Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases

Systemic and targeted therapy for advanced colon cancer

Colorectal cancer (CRC) is the third most common malignancy and the second most common cause of cancer-related death in the USA. Prognosis is best when the disease is detected early; however, nearly two-thirds of newly diagnosed cases of CRC have lymph node involvement or metastatic disease. For years, 5-fluorouracil (FU)-based regimens represented the only viable treatment option for patients with metastatic CRC. However, in recent years several newer agents have been added to the treatment arsenal for this disease. These agents include oxaliplatin, irinotecan and newer monoclonal antibodies targeting the epidermal growth factor receptor (cetuximab and panitumumab) and VEGF (bevacizumab). This review aims to discuss current systemic and targeted therapies for metastatic colon cancer with a focus on mechanism of action, indications, toxicity and efficacy.

A comparison of right and extended right hepatectomy with all other hepatic resections for colorectal liver metastases: a ten-year study

AIMS

Colorectal liver metastases are treated by a combination of adjuvant chemotherapy followed by liver resection. In this study we compared all major right-sided resections with left or parenchymal sparing resections.

METHODS

Consecutive patients (n=283) who had successful hepatic resections for colorectal metastases from September 1996 to November 2006 were prospectively studied. Early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardised for all.

RESULTS

The 1-, 3- and 5-year overall survival rates in the RH group were 84.1%, 54.3% and 38.9%, respectively. The 1-, 3- and 5-year overall survival rates in the AOLR group were 95.4%, 65.9% and 53.3%, respectively. The difference was statistically significant (p=0.03). The 1-, 3- and 5-year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5%, respectively and 68.4%, 34.91% and 34.91%, respectively in the AOLR group (p=0.46). Operative mortality was 3.9% in the RH group and 0.7% in the AOLR group (p=0.04). Morbidity was 31.3% in the RH group and 18% in the AOLR group.

CONCLUSION

Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

Quantification of risk of a positive (R1) resection margin following hepatic resection for metastatic colorectal cancer: an aid to clinical decision-making

BACKGROUND AND AIMS

Margin involvement following liver resection for colorectal cancer is associated with early disease recurrence and shorter long-term survival. This study aimed to develop a predictive index for quantifying the likelihood of a positive resection margin (R1) for patients undergoing hepatic resection for metastatic colorectal cancer.

METHODS

Clinical, pathological and complete follow-up data were prospectively collected from 1005 consecutive liver resections performed in 929 patients for colorectal liver metastases with curative intent at a single centre between 1987 and 2005. Ninety-four resections in 81 patients with extra-hepatic disease were excluded, leaving 911 resections (844 primary and 67 repeat) in 848 patients for analysis. Multivariate logistic regression was used to identify independent predictors of margin involvement and from the beta-coefficients generated, develop a predictive model that was validated using measures of discrimination and calibration.

RESULTS

There were 80 (8.8%) R1 resections, with a 5-year cancer-specific survival for R0 and R1 hepatic resections of 39.7% and 17.8%, respectively; p<0.001. On multivariate analysis, five risk factors were found to be independent predictors of an R1 resection: non-anatomical resection vs. anatomical resection (odds ratio (OR)=4.3, p=0.001), >3 hepatic metastases involving >50% of the liver vs. <3 metastases (OR=4.0, p<0.001); bilobar vs. unilobar disease (OR=2.9, p<0.001); repeat vs. primary hepatic resection (OR=3.1, p=0.006); abnormal vs. normal pre-operative liver function tests (OR=1.6, p=0.044). These five factors were used to develop a predictive model, which when tested, fitted the data well, with an area under the receiver operating characteristic curve of 78.1% (S.E.=2.7%).

CONCLUSIONS

This study describes an accurate model for quantifying the risk of a positive margin following hepatic resection for liver metastases. It may be used pre-operatively by multi-disciplinary teams to identify patients who may benefit from neoadjuvant therapy prior to liver surgery, thus minimizing the risk of a positive resection margin.

Optimizing the approach to patients with potentially resectable liver metastases from colorectal cancer

Liver metastases are a common event in colorectal carcinoma. Significant advances have been made in managing these patients in the last decade, including improvements in staging and surgical techniques, an increasing armamentarium of chemotherapeutics and multiple local ablative techniques. While combination chemotherapy significantly improves median patient survival, surgical resection provides the only prospect of cure and is the focus of this review. Interpretation of published work in this field is challenging, particularly as there is no consensus to what is resectable disease. Of particular interest recently has been the use of neoadjuvant treatment for downstaging and downsizing disease in patients with initially unresectable liver metastases, in the hope of response leading to potentially curative surgery. This review summarizes the recent developments and consensus guidelines in the areas of staging, chemotherapy, local ablative techniques, radiation therapy and surgery, emphasizing the multidisciplinary approach to this disease and ongoing controversies in this field and examines the changing paradigms in the management of colorectal hepatic metastases.

Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study

BACKGROUND

The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined.

METHODS

Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days.

RESULTS

A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV.

CONCLUSIONS

Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.

[Colorectal liver metastases. Neoadjuvant chemotherapy: aspects of medical and surgical oncology]

Colorectal liver metastases are detected in 15-20% of patients at the time of diagnosis of the primary tumor, they develop in an additional 20-30% of patients during further course of the disease. Radical resection enables 5-year survival rates of 30-50%. Resectability may be increased by surgical techniques including two-stage hepatectomy and portal vein embolization. Furthermore, modern chemotherapy including various combinations of oxaliplatin, irinotecan, bevacizumab, and cetuximab has led to secondary resectability correlating to response rates which may be up to 80%. Changes of hepatic histology such as sinusoidal obstruction (e.g. following oxaliplatin) or steatohepatitis (e.g. following irinotecan) have been described. Individually, this may increase the risk of subsequent liver resection. As of today the role of neoadjuvant chemotherapy for resectable lesions has not been definitively confirmed.

Comparison of two methods of future liver remnant volume measurement

BACKGROUND

In liver transplantation, a minimum graft to patient body weight (BW) ratio is required for graft survival; in liver resection, total liver volume (TLV) calculated from body surface area (BSA) is used to determine the future liver remnant (FLR) volume needed for safe hepatic resection. These two methods of estimating liver volume have not previously been compared. The purpose of this study was to compare FLR volumes standardized to BW versus BSA and to assess their utility in predicting postoperative hepatic dysfunction after hepatic resection.

METHODS

Records were reviewed of 68 consecutive noncirrhotic patients who underwent major hepatectomy after portal vein embolization between 1998 and 2006. FLR (cubic centimeter) was measured preoperatively with three-dimensional helical computed tomography; TLV (cubic centimeter) was calculated from the patients' BSA. The relationship between FLR/TLV and FLR/BW (cubic centimeter per kilogram) was examined using linear regression analysis. Receiver operating characteristic (ROC) curve analysis was used to determine FLR/TLV and FLR/BW cutoff values for predicting postoperative hepatic dysfunction (defined as peak bilirubin level>3 mg/dl or prothrombin time>18 s).

RESULTS

Regression analysis revealed that the FLR/TLV and FLR/BW ratios were highly correlated (Pearson correlation coefficient, 0.98). The area under the ROC curve was 0.85 for FLR/TLV and 0.84 for FLR/BW (95% confidence interval, 0.71-0.97). Sixteen of the 68 patients developed postoperative hepatic dysfunction. The ROC curve analysis yielded a cutoff FLR/BW value of <or=0.4, which had a positive predictive value (PPV) of 78% and a negative predictive value (NPV) of 85%. The corresponding FLR/TLV cutoff value of <or=20% had a PPV of 80% and a NPV of 86%.

CONCLUSIONS

Based on the strong correlation between the FLR measurements standardized to BW and BSA and their similar ability to predict postoperative hepatic dysfunction, both methods are appropriate for assessing liver volume. In noncirrhotic patients, a FLR/BW ratio of <or=0.4 and FLR/TLV of <or=20% provide equivalent thresholds for performing safe hepatic resection.

Effect of preoperative chemotherapy on liver resection for colorectal liver metastases

AIM

To compare the effects of preoperative chemotherapy on liver parenchyma morphology, as well as morbidity and mortality after liver resection for colorectal liver metastases.

METHODS

Prospectively collected data on 173 patients undergoing liver resection for CLM between 1/2003 and 9/2005 was analysed in three groups: A: preoperative oxaliplatin (Ox, n=70); B: other chemotherapeutic agents (OC, n=60); and C: surgery alone without chemotherapy (SA, n=43). Blood transfusion, hospital stay, operative procedure, peak postoperative bilirubin levels, complications and histopathology of the resected liver were compared.

RESULTS

Intra-operative blood transfusion requirement (34%) and biliary complications (16%) was higher in patients receiving oxaliplatin-based chemotherapy (p=0.01 and p=0.06, respectively). Oxaliplatin-based chemotherapy was also associated with sinusoidal dilatation of mild grade in 52.8% vs. 26.6% and 23.3% patients (p=0.007 and p=0.004) in other groups, respectively. Steatosis was similarly distributed across the study group. Postoperative mortality was 2, 1 and 4 patients, respectively (p=ns).

CONCLUSION

Oxaliplatin-based preoperative chemotherapy is associated with vascular alterations in the liver parenchyma without significantly increasing the risk of steatosis, or postoperative morbidity and mortality.

Preoperative prognostic score for predicting survival after hepatic resection for colorectal liver metastases

BACKGROUND

Despite indications for resection of colorectal liver metastases having expanded, debate continues about identifying patients that may benefit from surgery.

METHODS

Clinicopathologic data from a total of 700 patients was gathered between January 1993 and January 2006 from a prospectively maintained dataset. Of these, 687 patients underwent resection for colorectal liver metastases.

RESULTS

The median age of patient was 64 years and 36.8% of patients had synchronous disease. The overall 5-year survival was 45%. The presence of an inflammatory response to tumor (IRT), defined by an elevated C-reactive protein (>10 mg/L) or a neutrophil/lymphocyte ratio of >5:1, was noted in 24.5% of cases. Only the number of metastases and the presence or absence of an IRT influenced both overall and disease-free survival on multivariable analysis. A preoperative prognostic score was derived: 0 = less than 8 metastases and absence of IRT; 1 = 8 or more metastases or IRT, and 2 = 8 or more metastases and IRT-from the results of the multivariable analysis. The 5-year survival of those scoring 0 was 49% compared with 34% for those scoring 1. None of the patients that scored 2 were alive at 5 years.

CONCLUSION

The preoperative prognostic score is a simple and effective system allowing preoperative stratification.

Review article: Multimodality treatment of liver metastases increases suitability for surgical treatment

BACKGROUND

Liver metastases of colorectal cancer occur frequently, but only 10-20% are eligible for liver surgery. Recent new developments changed the concepts of treating patients with colorectal liver metastases.

AIM

To describe the available modalities that can result in increasing resectability rate.

METHODS

Potentials and drawbacks of portal vein embolization, radiofrequency ablation (RFA), trans-ablated tumour hepatectomy, neoadjuvant chemotherapy and the approach to patients with extrahepatic metastases are described.

RESULTS

Portal vein embolization is a well-established technique to increase the volume of the future liver remnant. RFA should be applied if partial liver resection alone cannot make the liver tumour-free. Neoadjuvant chemotherapy in patients with unresectable liver metastases can result in secondary resectability rates of 15-40%. Hepatotoxicity can lead to a higher complication rate after partial liver resection. A limited number of extrahepatic tumour localizations should be resected as well.

CONCLUSIONS

A more aggressive approach to patients with colorectal liver metastases improves resectability rate and survival. Unfortunately, these new options have not been thoroughly evaluated in randomized controlled trials. For some of these modalities, the currently available results are so promising that it might be difficult to start such trials in the future.

[Liver resection: Part I. Anatomy and operative planning]

Hepatic surgery has grown considerably in importance during the past two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care as well as general advancements in hepatic surgical technique. Enormous strides in liver transplantation resulted in new methods also finding use in resective surgery. We present findings on functional and segmental anatomy of the liver on which current hepatic surgery is based, along with technical and oncological aspects requiring consideration for indication. Operative planning and anesthesiological management are discussed.

Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome

BACKGROUND

This study evaluated the safety of portal vein embolization (PVE), its impact on future liver remnant (FLR) volume and regeneration, and subsequent effects on outcome after liver resection.

METHODS

Records of 112 patients were reviewed. Standardized FLR (sFLR) and degree of hypertrophy (DH; difference between the sFLR before and after PVE), complications and outcomes were analysed to determine cut-offs that predict postoperative hepatic dysfunction.

RESULTS

Ten (8.9 per cent) of 112 patients had PVE-related complications. Postoperative complications occurred in 34 (44 per cent) of 78 patients who underwent hepatic resection and the 90-day mortality rate was 3 per cent. A sFLR of 20 per cent or less after PVE or DH of not more than 5 per cent (versus sFLR greater than 20 per cent and DH above 5 per cent) had a sensitivity of 80 per cent and a specificity of 94 per cent in predicting hepatic dysfunction. Overall, major and liver-related complications, hepatic dysfunction or insufficiency, hospital stay and 90-day mortality rate were significantly greater in patients with a sFLR of 20 per cent or less or DH of not more than 5 per cent compared with patients with higher values.

CONCLUSION

DH contributes prognostic information additional to that gained by volumetric evaluation in patients undergoing PVE.

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND

Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding.

STUDY DESIGN

We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver.

RESULTS

Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins).

CONCLUSIONS

Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.

Preoperative radiographic assessment of hepatic steatosis with histologic correlation

BACKGROUND

The adverse impact of hepatic steatosis on perioperative outcomes after liver resection is gaining recognition. But the accuracy of preoperative radiologic assessment of fatty liver disease remains unclear. The objective of this study was to correlate preoperative radiologic estimation with postoperative histologic measurement of steatosis.

STUDY DESIGN

Patients who underwent partial hepatectomy between 1997 and 2001, with complete preoperative radiographic imaging and postoperative pathologic assessment of steatosis, were retrospectively analyzed. The presence of steatosis was assessed radiographically using noncontrast-enhanced CT (NCCT), contrast-enhanced CT (CCT), or MRI, using standard quantitative radiologic criteria. Repeat histologic analysis was used to quantify the extent of hepatic steatosis.

RESULTS

One hundred thirty-one patients were studied. The overall sensitivity and specificity for all imaging modalities in detecting pathologically confirmed hepatic steatosis were 56% and 82%, respectively. Sensitivity and specificity for NCCT, CCT, and MRI using standard quantitative criteria were 33% and 100%, 50% and 83%, and 88%, and 63%, respectively. Increasing body mass indices adversely affected the accuracy of NCCT (p=0.002). Preoperative chemotherapy did not notably affect radiologic accuracy.

CONCLUSIONS

The presence of a fatty-appearing liver on NCCT scans indicates clinically significant steatosis, but steatosis cannot be excluded based on a normal NCCT scan, particularly in obese patients. Conversely, normal MRI helps to exclude hepatic steatosis, but abnormal MRI is not a reliable indicator of fatty change. CCT is not an effective means of identifying steatosis. We conclude that, when used alone, conventional cross-sectional imaging does not consistently permit accurate identification of hepatic steatosis.

Extending the frontiers of resectability in advanced colorectal cancer

AIM

To review the advances in the past decade that have enabled more patients with colorectal liver metastases (CRLM) to undergo curative hepatic resection.

METHODS

A comprehensive literature review and pertinent data published on advanced CRLM from The University of Texas M. D. Anderson Cancer Center were used for this review.

RESULTS

Criteria for resectability of CRLM have expanded with the advent of effective chemotherapy, improved surgical technique, and novel strategies such as preoperative volumetry, portal vein embolization, and two-stage hepatectomy. Despite the aggressiveness of these approaches to treating patients with advanced disease, recent series show an improvement in 5-year survival rate for patients with CRLM.

CONCLUSIONS

Advances in multidisciplinary management and careful patient selection have enabled more patients to undergo curative resection for CRLM, with corresponding improvement in survival rates.

Neoadjuvant treatment before resection of liver metastases

Surgical resection remains the only treatment of colorectal liver metastases that can ensure long-term survival and cure in some patient. However, only a minority of patients with liver metastases are amenable to surgery. Other patients can benefit from modern chemotherapy regimens, which achieve high response rates but are rarely sufficient for cure. In patients with unresectable metastases, neoadjuvant chemotherapy may increase the number of candidates for potentially curative resection, hence affording these patients the possibility of prolonged survival. For patients with resectable metastases, it is likely that the benefit of neoadjuvant chemotherapy before surgery will be demonstrated in the near future but is not yet validated. The integration of novel targeted agents will probably transform the therapeutic strategy for colorectal liver metastases.

Hepatic resection after rescue cetuximab treatment for colorectal liver metastases previously refractory to conventional systemic therapy

PURPOSE

In patients with unresectable colorectal liver metastases (CLM) resistant to first-line chemotherapy, the impact of cetuximab therapy on resectability is unknown. This study was performed to determine the post-cetuximab resectability rate and to examine postoperative outcomes for these heavily pretreated patients.

PATIENTS AND METHODS

From February 2004 to April 2006, we evaluated 151 patients with unresectable CLM resistant to initial chemotherapy and subsequently treated with systemic cetuximab. Resectability rates, patient outcomes, and tumoral and nontumoral liver pathology were assessed.

RESULTS

A total of 27 patients underwent surgery after a median of six cycles of cetuximab + irinotecan (20 of 27), oxaliplatin (four of 27), or both (one of 27). Eighteen patients (67%) had experienced treatment failure after at least two lines of chemotherapy before cetuximab. Twenty-five of the 27 patients who had surgery underwent hepatectomy: nine of 133 patients who were treated completely at our institution (resectability rate, 7%) and 16 of 18 patients who were referred from other institutions after systemic cetuximab therapy. Postoperative mortality was 3.7% (one of 27), with a complication rate of 50%. Histopathologic liver abnormalities were found in nine patients (36%), without specific lesions attributable to cetuximab. After median follow-up of 16 months, 23 of 25 patients who underwent resection (92%) were alive, and 10 patients (40%) were disease free. Median overall (OS) and progression-free survival (PFS) from initiation of cetuximab therapy were 20 and 13 months, respectively.

CONCLUSION

For CLM refractory to conventional chemotherapy, combination therapy with cetuximab increases resectability rates without increasing operative mortality or liver injury. The median OS and PFS of 20 and 13 months, respectively, suggest that this novel oncosurgical strategy benefits patients with previously refractory disease who respond subsequently to cetuximab.

Systemic chemotherapy and two-stage hepatectomy for extensive bilateral colorectal liver metastases: perioperative safety and survival

BACKGROUND

Two-stage hepatectomy has been proposed for patients with bilateral colorectal liver metastases (CLM). The aim of this study was to compare the outcome of patients with CLM treated with preoperative chemotherapy followed by one- or two-stage hepatectomy.

METHODS

From a prospective database, 214 consecutive patients who received preoperative systemic chemotherapy (fluoropyrimidine with irinotecan or oxaliplatin) followed by planned one- or two-stage hepatectomy were retrospectively analyzed (1998-2006). In patients undergoing two-stage procedures, minor hepatectomy (wedge or segmental resection[s]) was systematically performed before major (more than three segments), second-stage hepatectomy. Preoperative portal vein embolization (PVE) was performed if indicated.

RESULTS

One- (group I) and two-stage (group II) hepatectomies were performed in 184 and 21 patients, respectively. Median number of metastases in groups I and II were two (range 1-20) and seven (range 2-20). All patients in group II had bilateral disease vs 39% in group I. Major hepatectomy was performed in all patients in group II and 79% in group I. PVE was performed in 18 group I and 12 group II patients without increase in morbidity. For group I, group II first stage, and group II second stage, respectively, morbidity (24%, 24%, 43%), median hospital stay (7 days, 6 days, 6.5 days) and 30 days postoperative mortality (2%, 0%, 0%) were not significantly different (P = NS). Median follow-up was 25 months; median survival has not been reached. One- and 3-year overall and disease-free survival rates from the time of hepatic resection were 95% and 75%, 63% and 39%, respectively in group I; 95% and 86%, 70% and 51%, respectively in group II (P = NS).

CONCLUSIONS

Two-stage hepatectomy with preoperative chemotherapy results in comparable morbidity and survival rates as one-stage hepatectomy. This approach enables selection and treatment of patients with multiple, bilateral CLM who will benefit from aggressive surgery with good outcomes.

[Effect of neoadjuvant chemotherapy on the results of resection of colorectal liver metastases]

INTRODUCTION

Surgery is the treatment of choice in patients with colorectal liver metastases. However, only 10% to 20% of these cases are resectable. The use of neoadjuvant chemotherapy may allow surgery in patients with tumors initially considered unresectable. The aim of this study was to compare the results of liver resection due to colorectal liver metastases in patients with and without neoadjuvant chemotherapy.

PATIENTS AND METHOD

We studied 105 patients who underwent surgery for liver metastases from colorectal cancer. The patients were divided into two groups according to treatment: surgery in patients with initially resectable tumors (group 1) and neoadjuvant chemotherapy plus surgery (group 2) in patients with initially irresectable tumors, who were considered for surgery after response to chemotherapy. Age, sex, origin of primary tumor, time of presentation, number, maximum size and location of metastases, CEA, resection margin, postoperative morbidity and mortality, length of hospital stay, recurrence rate, survival and disease-free survival were compared between the 2 groups of patients.

RESULTS

When group 1 was compared with group 2, statistically significant differences were observed in synchronicity (30.8% vs 77.4%), bilobarity (13.5% vs 58.5%), number and size of metastases (1 vs 3 nodules and 4 cm vs 2 cm), resectability rate (96.1% vs 81.1%), disease-free interval (25 vs 11 months) and long-term survival at 1, 3 and 5 years (93%, 67% and 36% vs 78%, 26% and 12%). However, no statistically significant differences were found in postoperative morbidity and mortality (28.8% and 0% in group 1 and 22.6% and 1.8% in group 2, respectively).

CONCLUSIONS

Neoadjuvant chemotherapy was not associated with greater postoperative morbidity and mortality after resection of colorectal liver metastases, but long-term survival was lower in the group of patients receiving this treatment modality than in those with tumors initially considered resectable.

A critical appraisal of the role of neoadjuvant chemotherapy for colorectal liver metastases: a case-controlled study

BACKGROUND

The aim of this study was to analyze the outcome of patients that received neoadjuvant chemotherapy prior to resection for colorectal liver metastases (CRLM) and compare them with a matched cohort of patients that underwent resection followed by adjuvant chemotherapy.

METHODS

687 patients have undergone curative resection between January 1993 and January 2006. In this period, 84 patients received neo-adjuvant chemotherapy and 71 of this group went on to resection. A control group was chosen, matched with these patients, made up of patients who underwent resection followed by adjuvant chemotherapy.

RESULTS

There was no difference in clinico-pathological features between the neoadjuvant and the control group. However patients in the control group had more-extended resections and longer hospital stays than those in the neoadjuvant group (p = 0.015). Patients in the control group had an increased incidence of early recurrences (p < 0.001). Despite this, there was no significant difference in either the cancer-specific or the disease-free survival between the two groups of patients.

CONCLUSION

Neoadjuvant chemotherapy has a role in the management of patients with disease that is considered initially unresectable as a down-sizing technique. In patients with resectable disease, the test-of-time approach that neoadjuvant therapy offers is yet to be proven.

Improved Long-Term Outcome of Surgery for Advanced Colorectal Liver Metastases: Reasons and Implications for Management on the Basis of a Severity Score

BACKGROUND

The outcome of liver resection for colorectal liver metastases (CRLM) appears to be improving despite the fact that surgery is offered to patients with more-severe disease. To quantify this assumption and to understand its causes we analyzed a series of patients on the basis of a standardized severity score and changes in management occurring over the years.

METHODS

Patients' characteristics, operative data, chemotherapies and follow-up were recorded. CRLM severity was quantified according to Fong's clinical risk score (CRS), modified to take into account the presence of bilateral liver metastases. Three periods were analyzed, in which different indications, surgical strategies and uses of chemotherapy were applied: 1984-1992, 1993-1998, and 1999-2005.

RESULTS

Between January 1984 and December 2005, 210 liver resections were performed in 180 patients (1984-1992, 43 patients; 1993-1998, 42 patients; 1999-2005, 95 patients). CRLM severity increased throughout the time periods, as did the use of neoadjuvant chemotherapies, repeat resections, and multistep procedures. While the disease-free survival did not improve over time, the 1-, 3- and 5-year overall survival rate increased from 85%, 30%, and 23% in the first period, to 88%, 60%, and 34% in the second period, and to 94%, 69%, and 46% in the third period.

CONCLUSIONS

Analysis according to the CRS showed that despite the fact that patients had more severe disease, the overall survival improved over the years, mainly thanks to more aggressive treatment of recurrent disease. Management of advanced CRLM should, from the start, take into account the likelihood of secondary procedures.

Addition of bevacizumab to irinotecan- and oxaliplatin-based preoperative chemotherapy regimens does not increase morbidity after resection of colorectal liver metastases

BACKGROUND

Although commonly used in combination with irinotecan or oxaliplatin (iri/oxal) for treatment of colorectal liver metastases before extirpation, the effects of preoperative bevacizumab on surgical outcomes are not established. The objective of this retrospective study was to determine if addition of bevacizumab to iri/oxal preoperative chemotherapy increases morbidity after hepatic resection.

STUDY DESIGN

We compared demographics, clinicopathologic data, treatments, and postoperative outcomes between patients given preoperative iri/oxal with and without bevacizumab and patients who underwent hepatic resection within and after 8 weeks from the last dose of bevacizumab.

RESULTS

From 1996 to 2006, 96 patients were treated with preoperative iri/oxal; 39 (40.6%) received concurrent bevacizumab. Preoperative bevacizumab treatment was associated with less blood loss (median 425 mL versus 600 mL, p=0.01) and lower RBC transfusion rates (43.9% versus 23.1%, p=0.06) after partial hepatectomy on univariable analysis. Only age>or=70 years (hazard ratio=8.52, 95% CI [2.00 to 36.45]) and concurrent extrahepatic procedures (hazard ratio=4.12, 95% CI [1.49 to 11.39]) independently predicted RBC transfusion and overall complications, respectively. There were no differences in overall (43.6% versus 38.6%), severe (28.2% versus 24.6%), hepatic (17.9% versus 26.3%), wound (10.3% versus 7%), or thromboembolic or bleeding (2.6% versus 5.3%) complications (all p > 0.05). For patients treated with iri/oxal and bevacizumab, overall complications were more common when resection was performed within 8 weeks after the last bevacizumab dose (62.5% versus 30.4%), but this difference was not statistically significant (p=0.06).

CONCLUSIONS

If discontinued at least 8 weeks before hepatic resection, addition of bevacizumab to preoperative iri/oxal does not increase morbidity after hepatic resection.

The pathological response to neoadjuvant chemotherapy with FOLFOX-4 for colorectal liver metastases: a comparative study

FOLFOX-4 (folinic acid/5-fluorouracil/oxaliplatin) chemotherapy is used to treat patients with colorectal liver metastases. We aimed to assess hepatic histopathological responses to neoadjuvant FOLFOX-4 chemotherapy in patients with colorectal liver metastases. We selected all patients (n = 54) treated with FOLFOX-4 for colorectal liver metastases between June 2002 and June 2005. Only 25 underwent hepatectomy and formed the study group. Histological responses were assessed in the study group and a matched control group (n = 25) that did not receive neoadjuvant chemotherapy. The median (IQR) body mass index in the study and control groups was 24 (22-26) and 24 (23-25) kg/m(2), respectively, (P = NS). Complete histological resolution of tumour occurred in six (24%) patients in the study group. Median residual tumour cellularity was less (35 vs 70%) and fibrosis greater (50 vs 5%) in patients in the study group when compared with controls (P < 0.001). The liver surrounding the tumour was steatotic in 17 (68%) patients in the study group and five (20%) controls (P = 0.001). Hepatic sinusoidal dilatation was more pronounced in patients in the study group than in controls (P < 0.001). The response to FOLFOX-4 was associated with tumour necrosis, fibrosis and inflammation. More than two thirds of patients undergoing hepatectomy after FOLFOX-4 had steatosis despite being non-obese.

Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group

Liver resection offers the only chance of cure for patients with advanced colorectal cancer (CRC). Typically, the 5-year survival rates following liver resection range from 25% to 40%. Unfortunately, approximately 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. However, the rapid expansion in the use of improved combination therapy regimens has increased the percentage of patients eligible for potentially curative surgery. Despite this, the selection criteria for patients potentially suitable for resection are not well documented and patient management by multidisciplinary teams, although essential, is still evolving. The goal of the European Colorectal Metastases Treatment Group is to establish pan-European guidelines for the treatment of patients with CRC liver metastases that can be adopted more widely by established treatment centres and to develop more accurate staging systems and evaluation criteria.

Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis

BACKGROUND

The safety of simultaneous resections of colorectal cancer and synchronous liver metastases (SCRLM) is not established. This multi-institutional retrospective study compared postoperative outcomes after simultaneous and staged colorectal and hepatic resections.

METHODS

Clinicopathologic data, treatments, and postoperative outcomes from patients who underwent simultaneous or staged colorectal and hepatic resections at three hepatobiliary centers from 1985-2006 were reviewed.

RESULTS

610 patients underwent simultaneous (n = 135) or staged (n = 475) resections of colorectal cancer and SCRLM. Seventy staged patients underwent colorectal and hepatic resections at the same institution. Simultaneous patients had fewer (median 1 versus 2) and smaller (median 2.5 versus 3.5 cm) metastases and less often underwent major (> or = three segments) hepatectomy (26.7% versus 61.3%, p < 0.05). Combined hospital stay was lower after simultaneous resections (median 8.5 versus 14 days, p < 0.0001). Mortality (1.0% versus 0.5%) and severe morbidity (14.1% versus 12.5%) were similar after simultaneous colorectal resection and minor hepatectomy compared with isolated minor hepatectomy (both p > 0.05). For major hepatectomy, simultaneous colorectal resection increased mortality (8.3% versus 1.4%, p < 0.05) and severe morbidity (36.1% versus 15.1%, p < 0.05). Combined severe morbidity after staged resections was lower compared to simultaneous resections (36.1% versus 17.6%, p = 0.05) for major hepatectomy but similar for minor hepatectomy (14.1% versus 10.5%, p > 0.05). Major hepatectomy independently predicted severe morbidity after simultaneous resections [hazard ratio (HR) = 3.4, p = 0.008].

CONCLUSIONS

Simultaneous colorectal and minor hepatic resections are safe and should be performed for most patients with SCRLM. Due to increased risk of severe morbidity, caution should be exercised before performing simultaneous colorectal and major hepatic resections.

Nodular regenerative hyperplasia: a deleterious consequence of chemotherapy for colorectal liver metastases?

AIMS

This report describes three patients suffering from nodular regenerative hyperplasia (NRH).

METHODS

These patients have received six, 16 and 20 cycles of neoadjuvant 5-fluorouracil and oxaliplatin-based chemotherapy before planned extended hepatectomy. Two patients underwent uneventful portal vein embolization to hypertrophy the future remnant liver.

RESULTS

At the end of chemotherapy, liver function tests deteriorated and portal hypertension appeared in two patients, including ascites, splenomegaly and oesophageal varices. Liver biopsy was performed through a percutaneous (two patients) or a transjugular approach (one patient) and allowed the diagnosis of NRH, which was considered to be a contraindication for major liver resection in all three patients, associated with extrahepatic disease progression in one patient. All patients died from neoplastic disease progression despite further chemotherapy at 6, 17 and 31 months following the diagnosis of NRH. One patient developed liver failure and ascites at the time of death.

CONCLUSIONS

Physicians should be aware of the potential occurrence and therapeutic impact of NRH in patients suffering from CRLM and treated by neoadjuvant 5FU-oxaliplatin-based chemotherapy before major liver surgery.

[Neoadjuvant treatments in digestive cancer]

Neoadjuvant chemotherapy or chemoradiotherapy is an important concept in the treatment of colorectal liver metastasis, gastric cancer, and esophageal or rectal tumors. This treatment strategy improves disease-free survival and sometimes overall survival. It allows surgical resection of lesions that where not resectable at diagnosis. The new standards of neoadjuvant treatments in gastrointestinal oncology are described in this article.

Hepatic complications following preoperative chemotherapy with oxaliplatin or irinotecan for hepatic colorectal metastases

AIMS

The aim of this article is to review the current state of knowledge in relation to the development of chemotherapy associated steatohepatitis (CASH) and sinusoidal obstruction syndrome (SOS) occurring following the administration of irinotecan and oxaliplatin respectively to patients with colorectal liver metastases and also to highlight potential concerns relating to other new agents.

METHODS

An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles related to the incidence, aetiology, pathology and effects of CASH and SOS outcome in patients undergoing hepatic resection.

RESULTS

CASH and SOS are relatively common findings in liver resection specimens following the administration of irinotecan and oxaliplatin-based regimes being reported in up to 50% and 20% of cases respectively. Whilst the aetiology and pathological changes are well-described, the relationship between the presence of these pathologies and outcomes is less well defined. The data in relation to SOS following oxaliplatin is limited but there may be an increased morbidity associated with the presence of SOS. There is significantly more evidence that the presence of CASH is associated with an increased morbidity and possibly mortality following hepatic resection as a result of the development of liver failure. Further studies are required to clarify these early observations.

CONCLUSIONS

The frequent identification of distinct pathological entities in association with oxaliplatin and irinotecan chemotherapy means that patients undergoing liver resection following treatment with these agents should be carefully monitored to accurately determine the morbidity and mortality attributable to the use of these agents. Furthermore, additional studies are required to clarify risk factors for the development of CASH and SOS so that certain regimens can be avoided in at risk populations thus reducing hepatic damage and increasing the chances of cure and survival following liver resection.

Impact of complete response to chemotherapy on overall survival in advanced colorectal cancer: results from Intergroup N9741

PURPOSE

To evaluate clinical characteristics and survival outcomes among patients with locally advanced or metastatic colorectal cancer who achieve a complete response (CR) to systemic treatment either alone or with multimodality approach.

PATIENTS AND METHODS

Data were collected retrospectively from CRC patients enrolled onto the phase III trial N9741, a National Cancer Institute-funded and Gastrointestinal Cancer Intergroup-sponsored study coordinated by the North Central Cancer Treatment Group. Patients were randomly assigned to combinations of oxaliplatin, fluorouracil (FU)/leucovorin (LV) and irinotecan. The three treatment arms consist of IFL (irinotecan + FU/LV), FOLFOX4 (oxaliplatin + FU/LV), and IROX (irinotecan + oxaliplatin). Median follow-up was 42.6 months.

RESULTS

Sixty-two (4%) of 1,508 patients had a CR to chemotherapy alone, and an additional 32 (2%) had a CR after multimodality treatment. Factors associated with achieving CR with systemic chemotherapy alone included FOLFOX4 treatment, patients with assessable disease, or a single site of metastasis. Continuing protocol treatment beyond two cycles after documentation of CR was not associated with improved survival. The rate of curative intent resection was significantly higher for patients treated with oxaliplatin-containing regimens (P = .02). Median survival was similar between patients with CR after chemotherapy alone (44.3 months) or after multimodality approach (47.4 months; P = .81).

CONCLUSION

FOLFOX4 was more likely to produce a CR than were IFL or IROX. Oxaliplatin regimens were more likely to result in successful surgical resections. Patients who have CR to systemic chemotherapy alone can achieve impressive survival outcomes similar to those seen among patients who attained a CR status after multimodality treatment.

Surgical therapy of liver metastases

The liver is the most common site of metastatic disease from both gastrointestinal and extra-intestinal malignancies. Historically, only a minority of patients with colorectal liver metastases were candidates for resection. However, over the past several decades, liver resection has evolved as a safe and potentially curative treatment for hepatic colorectal metastases. The development of active chemotherapy and molecular targeted therapies, together with newer modalities like radiofrequency ablation, have expanded the indications for hepatic resection and improved survival. Selected patients with isolated liver metastases from neuroendocrine tumors, germ cell cancers, ocular melanoma, gastrointestinal stromal tumors (GIST), and breast cancer also may be considered for hepatic surgery.

Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a matched case-control study

OBJECTIVE

To assess the impact of microsteatosis (MiS) and macrosteatosis (MaS) on major hepatectomy.

SUMMARY BACKGROUND DATA

While steatosis of a liver graft is an established risk factor in transplantation, its impact on major hepatectomy remains unclear.

METHODS

Fifty-eight steatotic patients who underwent major hepatectomy were matched 1:1 with patients with normal liver according to age, gender, ASA score, diagnosis, extent of hepatectomy, and need of hepaticojejunostomy. Steatosis was evaluated quantitatively and qualitatively. Primary endpoints were mortality and complications.

RESULTS

Pure MaS and MiS were present in only 10 and 3 patients, respectively, while mixed steatosis was noted in 45 patients. Forty-four patients had mild (10%-30%) and 14 moderate/severe (>30%) steatosis. Steatotic patients had significantly higher serum transaminase and bilirubin levels, and lower prothrombin time. Blood loss (P = 0.04) and transfusions (P = 0.03), and ICU stay (P = 0.001) were increased in steatotic patients. Complications were higher in steatotic patients when considered either overall (50% vs. 25%, P = 0.007) or major (27.5% vs. 6.9%, P = 0.001) complications. Patients with pure MaS had increased mortality (MaS: 20% vs. MiS: 6.6% vs. mixed: 0%; P = 0.36) and major complications (MaS: 66% vs. MiS: 50% vs. mixed: 24%; P = 0.59), but not significantly. Preoperative cholestasis was a highly significant risk factor for mortality in patients with hepatic steatosis.

CONCLUSION

Steatosis per se is a risk factor for postoperative complications after major hepatectomy and should be considered in the planning of surgery. Caution must be taken to perform major hepatectomy in steatotic patients with preexisting cholestasis.

Morbidity and mortality after liver resection: results of the patient safety in surgery study

BACKGROUND

Liver resection is performed with increasing frequency. Nearly all of the published information on operative mortality and morbidity rates associated with liver resection is derived from studies that rely on retrospective data collection from single centers. The goal of this study is to use audited multiinstitutional data from the private sector of the Patient Safety in Surgery Study to characterize complications after liver resection and to identify variables that are associated with 30-day morbidity and mortality.

STUDY DESIGN

Prospectively collected data on liver resection patients from 14 hospitals were collected using National Surgical Quality Improvement Program's methodology. Rates of occurrence of 21 defined postoperative complications were measured. Bivariate analyses and stepwise logistic regression were used to identify factors associated with 30-day morbidity and mortality.

RESULTS

At least one complication occurred in 22.6% of patients within 30 days. Stepwise logistic regression identified several preoperative factors associated with morbidity, including serum albumin, SGOT > 40, previous cardiac operation, operative work relative value unit, and history of severe COPD. Mortality within 30 days was observed in 2.6% of patients. Factors associated with mortality were found to be male gender, American Society of Anesthesiologists class 3 or higher, presence of ascites, dyspnea, and severe COPD. Only 0.7% of patients without any complications died, compared with 9.0% of patients with at least 1 complication (p < 0.0001).

CONCLUSIONS

Prospective, standardized, audited, multiinstitutional data were analyzed to identify several preoperative and intraoperative factors associated with morbidity and mortality after liver resection. These factors should be considered during patient selection and perioperative management.

Neoadjuvant chemotherapy for patients with liver metastases from colorectal cancer

Colorectal cancer is the second most common type of cancer in industrialized countries. Despite improved resection procedures and optimized adjuvant chemotherapy, local or distant recurrences occur in 22-25% of patients with stage II/III colon cancer. Approximately 30% of patients have advanced disease at presentation. The liver is the most common site of colorectal metastases and, interestingly, 20-30% of patients with colorectal cancer have liver-only metastases. The combined modality of chemotherapy and surgery increases overall survival and the chance of cure for metastatic patients, even if there is no agreement in terms of the best schedule and how long the treatment must last. In this paper, we review the role and the rationale of neoadjuvant chemotherapy within a multimodal approach, and discuss remaining questions and future directions.

Reversible grade 4 hyperbilirubinemia in a patient with UGT1A1 7/7 genotype treated with irinotecan and cetuximab

Irinotecan-induced gastrointestinal toxicities are common and typically present in the form of diarrhea or nausea and vomiting. However, severe hyperbilirubinemia (grade 3/4) has not been previously reported in association with this chemotherapeutic agent. We report a case of prolonged grade 4 hyperbilirubinemia after a single dose of irinotecan at 125 mg/m(2). This severe toxicity was attributed to a UGT1A1 7/7 genotype and resolved to grade 2 after 8 weeks of supportive care. This case outlines the possibility of severe hepatic toxicity with moderate doses of irinotecan in patients with a UGT1A1 7/7 genotype. Despite the severity and prolonged duration of the associated irinotecan-induced hepatic toxicity, the management of similar cases should focus on intensive supportive measures because the toxicity is likely to resolve eventually.