Rates and patterns of recurrence following curative intent surgery for colorectal liver metastasis: an international multi-institutional analysis of 1669 patients. Ann Surg. 2009;250:440-448. [PMID: 19730175 DOI: 10.1097/sla.0b013e3181b4539b]

Surgery Combined with Oncological Treatments in Liver Metastases from Colorectal Cancer

The patients with colorectal liver metastases used to have a rather disappointing prognosis in the past. At present there is moderate possibility for cure with liver resection. In addition more patients are accessible for liver resection and potential cure when modern chemotherapy combined with biological agents is used. At the time of diagnosis liver metastases of 10–20% of patients are resectable. Potentially unresectable metastases can be converted to resectable in 10–15% of patients with advances in surgery together with improved oncological therapy. Resection rate increases linearly with the response rate to chemotherapy. In this century the 5-year survival rates after resection have improved remarkably being around 50% in many reports. Multidisciplinary management of metastatic colorectal cancer has increased the number of patients with potentially curative treatment and has improved patient survival.

Inhibition of angiogenesis and suppression of colorectal cancer metastatic to the liver using the Sleeping Beauty Transposon System

Background

Metastatic colon cancer is one of the leading causes of cancer-related death worldwide, with disease progression and metastatic spread being closely associated with angiogenesis. We investigated whether an antiangiogenic gene transfer approach using the Sleeping Beauty (SB) transposon system could be used to inhibit growth of colorectal tumors metastatic to the liver.

Results

Liver CT26 tumor-bearing mice were hydrodynamically injected with different doses of a plasmid containing a transposon encoding an angiostatin-endostatin fusion gene (Statin AE) along with varying amounts of SB transposase-encoding plasmid. Animals that were injected with a low dose (10 μg) of Statin AE transposon plasmid showed a significant decrease in tumor formation only when co-injected with SB transposase-encoding plasmid, while for animals injected with a higher dose (25 μg) of Statin AE transposon, co-injection of SB transposase-encoding plasmid did not significantly affect tumor load. For animals injected with 10 μg Statin AE transposon plasmid, the number of tumor nodules was inversely proportional to the amount of co-injected SB plasmid. Suppression of metastases was further evident in histological analyses, in which untreated animals showed higher levels of tumor cell proliferation and tumor vascularization than animals treated with low dose transposon plasmid.

Conclusion

These results demonstrate that hepatic colorectal metastases can be reduced using antiangiogenic transposons, and provide evidence for the importance of the transposition process in mediating suppression of these tumors.

[Hepatectomy for colorectal liver metastases after neoadjuvant chemotherapy]

The majority of patients with colorectal liver metastases receive systemic chemotherapy. In the context of unresectable liver metastases, the objective of chemotherapy based on new and more effective regimens is not only to prolong survival, but also to induce enough response and shrinkage of the tumor to render resectable patients initially not deemed to be surgical candidates. In patients with resectable liver metastases, the goal of chemotherapy is to improve the outcome after surgery and especially to decrease the risk of recurrence. Although the principles of combined modality treatment become widely accepted, this therapeutic strategy is also associated with potential risks related to the preoperative use of chemotherapy.

Therapeutic efficacy of combined intraoperative ablation and resection for colorectal liver metastases: an international, multi-institutional analysis

BACKGROUND

Only 10-25% of patients presenting with colorectal liver metastases (CRLM) are amenable to hepatic resection. By combining resection and ablation, the number of patients eligible for surgery can be expanded. We sought to determine the efficacy of combined resection and ablation for CRLM.

METHODS

Between 1984 and 2009, 1,425 patients who underwent surgery for CRLM were queried from an international multi-institutional database. Of these, 125 patients underwent resection combined with ablation as the primary mode of treatment.

RESULTS

Patients presented with a median of six lesions. The median number of lesions resected was 4; the median number of lesions ablated was 1. At last follow-up, 84 patients (67%) recurred with a median disease-free interval of 15 months. While total number of lesions treated (hazard ratio (HR) = 1.47, p = 0.23) and number of lesions resected (HR = 1.18, p = 0.43) did not impact risk of intrahepatic recurrence, the number of lesions ablated did (HR = 1.36, p = 0.05). Overall 5-year survival was 30%. Survival was not influenced by the number of lesions resected or ablated (both p > 0.05).

CONCLUSION

Combined resection and ablation is associated with long-term-survival in a subset of patients; however, recurrence is common. The number of lesions ablated increases risk of intrahepatic recurrence but does not impact overall survival.

National trends in discharge disposition after hepatic resection for malignancy

BACKGROUND

There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy.

AIM

To analyse the national trends in discharge disposition after hepatic resection for malignancy.

METHODS

The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility).

RESULTS

A weighted total of 74,520 patients underwent hepatic resection of whom, 53,770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45,583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study.

CONCLUSIONS

The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.

Clinical impact of a macroscopically complete resection of colorectal cancer with peritoneal carcinomatosis

BACKGROUND

So far, few reports have focused on the clinicopathological features and patterns of recurrence after a complete resection of peritoneal carcinomatosis (PC) of colorectal origin. The purpose of the present study was to show the clinicopathological features of a macroscopically complete resected tumor and the pattern of recurrence after the curative resection of colorectal PC.

METHODS

In 153 patients with colorectal PC, 31 patients who underwent a complete resection of a synchronous primary lesion of a colorectal PC between 1998 and 2007 were assessed retrospectively.

RESULTS

Clinicopathological differences were observed in the tumor location, presence of extraperitoneal metastases, extent of PC, and presence of lymph node metastases between a macroscopically complete resection and noncomplete resection patients (P = .045, P < .0001, P < .001, and P = .039, respectively). Tumor recurrence after the complete resection of colorectal PC was observed in 24 patients (77.4%). The 5-year survival rate after complete resection was 36.0%. The survival rate in the macroscopically complete resection group was higher than in the incomplete resection group (P < .001). The 5-year intra- and extraperitoneal recurrence survival rates were 63.9% and 33.8%, respectively. No significant clinicopathological factors affected intraperitoneal recurrence-free survival. Conversely, a univariate analysis using the log-rank test revealed that extended PC and presence of lymph node metastases were poor factors affecting extraperitoneal recurrence (P = .009 and P = .023, respectively). Eleven of 31 patients survived for 5 years after resection. Two of the 4 patients with liver metastases had received a hepatectomy.

CONCLUSION

Although the 5-year survival rate after a macroscopically complete resection for colorectal PC approached 36.0%, 77.4% of patients developed intra- and extraperitoneal recurrence. Extended PC and presence of lymph node metastases were poor factors affecting extraperitoneal recurrence.

Disappearing colorectal liver metastases after chemotherapy: should we be concerned?

BACKGROUND

With increasing efficacy of preoperative chemotherapy for colorectal cancer, more patients will present with one or more disappearing liver metastases (DLM) on preoperative cross-sectional imaging.

PATIENTS AND METHODS

A retrospective review was conducted evaluating the radiological response to preoperative chemotherapy for 168 patients undergoing surgical therapy for colorectal liver metastases at Johns Hopkins Hospital between 2000 and 2008.

RESULTS

Forty patients (23.8%) had one or more DLM, accounting for a total of 127 lesions. In 22 patients (55%), all DLM sites were treated during surgery. Of the 17 patients with unidentified, untreated DLM, ten patients (59%) developed a local recurrence at the initial site, half of which also developed recurrences in other sites. While the intrahepatic recurrence rate was higher for patients with DLM left in situ (p = 0.04), the 1-, 3-, and 5-year overall survival rate was not significantly different for patients with DLM left in situ (93.8%, 63.5%, and 63.5%, respectively) when compared to patients with a radiological chemotherapy response in whom all original disease sites were surgically treated (92.3%, 70.8%, and 46.2%, respectively; p = 0.66).

CONCLUSIONS

DLM were frequently observed in patients undergoing preoperative chemotherapy for liver metastases. Survival was comparable in patients with untreated DLM, in spite of high intrahepatic recurrence rates seen in these patients. Therefore, aggressive surgical therapy should be considered in patients with marked response to chemotherapy, even when all DLM sites cannot be identified.

Endoscopic surveillance after curative surgery for sporadic colorectal cancer: patient-tailored, tumor-targeted or biology-driven?

OBJECTIVE

Endoscopy has been endorsed and introduced in most surveillance programs following curative surgery for colorectal cancer (CRC), yet little data are available to support its use in terms of patient selection, efficacy and frequency of surveillance.

MATERIAL AND METHODS

A literature search in the English language using the PubMed/Medline database for the MeSH terms "colorectal cancer", "surveillance", and "endoscopy", with focus on sporadic CRC, excluding CRC developed on a hereditary or inflammatory bowel disease background. Focus on results from the past 5 years was applied.

RESULTS

Recent systematic reviews, meta-analyses, randomized trials and prospective studies made the backbone of the article, supported by population-based findings and recent reports on tumor biology. Hard evidence to support a survival benefit from endoscopy alone is lacking. Definitions of "synchronous", "interval", and "metachronous" cancers are not uniform and hampers comparison of studies. The number of metachronous cancers (usually 2-4%) that develop after curative CRC surgery is small, and better patient-tailored surveillance could improve the diagnostic yield. Compliance with endoscopy is low compared to other modalities. Age and socio-demographic factors influence on the surveillance coverage and need to be addressed in any given program. The majority of local recurrences occur within the first 3 years after surgery independent of stage, and microsatellite instable (MSI) tumors appear to be at higher risk.

CONCLUSIONS

Endoscopy in surveillance after curative surgery for CRC is a resource demanding procedure. A tailored approach according to factors associated with an increased risk for metachronous cancer/local recurrence would increase efficiency.

Treatment of liver-limited metastatic colorectal cancer

Although liver metastases from colorectal cancer previously conferred a very dismal prognosis, advances in systemic therapy combined with surgical techniques now gives these patients a reasonable chance for cure. Traditional cytoxic chemotherapy combined with biologic agents result in impressive response rates, allowing a portion of patients who were considered unresectable to undergo hepatectomy with curative intent. This review discusses the role of systemic therapy in patients with liver-limited metastatic disease for patients with resectable, potentially resectable and unresectable disease.

Thermal ablative therapies for secondary hepatic malignancies

Hepatic metastatic disease affects more than half of the patients with colorectal cancer and neuroendocrine cancer. Hepatic resection remains the gold standard for liver metastasis from colorectal and neuroendocrine primaries. Thermal ablative technologies, however, are increasingly being used either alone or in combination with resection to treat this group of patients. Radiofrequency ablation is the most common modality used in the United States, whereas microwave ablation has been more widely used in the East. In addition to being adjuncts to hepatic resection, ablation has gained an increased popularity in the management of patients who are not operative candidates or have unresectable colorectal or neuroendocrine hepatic metastasis. Although radiofrequency ablation seems to have a higher local recurrence than resection, ablation remains an important therapeutic option for many patients with hepatic metastasis.

Surgical management of hepatic neuroendocrine tumor metastasis: results from an international multi-institutional analysis

BACKGROUND

Management of neuroendocrine tumor liver metastasis (NELM) remains controversial, with some advocating an aggressive surgical approach while others have adopted a more conservative strategy. We sought to define the efficacy of the surgical management of NELM in a large multicenter international cohort of patients.

METHODS

We identified 339 patients who underwent surgical management for NELM from 1985 to 2009 from an international database of eight major hepatobiliary centers. Relevant clinicopathologic data were assessed using Kaplan-Meier and Cox regression models.

RESULTS

Most patients had a pancreatic (40%) or small bowel (25%) neuroendocrine tumor (NET) primary. The majority of patients (60%) had bilateral liver disease. At surgery, 78% of patients underwent hepatic resection, 3% ablation alone, and 19% resection + ablation. Major hepatectomy was performed in 45% of patients, and 14% underwent a second liver operation. Carcinoid was the most common NET histological subtype (53%). Median survival was 125 months, with overall 5- and 10-year survival of 74%, and 51%, respectively. Disease recurred in 94% of patients at 5 years. Patients with hormonally functional NET who had R0/R1 resection benefited the most from surgery (P = 0.01). On multivariate analyses, synchronous disease [hazard ratio (HR) = 1.9], nonfunctional NET hormonal status (HR = 2.0), and extrahepatic disease (HR = 3.0) remained predictive of worse survival (all P < 0.05).

CONCLUSIONS

Liver-directed surgery for NELM is associated with prolonged survival; however, the majority of patients will develop recurrent disease. Patients with hormonally functional hepatic metastasis without prior extrahepatic or synchronous disease derive the greatest survival benefit from surgical management.

Radiofrequency ablation of colorectal liver metastases induces an inflammatory response in distant hepatic metastases but not in local accelerated outgrowth

BACKGROUND

Recently, we have shown in a murine model that radiofrequency ablation (RFA) induces accelerated outgrowth of colorectal micrometastases in the transition zone (TZ) surrounding the ablated lesion. Conversely, RFA also induces an anti-tumor T-cell response that may limit tumor growth at distant sites. Here we have evaluated whether an altered density of inflammatory cells could be observed in the perinecrotic (TZ) metastases compared to hepatic metastases in the distant reference zone (RZ).

METHODS

RFA-treated tumor-bearing mice (n = 10) were sacrificed. The inflammatory cell density (neutrophils, macrophages, CD4(+) T-cells, and CD8(+) T-cells) of tumors in the TZ (TZ tumors) was compared to that in tumors in the RZ (RZ tumors). Sham-operated, tumor-bearing mice (n = 10) were analyzed simultaneously as controls (sham-treated tumors).

RESULTS

In RFA-treated, tumor-bearing mice RZ tumors contained a significantly higher density of neutrophils and CD4(+) T-cells, but not macrophages and CD8(+) T-cells compared to sham-treated tumors. Notably, TZ tumors had a significantly lower density of neutrophils, CD4(+) T-cells, and CD8(+) T-cells, but not macrophages, when compared to RZ tumors.

CONCLUSIONS

The accelerated perinecrotic tumor outgrowth following RFA is associated with a reduced density of neutrophils and T-cells compared to distant hepatic metastases. This may have implications for local tumor recurrence following RFA.

Two-stage strategy for patients with extensive bilateral colorectal liver metastases

BACKGROUND

Two-stage hepatectomy has been proposed for patients with bilateral colorectal liver metastases. The present study assesses the feasibility and outcome of two-stage hepatectomy for the treatment of colorectal liver metastases.

METHODS

From January 1994 to December 2008, 720 patients underwent liver resections at two institutions for colorectal liver metastases. The feasibility and outcomes of two-staged hepatectomies were evaluated.

RESULTS

Forty-five patients were eligible for the two-stage approach and both stages were completed in 35 patients (78%). Reasons for failure included disease progression (n= 7), poor performance status (n= 1) and death after the first stage (n= 2). Patients who completed both stages had significantly fewer lesions than patients who failed to complete the second stage (5 vs. 8; P= 0.02). No differences between the two groups were observed with regard to lesion size, receipt of radiofrequency ablation (RFA) or presence of extrahepatic disease. Post-operative morbidity (24% vs. 26%; P= 0.9) and mortality (4% vs. 5%; P= 0.8) was similar between the first and second stages. Median overall survival was 16 months. Three-year survival was significantly worse for patients failing to complete both stages (18%) compared with patients completing both stages (58%) (P < 0.001). Similar survival rates were observed between patients who completed two-stage vs. patients treated with a planned single-stage hepatectomy (58% vs. 53%; P= 0.34).

CONCLUSION

The two-stage strategy for colorectal liver metastases can be performed with acceptable morbidity and mortality. The second stage will not be feasible in 20-25% of patients. Patients who are able to complete the two-stage approach, however, may have long-term survival comparable to patients treated with a planned single-stage hepatectomy.

Liver transplantation for colorectal liver metastases: revisiting the concept

Liver transplantation (Lt) for colorectal cancer (CRC) liver metastases is no more considered due to the poor outcome observed up to the 1990s. According to the European Liver Transplant Registry (ELTR), 1- and 5-year patient survival following Lt for CRC liver metastases performed prior to 1995 was 62% and 18%, respectively. However, 44% of graft loss or patient deaths were not related to tumor recurrence. Over the last 20 years there has been dramatic progress in patient survival after Lt, thus it could be anticipated that survival after Lt for CRC secondaries today would exceed from far, the outcome of the past experience. By utilizing new imaging techniques for proper patient selection, modern chemotherapy and aggressive multimodal treatment against metastases, long term survivors and even cure could be expected. Preliminary data from a pilot study show an overall survival rate of 94% after a median follow up of 25 months. While long term survival after the first Lt is 80% all indications confounded, 5-year survival after repeat Lt is no more than 50% to 55%. If patients transplanted for CRC secondaries can reach the latter survival rate, it could be difficult to discriminate them in the liver allocation system and live donation could be an option.

Role of adjuvant therapy after resection of colorectal cancer liver metastases

Liver resection is the goal of treatment strategies for liver-confined metastatic colorectal cancer. However, after resection the majority of patients will experience recurrence. Chemotherapy seems to improve outcomes compared with surgery alone. We reviewed the data of the role of adjuvant chemotherapy after resection of liver- confined metastatic colorectal cancer. Optimal regimens and sequencing of chemotherapies when liver resection is an option are unclear. Some suggest that resectable liver metastases, in the absence of high-risk features, should begin with surgery and consideration given to adjuvant chemotherapy after surgery. If high-risk features are present, most physicians prefer a short course of systemic preoperative chemotherapy. Perioperative therapy and regional therapy with hepatic arterial infusion (HAI) both increase disease-free survival (DFS) when compared with surgery alone. In unresectable disease, consideration should be given to systemic chemotherapy with or without a biologic agent or HAI with systemic therapy. If the disease becomes resectable, adjuvant treatment should follow surgery. Adjuvant chemotherapy is usually FOLFOX, but HAI combined with systemic chemotherapy is also an option. The role of adjuvant treatment post-liver resection should not be viewed in isolation but rather in the context of prior treatment, surgical preference, and individual patient characteristics. Perioperative therapy and regional therapy have both shown an increase in DFS. Conducting randomized trials examining the role of adjuvant chemotherapy has been difficult because of rapidly changing chemotherapies.

Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis

INTRODUCTION

Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.

METHODS

Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed.

RESULTS

Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01).

CONCLUSION

Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.

Culture and characterization of thymic epithelium from autoimmune NZB and NZB/W mice

Autoimmune NZB and NZB/W mice display early abnormalities in thymus histology, T cell development, and mature T cell function. Abnormalities in the subcapsular/medullary thymic epithelium (TE) can also be inferred from the early disappearance of thymulin from NZB. It has also been reported that NZB thymic epithelial cells do not grow in culture conditions that support the growth of these cells from other strains of mice. In order to study the contribution of TE to the abnormal T cell development and function in NZB and NZB/W mice, we have devised a culture system which supports the growth of TE cells from these mice. The method involves the use of culture vessels coated with extracellular matrix produced by a rat thymic epithelial cell line. TEA3A1, and selective low-calcium, low-serum medium. In addition TEA3A1 cells have been used as an antigen to generate monoclonal antibodies specific for subcapsular/medullary TE. These antibodies, as well as others already available, have been used to show that the culture conditions described here select for cells displaying subcapsular/medullary TE markers, whereas markers for cortical TE and macrophages are absent.