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

The Role of Chemotherapy in the Curative Treatment of Patients with Liver Metastases from Colorectal Cancer

As improved surgical techniques allow more patients with CRLM to be operated on with intent to cure, new systemic chemotherapy combinations and regional chemotherapy via the hepatic artery improve disease-free survival. Candidates for complete surgical resection with curative intent should proceed to surgery without neoadjuvant chemotherapy. Postoperative adjuvant therapy is appropriate for those remaining fit with potential for cure. Patients whose liver metastases cannot be resected safely who are otherwise fit for surgery should be treated aggressively with systemic or regional chemotherapy to sufficiently down stage the tumor for surgical resection. Correct timing of surgery, especially with bevacizumab use, has not been established. Without a multidisciplinary team, the potential to cure a select group of patients could be missed.

Preoperative chemotherapy for colorectal liver metastases: impact on hepatic histology and postoperative outcome

Some investigators have suggested that preoperative chemotherapy for hepatic colorectal metastases may cause hepatic injury and increase perioperative morbidity and mortality. The objective of the current study was to examine whether treatment with preoperative chemotherapy was associated with hepatic injury of the nontumorous liver and whether such injury, if present, was associated with increased morbidity or mortality after hepatic resection. Two-hundred and twelve eligible patients who underwent hepatic resection for colorectal liver metastases between January 1999 and December 2005 were identified. Data on demographics, clinicopathologic characteristics, and preoperative chemotherapy details were collected and analyzed. The majority of patients received preoperative chemotherapy (n = 153; 72.2%). Chemotherapy consisted of fluoropyrimidine-based regimens: 5-FU monotherapy, 31.6%; irinotecan, 25.9%; and oxaliplatin, 14.6%. Among those patients who received chemotherapy, the type of chemotherapy regimen predicted distinct patterns of liver injury. Oxaliplatin was associated with increased likelihood of grade 3 sinusoidal dilatation (p = 0.017). Steatosis >30% was associated with irinotecan (27.3%) compared with no chemotherapy, 5-FU monotherapy, and oxaliplatin (all p < 0.05). Irinotecan also was associated with steatohepatitis, as two of the three patients with steatohepatitis had received irinotecan preoperatively. Overall, the perioperative complication rate was similar between the no-chemotherapy group (30.5%) and the chemotherapy group (35.3%) (p = 0.79). Preoperative chemotherapy was also not associated with 60-day mortality. In patients with hepatic colorectal metastases, preoperative chemotherapy is associated with hepatic injury in about 20 to 30% of patients. Furthermore, the type of hepatic injury after preoperative chemotherapy was regimen-specific.

90Y radioembolization of metastatic breast cancer to the liver: toxicity, imaging response, survival

PURPOSE

To present data from patients with breast cancer liver metastases who underwent radioembolization with yttrium (90Y) microspheres.

MATERIALS AND METHODS

Using standard 90Y lobar treatment protocol, 27 female patients with progressing liver metastases on standard of care polychemotherapy were treated under an open-label phase 2 protocol. After treatment, we assessed (a) tumor response using computed tomography and/or positron emission tomography, (b) biochemical toxicity, and (c) survival.

RESULTS

The mean age of the patients was 52. Seventeen (63%) patients received 20 left lobe treatments (median radiation dose, 123 Gy; mean, 119 Gy), and 20 (74%) patients received 22 right lobe treatments (median radiation dose, 121 Gy; mean, 109 Gy) to the treatment site. No significant dose-difference was noted between the two lobes (P=.69). Tumor response on 90-day follow-up computed tomography showed (a) complete and partial response in nine (39.1%) patients, (b) stable disease in 12 (52.1%) patients, and (c) progressive disease in 2 (8.8%) patients. Positive tumor response on positron emission tomography was noted in 17 (63%) patients. Three of 27 (11%) patients (Eastern Cooperation Oncology Group 1, 2, or 3) showed bilirubin toxicity of grade 3, all of which were attributed to disease progression. Median survival for Eastern Cooperation Oncology Group 0 versus 1, 2, or 3 patients was 6.8 months and 2.6 months, respectively (P=.24) and for patients with tumor burden<25% versus >25% was 9.4 and 2.0 months, respectively (P=.46).

CONCLUSIONS

Radioembolization with 90Y brachytherapy device may be a viable therapeutic option for the treatment of breast cancer liver metastases in patients who have progressed or failed on standard of care polychemotherapy.

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.

Chemotherapy for colorectal cancer in the metastatic and adjuvant setting: past, present and future

There have been significant advances in the use of chemotherapy in the treatment of colorectal cancer patients over the last 20 years. Initial improvements in treatment were made with increased understanding of the pharmacology of 5-fluorouracil and the discovery of modulators of its activity (e.g., leucovorin). However, in the last few years the discovery of new cytotoxic drugs with efficacy in large bowel cancer (e.g., oxaliplatin and irinotecan) and monoclonal antibodies (e.g., bevacizumab and cetuximab) have significantly improved patient outcome and prognosis. Systemic chemotherapy in the metastatic setting has been shown to prolong survival and improve quality of life. Chemotherapy now also has a clear role as an adjunct to surgery to improve survival in stage III and certain 'high-risk' stage II colorectal cancer patients. The evolution of chemotherapy use, current practice in the metastatic and adjuvant setting and possible future directions are discussed.

Modern multimodality approach to hepatic colorectal metastases: solutions and controversies

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of those patients with disease limited to the liver, which translates into only 5-10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort being directed towards novel approaches to permit curative hepatic resection such as: neoadjuvant systemic and regional chemotherapy, pre-operative portal vein embolization for hypertrophy of future liver remnant, staged hepatic resection and radio frequency ablation combined with resection for addressing multiple bilobar metastases. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

Intraoperative margin re-resection for colorectal liver metastases

OBJECTIVE

Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases.

DESIGN

Retrospective analysis.

SETTING

University Hospital, Cincinnati, Ohio. Academic medical center.

PARTICIPANTS

Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21).

RESULTS

Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant.

CONCLUSION

Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.

Comparison of CT methods for determining the fat content of the liver

OBJECTIVE

The purpose of this study was to assess which of a number of methods of measuring attenuation on CT scans is best for prediction of hepatic fat content.

MATERIALS AND METHODS

This retrospective study was approved by our institutional review board. Consecutively registered patients who underwent liver resection for metastatic disease formed the study group. Attenuation measurements were obtained from 12 regions of interest in the liver and three in the spleen on both unenhanced and portal phase contrast-enhanced preoperative hepatic CT images. Hepatic attenuation measurements were analyzed both with and without normalization with the spleen. Normalization included both differences and ratios between hepatic and splenic attenuation values. Pathologic fat content was graded semiquantitatively as a percentage of the nonneoplastic liver parenchyma of the resected specimen. Average attenuation values of the liver were compared with pathologic fat content, as were the differences and ratios between hepatic and splenic attenuation values. Linear regression analysis was conducted on a log-log scale.

RESULTS

Data on 88 patients were analyzed. On unenhanced and contrast-enhanced CT images, all associations between pathologic fat content and attenuation measurements were significant (p < 0.0001). All series of R2 values for unenhanced CT scans were much higher than those for contrast-enhanced CT scans. The R2 values of liver-only measurement were higher than those of hepatic values normalized with splenic values on both unenhanced (0.646-0.649 > 0.523, 0.565) and contrast-enhanced (0.516 > 0.242, 0.344) CT.

CONCLUSION

Measurement of attenuation of liver only on unenhanced CT scans is best for prediction of pathologic fat content.

Safe liver resection following chemotherapy for colorectal metastases is a matter of timing

Neoadjuvant chemotherapy (NC) can improve the resectability of hepatic colorectal metastases (CRM). However, there is concern regarding its impact on operative risk. We reviewed 750 consecutive liver resections performed for CRM in a single unit (1996-2005) to evaluate whether NC affected morbidity and mortality. Redo hepatic resections or patients receiving adjuvant chemotherapy following primary resection were excluded. A total of 245 resections were performed in patients not requiring NC (control group) (mean age 63, 67% male) and 252 in patients who had NC (mean age 62, 67% male). The mean (s.d.) duration of surgery was less in the control group (241(64) vs 255(64)min, P=0.014) as was the mean blood loss (390(264) vs 449(424)ml, P=0.069). Postoperative mortality (2 vs 2%) and morbidity (27 vs 29%, P=0.34) was similar between groups. More NC patients developed septic (2.4%) or respiratory (10.3%) complications compared to controls (0 and 5.3%, P<0.03), with significantly more surgical complications if the interval between stopping NC and undergoing surgery was Collapse

Key Words

• colorectal metastases
• liver resection
• neoadjuvant chemotherapy

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MESH Headings

• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Chemotherapy, Adjuvant
• Colorectal Neoplasms/drug therapy
• Colorectal Neoplasms/pathology
• Combined Modality Therapy
• Female
• Hepatectomy
• Humans
• Liver Neoplasms/mortality
• Liver Neoplasms/secondary
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Neoadjuvant Therapy
• Neoplasm Staging
• Postoperative Care
• Prognosis
• Prospective Studies
• Survival Rate
• Time Factors
• Treatment Outcome

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Grants Collapse

Affiliation(s)

F K S Welsh Hepatobiliary Unit, North Hampshire Hospital, Basingstoke, UK
H S Tilney Department of Biosurgery and Surgical Technology, St Mary's Hospital, Imperial College, London, UK
P P Tekkis Department of Biosurgery and Surgical Technology, St Mary's Hospital, Imperial College, London, UK
T G John Hepatobiliary Unit, North Hampshire Hospital, Basingstoke, UK
M Rees Hepatobiliary Unit, North Hampshire Hospital, Basingstoke, UK

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Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases

BACKGROUND

Preoperative systemic chemotherapy is increasingly used in patients who undergo hepatic resection for colorectal liver metastases (CLM). Although chemotherapy-related hepatic injury has been reported, the incidence and the effect of such injury on patient outcome remain ill defined.

METHODS

A systematic review of relevant studies published before May 2006 was performed. Studies that reported on liver injury associated with preoperative chemotherapy for CLM were identified and data on chemotherapy-specific liver injury and patient outcome following hepatic resection were synthesized and tabulated.

RESULTS

Hepatic steatosis, a mild manifestation of non-alcoholic fatty liver disease (NAFLD), may occur after treatment with 5-fluorouracil and is associated with increased postoperative morbidity. Non-alcoholic steatohepatitis, a serious complication of NAFLD that includes inflammation and hepatocyte damage, can occur after treatment with irinotecan, especially in obese patients. Irinotecan-associated steatohepatitis can affect hepatic reserve and increase morbidity and mortality after hepatectomy. Hepatic sinusoidal obstruction syndrome can occur in patients treated with oxaliplatin, but does not appear to be associated with an increased risk of perioperative death.

CONCLUSION

Preoperative chemotherapy for CLM induces regimen-specific hepatic changes that can affect patient outcome. Both response rate and toxicity should be considered when selecting preoperative chemotherapy in patients with CLM.

Radioembolization with Yttrium-90 microspheres: review of an emerging treatment for liver tumors

Understanding the effect of radiation on tissue, the principles of dosimetry and fractionation have led to the acceptance and adoption of radiation as a standard treatment option for cancer. Delivered in staged and scheduled aliquots, radiation will break nucleic strands and cause cellular death. In general, radiation therapies are delivered using external techniques (external beam and intensity-modulated therapy). One of the limitations of such external techniques is that of nontarget radiation. That is, despite best efforts to collimate and reflect radiation beams to a small target, nontarget radiation and a dose to areas outside the tumor remains a distinct possibility. With the advent of radioembolization using Yttrium-90 microspheres (90Y), the radiation source is delivered optimally through a novel mechanism: directly into the blood vessel providing flow to the tumor. This revolutionary approach capitalizes on the basic principles of tumor hypervascularity, concentrating radiation within that tumor, while at the same time minimizing the risks of nontarget radiation. This review elaborates on this technology.

The continuum of care: a paradigm for the management of metastatic colorectal cancer

New agents for the treatment of metastatic colorectal cancer have extended median overall survival to more than 20 months, an increase that has changed the view of advanced colorectal cancer from an acute to a chronic condition. This article proposes a shift in treatment strategy from the concept of successive "lines" of therapy, in which chemotherapy is continued until disease progression, to that of a continuum of care, in which the use of chemotherapy is tailored to the clinical setting and includes switching chemotherapy prior to disease progression, maintenance therapy, drug "holidays," and surgical resection of metastases in selected patients. In this approach, the distinction between lines of therapy is no longer absolute. This represents a paradigm shift in the management of metastatic colorectal cancer to that of a continuum of care approach that includes individualized planning, in which patients are given the opportunity to benefit from exposure to all active agents and modalities while minimizing unnecessary treatment and toxicity, with the ultimate goal of improving survival as well as quality of life.

Predictors of early disease recurrence following hepatic resection for colorectal cancer metastasis

BACKGROUND

With the broadening indications of hepatic resection for colorectal liver metastases (CRLM), the exact group of patients who would benefit from surgery is still debatable. The aim of this study was to identify predictors for early recurrence, defined as recurrence within 6 months of CRLM resection, in order to identify those patients who may require further pre-operative radiological staging of the disease prior to surgery.

METHODS

Prospectively collected dataset of patients undergoing curative resection for CRLM during the 10-year period (January 1993-May 2003) were analyzed. Patients who received neo-adjuvant chemotherapy and patients who underwent repeat hepatic resections whose primary resection was not performed during the study period were excluded.

RESULTS

Four hundred and thirty patients (89%) were included in the analysis. Eighty-six (20%) patients developed early recurrence. Early recurrence was associated with poorer outcome when compared to late recurrences (p<0.001). The predictor of early recurrence on multivariable analysis was the presence of eight or more metastases (p=0.036).

CONCLUSION

We have identified a group of patients with multiple metastases who recur early following resection of CRLM. We suggest that these patients should be considered for additional pre-operative radiological workup in the form of PET scanning to identify those patients who would be deemed suitable for resection.

Fatty liver and the metabolic syndrome

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease and its subset nonalcoholic steatohepatitis represent the liver manifestations of insulin resistance. This review briefly summarizes advances in our understanding of the pathogenesis of nonalcoholic fatty liver disease and its prevalence, natural history and treatment.

RECENT FINDINGS

The recognition of the role the renin-angiotensin system in promoting insulin resistance is worth noting because of available drugs. Endoplasmic reticulum stress has also become a recent target of investigation because endoplasmic reticulum stress is common in obesity, diabetes and various forms of liver disease including nonalcoholic fatty liver disease. Endoplasmic reticulum stress may be responsible for activation of c-Jun kinase, a process that may cause the hepatocellular injury in nonalcoholic steatohepatitis. Progress has also been made in estimating the prevalence of nonalcoholic fatty liver disease in adults and children. Patients enrolled in the Dallas Heart Study were found to have a 33% prevalence of nonalcoholic fatty liver disease and children dying of accidental deaths in San Diego were found to have a 13% prevalence of nonalcoholic fatty liver disease. Because about 10% of people with nonalcoholic fatty liver disease are at risk for progressive fibrosis, the burden of this disease is now quite substantial.

SUMMARY

Incremental progress in understanding nonalcoholic fatty liver disease and nonalcoholic steatohepatitis promises to lead to new therapeutic options for this common disease.

Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy

BACKGROUND

To establish a reliable definition of postoperative hepatic insufficiency (PHI) in noncirrhotic patients undergoing major hepatectomy. No standard definition of PHI has been established, but one is essential for meaningful comparison of outcomes data across studies.

METHODS

Data from 1,059 noncirrhotic patients who underwent major hepatectomy (3 or more liver segments) at 3 centers from 1995 to 2005 were analyzed. Receiver operating characteristics (ROC) analysis of peak postoperative bilirubin ((Peak)Bil) and international normalized ratio ((Peak)INR) were used to define PHI.

RESULTS

A total of 669 patients (63%) underwent resection of 3 to 4 liver segments; 390 (37%) underwent resection of 5 or more segments. Complications occurred in 453 (43%). The 90-day all-cause mortality rate was 4.7%, which is 47% higher than the 30-day rate (3.2%). Twenty (1.9%) patients died of causes unrelated to the liver. Of the remaining 1,039 patients, 30 (2.8%) died a median 36 days from liver-related causes (liver failure with or without multiorgan failure). ROC analysis revealed cut-offs that predict liver-related death are (Peak)Bil 7.0 mg/dL (area under the curve 0.982; sensitivity 93.3%; specificity 94.3%) and (Peak)INR 2.0 (area under the curve 0.846; sensitivity 76.7%; specificity 82.0%). (Peak)Bil > 7.0 mg/dL was the most powerful predictor of any (odds ratio [OR] = 83.3) or major complication (OR = 10.0), 90-day mortality (OR = 10.8), and 90-day liver-related mortality (OR = 250) (all p < 0.0001).

CONCLUSIONS

PHI defined as (Peak)Bil > 7.0 mg/dL accurately predicts liver-related death and worse outcomes after major hepatectomy. Standardized reporting of complications, PHI, and 90-day mortality is essential to accurately determine the risk of major hepatectomy and to compare outcomes data.

Role of ischaemic preconditioning in liver regeneration following major liver resection and transplantation

Liver ischaemic preconditioning (IPC) is known to protect the liver from the detrimental effects of ischaemic-reperfusion injury (IRI), which contributes significantly to the morbidity and mortality following major liver surgery. Recent studies have focused on the role of IPC in liver regeneration, the precise mechanism of which are not completely understood. This review discusses the current understanding of the mechanism of liver regeneration and the role of IPC in this setting. Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords “liver”, “ischaemic reperfusion”, “ischaemic preconditioning”, “regeneration”, “hepatectomy” and “transplantation”. The underlying mechanism of liver regeneration is a complex process involving the interaction of cytokines, growth factors and the metabolic demand of the liver. IPC, through various mediators, promotes liver regeneration by up-regulating growth-promoting factors and suppresses growth-inhibiting factors as well as damaging stresses. The increased understanding of the cellular mechanisms involved in IPC will enable the development of alternative treatment modalities aimed at promoting liver regeneration following major liver resection and transplantation.

Resection of hepatic colorectal metastases involving the caudate lobe: perioperative outcome and survival

PURPOSE

To examine clinical features and outcome of patients who underwent hepatic resection for colorectal liver metastases (LM) involving the caudate lobe.

PATIENTS AND METHODS

Consecutive patients who underwent hepatic resection for LM from May 1990 to September 2004 were analyzed from a multicenter database. Demographics, operative data, pathologic margin status, recurrence, and survival were analyzed.

RESULTS

Of 580 patients, 40 (7%) had LM involving the caudate. Six had isolated caudate LM and 34 had LM involving the caudate plus one or more other hepatic segments. Patients with caudate LM were more likely to have synchronous primary colorectal cancer (63% vs. 36%; P = 0.01), multiple LM (70% vs. 51%; P = 0.02) and required extended hepatic resection more often than patients with non-caudate LM (60% vs. 18%; P < 0.001). Only four patients with caudate LM underwent a vascular resection; three at first operation, one after recurrence of a resected caudate tumor. All had primary repair (vena cava, n = 3; portal vein, n = 1). Perioperative complications (43% vs. 28%) and 60-day operative mortality (0% vs. 1%) were similar (caudate vs. non-caudate LM, both P > 0.05). Pathological margins were positive in 15 (38%) patients with caudate LM and in 43 (8%) with non-caudate LM (P < 0.001). At a median follow-up of 40 months, 25 (64%) patients with caudate LM recurred compared with 219 (40%) patients with non-caudate LM (P = 0.01). Patients with caudate LM were more likely to have intrahepatic disease as a component of recurrence (caudate: 51% vs. non-caudate: 25%; P = 0.001). No patient recurred on the vena cava or portal vein. Patients with caudate LM had shorter 5-year disease-free and overall survival than patients with non-caudate LM (disease-free: 24% vs. 44%; P = 0.02; overall: 41% vs. 58%; P = 0.02).

CONCLUSIONS

Patients who undergo hepatic resection for caudate LM often present with multiple hepatic tumors and tumors in proximity to the major hepatic veins. Extended hepatectomy is required in the majority, although vascular resection is not frequently necessary; when performed, primary repair is usually possible. Despite resection in this population of patients with multiple and bilateral tumors, and despite close-margin and positive-margin resection in a significant proportion, recurrence on the portal vein or vena cava was not observed, and long-term survival is accomplished (41% 5-year overall survival).

Practical questions in liver metastases of colorectal cancer: general principles of treatment

Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.

Stellenwert der Anästhesie in multimodalen onkologischen Therapiekonzepten

Patients with malignant diseases are increasingly being treated with multimodal therapeutical concepts based on the three major modalities surgery, radiotherapy and chemotherapy. The perioperative period is crucial within this multimodal concept as the prognosis of patients may be directly influenced by perioperative measures. In addition, it is of major importance to avoid complications in the perioperative phase, as these might worsen the prognosis of the patient and in order to prevent a delay in the beginning of planned adjuvant therapies. These aspects demonstrate the important role of anesthesia in the treatment of patients with cancer. Further studies defining the relevance of anesthesiologic measures in oncologic patients are needed.

Liver resection for metastatic colorectal cancer in the age of neoadjuvant chemotherapy and bevacizumab

Hepatic metastases from colorectal carcinoma (CRC) were once thought to portend a uniformly grim outcome; however, improvements in chemotherapeutic and surgical approaches have led to significant advances as well as new clinical challenges. Some 60% of the 150,000 patients diagnosed with CRC each year in the United States will develop hepatic metastases. Only a fraction of these metastases are resectable at the time of presentation, but an increasing number of patients are able to undergo resection after neoadjuvant chemotherapy. Additionally, recent trials have demonstrated the efficacy of using chemotherapy with bevacizumab as first-line therapy for metastatic CRC, but how this treatment will affect surgical resection is unknown. Herein, we review the recent literature regarding neoadjuvant chemotherapy for hepatic metastases from CRC, discuss key aspects of the basic science of hepatic regeneration with regard to angiogenic mediators, and outline the key problems to be solved so that a rational strategy can be developed to treat patients with hepatic colorectal metastases in the age of neoadjuvant chemotherapy and antiangiogenic drugs.

Liver histology and surgical outcomes after preoperative chemotherapy with fluorouracil plus oxaliplatin in colorectal cancer liver metastases

PURPOSE

Preoperative chemotherapy for colorectal liver metastases (CLM) can produce histologic changes in the nontumor-bearing liver (NTBL) that may impact on surgical outcomes.

PATIENTS AND METHODS

From a cohort of 303 patients treated for CLM with liver resection, 92 patients (75 received preoperative chemotherapy: group C+; and 17 were chemotherapy naïve: group C-) were randomly selected for detailed pathologic analysis. Preoperative chemotherapy consisted of fluorouracil (FU)/leucovorin alone (23 patients, the majority chronomodulated) or in combination with oxaliplatin (52 patients, all chronomodulated). To determine associations between study factors, clinical and operative variables were compared with pathology data and surgical outcomes.

RESULTS

Although clinical and operative factors were similarly distributed, C+ patients, compared with C- patients, were more likely to receive intraoperative RBC transfusions (mean units: 1.9 v 0.5, respectively; P = .03) and to have vascular abnormalities in the NTBL (52% v 18%, respectively; P = .01). Presence of the most severe forms of vascular alterations was closely associated with RBC transfusion requirements (P = .04). In contrast, moderate to severe steatosis was similarly distributed (C- group, 12%; C+ group, 13%). Although perioperative mortality and morbidity rates were similar in all groups, more than 12 courses of chemotherapy, compared with < or = 12 courses, predisposed patients to reoperation (11% v 0%, respectively; P = .04) and to longer hospitalization (15 v 11 days, respectively; P = .02).

CONCLUSION

The main hepatic lesion induced by preoperative FU/oxaliplatin chemotherapy in patients with CLM is vascular and not steatosis. Detailed pathologic analysis determined that the most severe vascular lesions are associated with increased intraoperative transfusions. The risk for other postoperative complications is related to the duration of preoperative chemotherapy administration.

Portal thrombosis and steatosis after preoperativechemotherapy with FOLFIRI-bevacizumab for colorectal liver metastases

In order to discuss the role of preoperative chemo-therapy for colorectal liver metastases, which is used frequently before hepatic resection, even in patients with resectable disease at presentation, we herein report the development of two complications, partial portal vein thrombosis and hepatic steatosis with lobular inflammation, during the course of preoperative chemotherapy with FOLFIRI plus bevacizumab for colorectal liver metastases, which recognition led to timely discontinuation of chemotherapy as well as a change in the surgical strategy to resect the tumors and the damaged liver through advanced techniques. We conclude that duration of treatment and drug doses and combinations may impact the development of chemotherapy-induced liver injury. Surgeons and medical oncologists must work together to devise safe, rational, and oncologically appropriate treatments for patients with multiple colorectal liver metastases, and to improve the understanding of the pathogenesis of chemotherapy-induced liver injury.

Selective resection of colorectal liver metastases

AIMS

Safety of liver surgery for colorectal cancer liver metastases after neoadjuvant chemotherapy has to be re-evaluated.

PATIENTS AND METHODS

Two hundred Patients were prospectively analyzed after surgery for colorectal cancer liver metastases between 2001 and 2004 at our institution. Special emphasis was given to perioperative morbidity and mortality under modern perioperative care.

RESULTS

There was no in-hospital mortality and the perioperative morbidity was 10% (20/200). Four patients had to be reoperated due to bile leak or intraabdominal abscess. The remainder either had infectious complications or pleural effusion and/or ascites requiring tapping. Variables strongly associated with decreased survival were T, N, G and UICC (International Union against cancer) classification of the primary, hepatic lesions>5 cm and elevated tumour markers. Short disease free interval and neoadjuvant chemotherapy without response predicted impaired recurrence free survival (RFS). Multivariate analysis revealed lymph node status and differentiation of the primary, presence of extrahepatic tumour and gender as factors associated with decreased survival. Administration of neoadjuvant chemotherapy was not associated with higher postoperative morbidity or prolonged hospital stay.

CONCLUSIONS

Modern dissection techniques and improved perioperative care contributed to a very low rate of surgery-related morbidity (10%) and a zero percent mortality which was also observed in patients pretreated with neoadjuvant chemotherapy prior to resection. Liver resection in experienced hands has become a safe part in the potentially curative attempt of treating patients with metastatic colorectal cancer.

Radioembolization with 90Yttrium Microspheres: A State-of-the-Art Brachytherapy Treatment for Primary and Secondary Liver Malignancies

Yttrium-90 microspheres are increasingly being used as a treatment modality for primary and secondary liver tumors. As these therapies continue to be accepted, it is natural that their application in more complex clinical scenarios will become more common. This article is meant to introduce these controversies and to generate interest and dialogue by the interventional oncology community. This discussion is based on more than 900 (90)Y radioembolization procedures performed over a 5-year period.

Metastatic colorectal cancer

Metastatic colorectal cancer remains a public-health issue on a global scale. With development of a new generation of cytotoxic agents, survival has improved for patients with metastatic disease. How to maximize the benefit of chemotherapy with acceptable toxicity remains incompletely answered. Hepatic resection can provide a significant hope for long term survival, and a subset of patients might benefit from perioperative approaches. More recently, specific molecular processes have been targeted for therapeutic interventions, and encouraging results have been achieved using inhibitors of the Epidermal Growth Factor Receptor and the Vascular Endothelial Growth Factor.

Biological agents versus chemotherapy in the treatment of colorectal cancer

Biological agents are commonly incorporated as an adjunct to cytotoxic chemotherapy in the treatment of patients with advanced colorectal cancer. In contrast to cytotoxic chemotherapy, biological agents have minimal single agent activity and are largely considered to be cytostatic. Recent data supports the use of either combination regimens with chemotherapy and/or biological therapy. Interest in combining biological agents of co-existing molecular pathways is the most recent strategic approach. However, with the advent of these novel therapies, questions have arisen regarding appropriate clinical indication and potential treatment-related toxicities. The role of biological agents in the treatment of colorectal cancer and their role in contrast to cytotoxic chemotherapy will be explored.

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.