases are the most predictive factors for prolonged survival.

Hepatectomy vs radiofrequency ablation for colorectal liver metastasis: A propensity score analysis

AIM: To compare outcomes from radiofrequency ablation (RFA) and hepatectomy for treatment of colorectal liver metastasis (CRLM).

METHODS: From January 2000 to December 2009, 408 patients underwent curative intent treatment for CRLM. We excluded patients using the criteria: size of CRLM > 3 cm, number of CRLM ≥ 5, percutaneous RFA, follow-up period < 12 mo, double primary cancer, or treatment with both RFA and hepatectomy. We matched 51 patients who underwent RFA with 102 patients who underwent hepatectomy by propensity scores.

RESULTS: The median follow-up period was 45 mo (range, 12 mo to 158 mo). Hepatic recurrence was more frequent in the RFA than the hepatectomy group (P = 0.021) although extrahepatic recurrence curves were similar (P = 0.716). Survival curves of hepatectomy group were better than that of RFA for multiple, large (> 2 cm) CRLM (P = 0.034). However, survival curves were similar for single or small (≤ 2 cm) CRLM (P = 0.714, P = 0.740).

CONCLUSION: Hepatectomy is better than RFA for the treatment of CRLM. However, RFA might be suitable for selected patients with single, small (≤ 2 cm) CRLM.

Stereotactic body radiotherapy for colorectal lung oligometastases: preliminary single-institution results

PURPOSE

To present the preliminary results of stereotactic body radiotherapy (SBRT) for lung oligometastases originated from colorectal cancer (CRC).

METHODS

Thirteen patients (9 male, 4 female) with lung oligometastases from CRC were prospectively selected for SBRT between July 2009 and July 2013. We used a dose risk-adapted schedule of radiation.

RESULTS

The median follow-up was 9.16 months (range 2-45.6). The median age was 69 years (range 40-84). Three cases (23.1%) were treated with 12.5 Gy in 4 fractions (112.5 biological effective dose/BED). Four cases (30.8%) received 18Gy (151.2 BED), 2 (15.4%) 7.5 Gy in 8 fractions (BED 105) and 4 (30.8%) a monofraction of 34 Gy (149.6 BED). There were 5 (38.5%) complete responses, 5 (38.5%) partial responses and 3 (23%) patients remained with stable disease. During follow-up 6 patients (46.2%) showed distant metastases: liver (N=3, 50%), bone (N=1, 16.6%) and contralateral lung (N=2, 33.3%). Median time to systemic progression was 9 months. One- and two-year distant progression-free survival (DPFS) was 45.8% and 22.9%, respectively. Local control (LC), overall survival (OS), and cause-specific survival (CSS) at one- and two-years were all 92.3%. A tendency for a better local response and DFPS in patients aged ≤70 years and BED > 120 Gy was observed. No grade 3-4 toxicity was noticed.

CONCLUSIONS

Excellent LC and longer DFS could be achieved with SBRT in oligometastatic lung disease from CRC, delaying thus disease progression and the need for further treatment.

Outcome after liver resection in patients presenting with simultaneous hepatopulmonary colorectal metastases

BACKGROUND

The most common sites of metastasis from colorectal cancer (CRC) are hepatic and pulmonary; they can present simultaneously (hepatic and pulmonary metastases) or sequentially (hepatic then pulmonary metastases, or vice versa). Simultaneous disease may be aggressive, and thus may be approached with caution by the clinician. The aim of this study was to determine the outcomes following hepatic and pulmonary resection for simultaneously presenting metastatic CRC.

METHODS

A retrospective review was undertaken of a prospectively maintained database to identify patients presenting with simultaneous hepatopulmonary disease who underwent hepatic resection. Patients' electronic records were used to identify clinicopathological variables. The log rank test was used to determine survival, and χ(2) analysis to determine predictors of failure of intended treatment.

RESULTS

Fifty-nine patients were identified and underwent hepatic resection; median survival was 45·4 months and the 5-year survival rate 38 per cent. Twenty-two patients (37 per cent) did not have the intended pulmonary intervention owing to progression or recurrence of disease. Thirty-seven patients who progressed to hepatopulmonary resection had a median survival of 54·2 months (5-year survival rate 43 per cent). Those who had hepatic resection alone had a median survival of 24·0 months (5-year survival rate 30 per cent). Failure to progress to pulmonary resection was predicted by heavy nodal burden of primary colorectal disease and bilobar hepatic metastases. Redo pulmonary surgery following pulmonary recurrence did not confer a survival benefit.

CONCLUSION

Selected patients with simultaneous hepatopulmonary CRC metastases should be considered for attempted curative resection, but some patients may not receive the intended treatment owing to progression of pulmonary disease after hepatic resection.

History and present status of pulmonary metastasectomy in colorectal cancer

Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers, breast and lung, in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal. We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day. Our sources included published citation network analyses, the documented proposal for randomised trials, large systematic reviews, and meta-analysis of observational studies. The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done, or having been done, were not reported. Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias. Randomised controlled trials (RCTs) are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice. One such trial is recruiting and shows that controlled trial are possible.

The prognosis of pulmonary metastasectomy depends on the location of the primary colorectal cancer

BACKGROUND

Rectal cancer has a higher risk of developing lung metastasis compared with colon cancer. It is unclear whether the prognosis after pulmonary metastasectomy for these distinct tumors is different.

METHODS

Patients who underwent pulmonary metastasectomy for colorectal carcinoma were analyzed for survival and patterns of recurrence depending on the location of the primary colorectal cancer. Multivariate regression analysis was performed to identify clinical variables predictive of survival after pulmonary metastasectomy.

RESULTS

Between 1985 and 2012, 698 patients underwent pulmonary metastasectomy for metastatic colorectal cancer. Complete information was available in 626 patients. These patients were divided into groups based on whether the primary tumor was colon or rectal in origin. Median follow-up was 45.5 months (range, 23 to 287 months). There were no statistical differences between the two groups in terms of number of lung metastases, tumor size, or lymph node involvement. There was no difference in overall survival (p = 0.545). Five-year disease-free survival for colon cancer patients was 67.2% compared with 60.1% for rectal cancer (p = 0.004). The most common sites of recurrence after pulmonary metastasectomy were liver in colon cancer and lung in rectal cancer. Multivariate Cox proportional hazards analysis indicated that rectal cancer (hazard ratio, 1.39; 95% confidence interval, 1.07 to 1.83; p = 0.015) and multiple metastases (>3; hazard ratio, 1.41; 95% confidence interval, 1.04 to 1.89; p = 0.027) were independent adverse risk factors affecting disease-free survival after pulmonary metastasectomy.

CONCLUSIONS

Disease-free survival and site of recurrence after pulmonary metastasectomy for colorectal carcinoma are dependent on the site of the primary tumor. Lung metastases from rectal cancer have a worse disease-free survival compared with colon cancer. This may influence treatment and follow-up strategies.

Clinical benefit of surgical management for gastric cancer with synchronous liver metastasis

BACKGROUND/AIMS

The aim of this study was to evaluate the benefit of resection for liver metastasis from gastric cancer.

METHODOLOGY

Consecutive 74 patients of gastric cancer who undergone the gastrectomy for primary gastric cancer and simultaneous hepatic resection for synchronous liver metastasis were enrolled. The clinicopathological factors were retrospectively compared to the prognosis.

RESULTS

The median survival time and 5-year overall survival rate in 53 patients who accomplished microscopically negative margin resection was 27.4 months and 18.6%, respectively. In the multivariate survival analysis, the number of liver metastasis was identified as an independent prognostic factor (HR;2.232, 95%CI;1.036-4.808, p=0.04). When the patients undergone curative resection were subdivided into solitary and multiple liver metastasis, the median survival time and 5-year overall survival rate in a subgroup with solitary liver metastasis was 24.2 months and 27.2%, which was superior to the corresponding values of 12.6 months and 5.5% in another group with multiple liver metastasis (p=0.02).

CONCLUSIONS

The resection for liver metastasis might offer a chance for long-term survival in a carefully selected group of patients. The number of liver metastasis was a reliable criterion to discriminate the subgroup of patients who are most likely to benefit from hepatic resection.

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

OBJECTIVE

A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).

METHODS

A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.

RESULTS

Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.

CONCLUSION

A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.

Radiofrequency ablation as treatment for pulmonary metastasis of colorectal cancer

Radiofrequency ablation (RFA) causes focal coagulation necrosis in tissue. Its first clinical application was reported in 2000, and RFA has since been commonly used in both primary and metastatic lung cancer. The procedure is typically performed using computed tomography guidance, and the techniques for introducing the electrode to the tumor are simple and resemble those used in percutaneous lung biopsy. The most common complication is pneumothorax, which occurs in up to 50% of procedures; chest tube placement for pneumothorax is required in up to 25% of procedures. Other severe complications, such as pleural effusion requiring chest tube placement, infection, and nerve injury, are rare. The local efficacy depends on tumor size, and local progression after RFA is not rare, occurring in 10% or more of patients. The local progression rate is particularly high for tumors > 3 cm. Repeat RFA may be used to treat local progression. Short- to mid-term survival after RFA appears promising and is approximately 85%-95% at 1 year and 45%-55% at 3 years. Long-term survival data are sparse. Better survival may be expected for patients with small metastasis, low carcinoembryonic antigen levels, and/or no extrapulmonary metastasis. The notable advantages of RFA are that it is simple and minimally invasive; preserves pulmonary function; can be repeated; and is applicable regardless of previous treatments. Its most substantial limitation is limited local efficacy. Although surgery is still the method of choice for treatment with curative intent, the ultimate application of RFA may be to replace metastasectomy for small metastases. Randomized trials comparing RFA with surgery are needed.

Size of metastatic deposits affects prognosis in patients undergoing pulmonary metastectomy for colorectal cancer

INTRODUCTION

Pulmonary metastectomy for colorectal cancer (CRC) is a well accepted procedure although data regarding indications and prognostic outcomes are inconsistent. This study aimed to analyse our experience with resection of pulmonary CRC metastases to evaluate clinically relevant prognostic factors affecting survival.

METHODS

A retrospective analysis was undertaken of the records of all patients with pulmonary metastases from CRC who underwent a thoracotomy between 2004 and 2010 at a single surgical centre.

RESULTS

Sixty-six patients with pulmonary metastases from the colon (n=34) and the rectum (n=32) were identified. The 30-day hospital mortality rate was 0%, with 63 patients undergoing a R0 resection and 3 having a R1 resection. The median survival was 45 months and the cumulative 3-year survival rate was 61%. Size of pulmonary metastasis and ASA (American Society of Anesthesiologists) grade were statistically significant prognostic factors (p=0.047 and p=0.009 respectively) with lesions over 20mm associated with a worse prognosis. Sex, age, site, disease free interval (cut-off 36 months), primary tumour stage, hepatic metastases, number of metastases (solitary vs multiple), type of operation (wedge vs lobe resection), hilar lymph node involvement and administration of adjuvant chemotherapy were not found to be statistically significant prognostic factors.

CONCLUSIONS

Pulmonary metastectomy has a potential survival benefit for patients with metastatic CRC. Improved survival even in the presence of hepatic metastases or multiple pulmonary lesions justifies aggressive surgical management in carefully selected patients. In our cohort, size of metastatic deposit was a statistically significant poor prognostic factor.

Carcinoembryonic antigen elevation in post-hepatectomy patients with colorectal cancer liver metastasis indicates recurrence with high accuracy

BACKGROUND/AIMS

We aimed to retrospectively determine the accuracy of postoperative serum carcinoembryonic antigen (CEA) monitoring to detect or rule out recurrence in post-hepatectomy colorectal cancer patients by using a new statistical technique, likelihood ratio and post-test probability.

METHODS

A total of 110 colorectal cancer patients who underwent curative hepatectomy were enrolled. A serum CEA assay and radiological examination were performed routinely for 5 years after surgery or until recurrence was detected. Yearly recurrence rates, sensitivities, specificities, and likelihood ratios were calculated. Post-test probabilities were calculated using these values.

RESULTS

All episodes of recurrence occurred within 3 years after hepatectomy. The most frequent recurrence site was the liver, with a recurrence rate of 61.4% of all recurrence. The post-test probabilities of recurrence in post-hepatectomy colorectal cancer patients with positive and negative serum CEA were approximately 70-90% and 10%, respectively.

CONCLUSIONS

CEA elevation in colorectal cancer patients who underwent curative resection indicated recurrence with high accuracy because of the high recurrence rate in the liver, in which CEA elevation is more frequent than in other recurrent sites. The elevation of CEA in post-hepatectomy patients necessitates frequent examination using imaging techniques to reveal undetected metastasis as soon as possible.

Importance of liver resection in case of hepatic breast cancer metastases

BACKGROUND/AIMS

Primary focus of the therapy of metastatic breast cancer is currently a systemic therapy. Surgical therapies are of minor importance. Aim of this study was to investigate the relevance of hepatectomy in case of hepatic breast cancer metastases (HBCM) as an important part of multimodal therapy.

METHODOLOGY

From January 2002 to December 2011, 30 patients with HBCM underwent hepatectomy. Criteria for hepatectomy were good condition, technical feasibility and control of extrahepatic metastases. For a heterogeneous group of women with HBCM the 3- and 5-year survival rate was determined by Kalpan-Meier survival estimate.

RESULTS

The postoperative morbidity was 13.3%, the mortality rate was 3.3%. Minor hepatectomy has been performed in 62.1% and major hepatectomy in 37.9% of the cases. In all patients a R0 resection margin was performed. At a median follow-up interval of 34.1 months, 16 patients were still alive. The 3- and 5-year survival rates after surgically resection of HBCM in our collective were 31.0% and 20.7%.

CONCLUSIONS

Hepatectomy is a safe therapy with low morbidity, mortality and improves long-term survival in most patients with limited, resectable HBCM. In our opinion patient selection should not be that strict. The combination of systemic and surgical therapies can improve prognosis and long-term survival of these patients.

Prognostic factors for longer disease free survival and overall survival after surgical resection of isolated liver metastasis from breast cancer

PURPOSE

Isolated liver metastases (LMs) from breast cancer (BC) occur in only 1-3% of the cases. Resection of isolated LMs improves survival. We examined the prognostic factors for time to LM development, disease free survival (DFS) and overall survival (OS) after BCLM resection.

METHODS

From 2006 to 2009, 32 patients underwent LM resection. All of them had breast cancer surgery for their primary tumor and developed resectable LMs as the first and only site of disease progression.

RESULTS

LMs developed after a median of 25 months. With a median follow up of 37 months (range 7-66) after metastases resection, median DFS and OS (with 95% CI) were 22.5 (12-40) and 37 (≥23) months, respectively. Tumor size ≥3 vs <3 cm and adjuvant chemotherapy vs no adjuvant chemotherapy correlated with shorter time to LM development (p<0.01 for both parameters). These parameters and BC negative estrogen (ER)/ progesterone receptors (PR) (ER?/PR? vs other) were related with shorter DFS. Positive (vs negative) axillary lymph nodes and BC negative ER/ PR (ER?/PR? vs other) status correlated with shorter OS (p<0.01 for both parameters). A period to metastases development ≥ 24 months (vs ≤24) and single (vs multiple) metastases were related with longer DFS and OS (p<0.01 for both conditions).

CONCLUSION

Despite the relatively small number of patients in this study, we believe that positive ER/PR status for both BC and LMs, negative axillary lymph nodes, time to liver metastases development >24 months and single liver metastases predict longer DFS and OS after LM resection.