Role of neoadjuvant chemotherapy in the treatment of multiple colorectal metastases to the liver

Surgery for colorectal liver metastases: The evolution of determining prognosis

Despite improvements in the multi-modality treatment of colorectal liver metastasis (CRLM), survival after resection remains varied. Determining prognosis after surgical resection has historically been predicated on preoperative clinicopathological factors such as primary tumor stage, carcinoembryonic antigen levels, number of liver metastases, presence of extrahepatic disease, as well as other factors. While scoring systems have been developed by combining certain preoperative factors, these have been inconsistent in accurately determining prognosis. There has been increasing interest in the use of biologic and molecular markers to predict prognosis following CRLM. The role of markers such as KRAS, BRAF, p53, human telomerase reverse transcriptase, thymidylate synthase, Ki-67, and hypoxia inducible factor-1α and their correlation with accurately predicting survival after surgical resection have been supported by several studies. Furthermore, other elements such as pathological response to chemotherapy and the presence of circulating tumor cells have shown promise in accurately determining prognosis after resection for colorectal liver metastasis. We herein review past, present, and possible future markers of prognosis among colorectal cancer patients with liver metastasis undergoing resection with curative intent.

Limiting factors for liver regeneration after a major hepatic resection for colorectal cancer metastases

BACKGROUND

Chemotherapy before resection of colorectal metastases in the liver is extensively used and has been shown to induce histopathological changes in the liver parenchyma, although little is known about the effect of chemotherapy on liver regeneration. The aim of this study was to determine if pre-operative chemotherapy influences the regenerated liver volume after a major liver resection.

PATIENTS AND METHODS

This retrospective cohort study included 74 patients subjected to a major liver resection for colorectal metastases. Patients were divided into two groups depending on whether they had been treated with chemotherapy less than 3 months before surgery or not. Liver volumes were measured before and 1 year after resection.

RESULTS

Pre-operative chemotherapy reduced volumetric liver regeneration (83 ± 2% versus 91 ± 2%; P = 0.007) as compared with patients without chemotherapy. There was a linear correlation between regenerated volume and time interval between the end of chemotherapy to resection (P = 0.031).

CONCLUSIONS

Pre-operative chemotherapy in patients with colorectal liver metastases negatively affects volume regeneration after a partial hepatectomy. The time interval between chemotherapy and surgery determines the impact of these affects.

Prognostic factors after resection of colorectal liver metastases: from morphology to biology

Despite improved overall survival rates after potentially curative liver resection (~50-58% at 5 years), almost half of patients experience disease recurrence highlighting the need for a precise definition of outcomes to stratify patients for clinical trials and to guide treatment decisions. In the past, several factors, such as an advanced primary T stage, the primary N+ status, a large tumor size, multiple tumors, a disease-free interval of <12 months, an elevated carcinoembryonic antigen level, the presence of an extrahepatic disease, and the margin width (<1 cm) and status (positive), have been recognized to predict poor outcomes, but most of them lack the sensitivity for accurate individual prognostication. Thus, in recent years, new factors, such as response to chemotherapy, either clinical or pathological, that more closely reflect tumor biology have been established and adopted in the clinical practice. Similarly, biomarkers of poor prognosis, especially mutations in KRAS and BRAF and the expression of thymidylate synthase, have been studied, yielding promising results. However, robust evidence of their prognostic utility awaits prospective validation.

Liver resection for colorectal liver metastases with peri-operative chemotherapy: oncological results of R1 resections

BACKGROUND

Retrospective analysis of outcomes of R0 (negative margin) versus R1 (positive margin) liver resections for colorectal metastases (CLM) in the context of peri-operative chemotherapy.

METHODS

All CLM resections between 2000 and 2006 were reviewed. Exclusion criteria included: macroscopically incomplete (R2) resections, the use of local treatment modalities, the presence of extra-hepatic disease and no peri-operative chemotherapy. R0/R1 status was based on pathological examination.

RESULTS

Of 86 eligible patients, 63 (73%) had R0 and 23 (27%) had R1 resections. The two groups were comparable for the number, size of metastases and type of hepatectomy. The R1 group had more bilobar CLM (52% versus 24%, P = 0.018). The median follow-up was 3.1 years. Five-year overall and disease-free survival were 54% and 21% for the R0 group and 49% and 22% for the R1 group (P = 0.55 and P = 0.39, respectively). An intra-hepatic recurrence was more frequent in the R1 group (52% versus 27%, P = 0.02) and occurred more frequently at the surgical margin (22% versus 3%, P = 0.01).

DISCUSSION

R1 resections were associated with a higher risk of intra-hepatic and surgical margin recurrence but did not negatively impact survival suggesting that in the era of efficient chemotherapy, the risk of an R1 resection should not be considered as a contraindication to surgery.

Preoperative administration of bevacizumab is safe for patients with colorectal liver metastases

AIM: To assess the impact of preoperative neoadjuvant bevacizumab (Bev) on the outcome of patients undergoing resection for colorectal liver metastases (CLM).

METHODS: Eligible trials were identified from Medline, Embase, Ovid, and the Cochrane database. The data were analyzed with fixed-effects or random-effects models using Review Manager version 5.0.

RESULTS: Thirteen nonrandomized studies with a total of 1431 participants were suitable for meta-analysis. There was no difference in overall morbidity and severe complications between the Bev + group and Bev - group (43.3% vs 36.8%, P = 0.06; 17.1% vs 11.4%, P = 0.07, respectively). Bev-related complications including wound and thromboembolic/bleeding events were also similar in the Bev + and Bev - groups (14.4% vs 8.1%, P = 0.21; 4.1% vs 3.8%, P = 0.98, respectively). The incidence and severity of sinusoidal dilation were lower in patients treated with Bev than in patients treated without Bev (43.3% vs 63.7%, P < 0.001; 16.8% vs 46.5%, P < 0.00, respectively).

CONCLUSION: Bev can be safely administered before hepatic resection in patients with CLM, and has a protective effect against hepatic injury in patients treated with oxaliplatin chemotherapy.

Single-center multidisciplinary management of patients with colorectal cancer and resectable synchronous liver metastases improves outcomes

BACKGROUND

Management of patients with synchronous liver metastasis (SLM) is complex and the surgical decision process should be based on a comprehensive oncological strategy. The aim of the study was to compare outcome of single-center management of patients with colorectal cancer (CRC) and resectable SLM to those of referred patients for liver resection only after removal of their primary tumor (PT).

METHODS

Between 2000 and 2007, 47 patients with CRC and SLM underwent resection of both the PT and metastases under our care (unicentric) and 32 were referred after resection of their PT.

RESULTS

The two groups were comparable for demographics, PT and metastatic disease data. In unicentric group, 23% received upfront chemotherapy with the PT in place, 53% had a combined CRC and SLM resection, 11% had a two-stage hepatectomy with resection of the primary during the first stage and 36% underwent delayed hepatectomy. The number of surgical interventions, the delay between diagnosis and liver resection (9 vs. 5 months, P < 0.001), the median number of cycles of chemotherapy before hepatectomy (12 vs. 6 months, P < 0.001) were significantly higher in the referred group. Postoperative morbidity was significantly higher in the referred group (75 vs. 47%, P = 0.023). The median follow-up was 43 months. OS and DFS were not significantly different between the two groups.

CONCLUSION

Although the survival benefit is not proven, single-center management of patients with CRC and resectable SLM reduces the number of interventions, the number of cycles of chemotherapy and postoperative morbidity.

Staging of colorectal liver metastases after preoperative chemotherapy. Diffusion-weighted imaging in combination with Gd-EOB-DTPA MRI sequences increases sensitivity and diagnostic accuracy

OBJECTIVES

To compare the diagnostic accuracy and sensitivity of Gd-EOB-DTPA MRI and diffusion-weighted (DWI) imaging alone and in combination for detecting colorectal liver metastases in patients who had undergone preoperative chemotherapy.

METHODS

Thirty-two consecutive patients with a total of 166 liver lesions were retrospectively enrolled. Of the lesions, 144 (86.8 %) were metastatic at pathology. Three image sets (1, Gd-EOB-DTPA; 2, DWI; 3, combined Gd-EOB-DTPA and DWI) were independently reviewed by two observers. Statistical analysis was performed on a per-lesion basis.

RESULTS

Evaluation of image set 1 correctly identified 127/166 lesions (accuracy 76.5 %; 95 % CI 69.3-82.7) and 106/144 metastases (sensitivity 73.6 %, 95 % CI 65.6-80.6). Evaluation of image set 2 correctly identified 108/166 (accuracy 65.1 %, 95 % CI 57.3-72.3) and 87/144 metastases (sensitivity of 60.4 %, 95 % CI 51.9-68.5). Evaluation of image set 3 correctly identified 148/166 (accuracy 89.2 %, 95 % CI 83.4-93.4) and 131/144 metastases (sensitivity 91 %, 95 % CI 85.1-95.1). Differences were statistically significant (P < 0.001). Notably, similar results were obtained analysing only small lesions (<1 cm).

CONCLUSIONS

The combination of DWI with Gd-EOB-DTPA-enhanced MRI imaging significantly increases the diagnostic accuracy and sensitivity in patients with colorectal liver metastases treated with preoperative chemotherapy, and it is particularly effective in the detection of small lesions.

Progression while receiving preoperative chemotherapy should not be an absolute contraindication to liver resection for colorectal metastases

PURPOSE

Tumor progression while receiving neoadjuvant chemotherapy (PD) has been associated with poor outcome and is commonly considered a contraindication to liver resection (LR). This study aims to clarify in a large multicenter setting whether PD is always a contraindication to LR.

METHODS

Data from the LiverMetSurvey international registry were analyzed. Patients undergoing LR for colorectal metastases without extrahepatic disease after neoadjuvant chemotherapy between 1990 and 2009 were reviewed.

RESULTS

Among 2143 patients, PD occurred in 176 (8.2 %). Risk of progression was increased after 5-FU or irinotecan (22.7 % vs. 6.8 % after other regimens, p < 0.0001; 14.9 % vs. 7.2 %, p < 0.0001), while it was reduced after oxaliplatin (5.6 % vs. 12.0 %, p < 0.0001) and still diminished among patients receiving targeted therapies (2.6 %). PD was an independent prognostic factor of survival at multivariate analysis (35 % vs. 49 %, p = 0.0006). In the PD group, 3 independent prognostic factors were identified: carcinoembryonic antigen (CEA) ≥ 200 ng/mL (p = 0.003), >3 metastases (p = 0.028), and tumor diameter ≥ 5 0 mm (p = 0.002). A survival predictive model showed that patients without any risk factors had 5-year survival rates of 53.3 %; good survival results were still observed if metastases were >3 or ≥ 50 mm (29.9 and 19.1 %, respectively). On the contrary, survival was less than 10 % at 3 years in the presence of >1 prognostic factor or CEA of ≥ 200 ng/mL.

CONCLUSIONS

PD is a negative prognostic factor, but it is not an absolute contraindication to LR. Patients with PD could be scheduled for LR except for those with >3 metastases and ≥ 50 mm, or CEA ≥ 200 ng/mL in whom further chemotherapy is recommended.

Outcome of patients with colorectal liver metastasis: analysis of 1,613 consecutive cases

OBJECTIVE

This study was designed to evaluate the long-time outcome of patients with colorectal liver metastasis (CRLM) undergoing different types of therapy and identify prognosis factors.

METHODS

From 2000 to 2010, 1,613 consecutive patients with CRLM were identified. Clinicopathological and outcome data were collected and analyzed by univariate and multivariate analyses.

RESULTS

Synchronous liver metastasis (SLM), female, grade III-IV, T4 and N positive of primary tumor, bilobar disease, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, serum CEA level ≥ 5 ng/ml, and CA19-9 level ≥ 37 u/ml were the predictors of adverse outcome using univariate analysis. The median survival and 5-year survival rate for patients after resection of liver metastases was 49.8 months and 47%, better than that for those after other therapy. In addition, patients without treatment had the poorest survival. Sixty-four initially unresectable patients underwent surgery after conversion therapy with a median survival of 36.9 months and a 5-year survival of 30%. By multivariate analysis, SLM, poorly differentiated primary tumor, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, and no surgical treatment of liver metastases were found to be independent predictors of poor survival.

CONCLUSIONS

Patients with CRLM could get long-term survival benefit from different types of therapy, and resection of liver metastases was the optimal strategy. A predictive model using these above five factors may be of use in stratifying patients who may benefit from intensive surveillance and adjuvant therapy.

Locally advanced mid/low rectal cancer with synchronous liver metastases

BACKGROUND

Management of patients with T3/4 and/or N+ mid/low rectal cancer with synchronous liver metastases is not codified. The aim of this study was to analyze outcomes of our approach which consists of neoadjuvant chemotherapy or chemoradiotherapy, according to liver disease extension, followed by simultaneous rectal and liver resection.

METHODS

Between 2000 and 2009, 354 patients underwent hepatectomy for synchronous metastases. Thirty-six consecutive patients who underwent rectal and liver resection for metastatic T3/4 and/or N+ mid/low rectal cancer were analyzed.

RESULTS

Liver metastases were multiple in 27 patients, bilobar in 22, and >5 cm in six. Up-front treatment was chemotherapy in 15 patients, chemoradiotherapy in seven, chemotherapy followed by chemoradiotherapy in six, and surgery in eight (five symptomatic tumors). After chemotherapy alone (median number of cycles = 6), primary tumor response was observed in 11 patients (three complete responses). After chemoradiotherapy, only one patient had liver disease progression. Eighty-nine percent of patients underwent simultaneous rectal and hepatic resection. Mortality and morbidity rates were 2.8% (one pulmonary embolism) and 36%, respectively. After a mean follow-up of 39 months, 5-year overall and disease-free survival were 59.3 and 39.6%, respectively. Twenty-one patients had recurrence, including three pelvic recurrences (8.3%). No pelvic recurrence occurred among patients who correctly completed treatment strategy. All patients who received neoadjuvant chemoradiotherapy were alive and disease-free; 5-year overall and disease-free survival of patients receiving neoadjuvant chemotherapy were 59.3 and 25%, respectively.

CONCLUSIONS

For patients with metastatic T3/4 and/or N+ mid/low rectal cancer, the present strategy was safe and effective. Good disease control was achieved by neoadjuvant treatments, low morbidity rates were associated with simultaneous resection, and excellent long-term outcomes with low local relapse rate were obtained.

Evolution of long-term outcome of liver resection for colorectal metastases: analysis of actual 5-year survival rates over two decades

BACKGROUND

Liver resection (LR) is the only potentially curative treatment of colorectal liver metastases (CRLM). Its outcome over the past 2 decades was studied using actual 5-year survival rates.

METHODS

Data of 393 consecutive patients who underwent LR for CRLM at Mauriziano Umberto I (Turin) until June 2005 were analyzed. Excluding R2 resections (n = 4) or incomplete 5-year follow-up (n = 13), 376 patients were divided according to LR date into groups A (before 1995: 90 patients), B (1995-2000: 94 patients), C (2001-2005: 192).

RESULTS

Group C presented increased multiple and bilobar metastases compared with combined group A and B (C vs AB: 54.7% vs 40.2%, P = 0.005; 28.1% vs 19.0%, P = 0.038, respectively), decreased metastases diameter (C vs AB: 32 vs 40 mm, P = 0.0001). The 5-year overall survival, calculated excluding 4 operative mortalities (group AB), increased over the years (A, 20.5%; B, 32.6%; C, 46.4%; P < 0.0001). Early recurrences (1 year) were not decreased, extrahepatic recurrences even increased (C vs AB: 17.2% vs 8.6%, P = 0.015). Recurrence-free 5-year survival improved (C vs AB: 23.4% vs 13.9%, P = 0.019) linked to decreased liver recurrences (C vs AB: 26.8% vs 37.4%, P = 0.023). Resection rate (59% overall for liver recurrence) increased along with 5-year survival after recurrence (A, 4.0%; B, 14.2%; C, 21.4%; P < 0.0001). Survival improvement was confirmed for multiple (P = 0.003) and synchronous metastases (P = 0.008), N+ tumors (P = 0.005), and in patients without chemotherapy (P = 0.001).

CONCLUSIONS

Long-term outcome of LR for CRLM improved over 20 years, even in patients with negative prognostic factors, linked to hepatic recurrences reduction and increased survival after recurrence.

Predictive factors for anastomotic leakage after simultaneous resection of synchronous colorectal liver metastasis

BACKGROUND

The optimal surgical strategy for resectable, synchronous, colorectal liver metastases remains unclear. The objective of this study was to determine which patients could benefit from staged resections instead of simultaneous resection by identifying predictive factors for postoperative morbidity and anastomotic leakage after simultaneous resection of synchronous, colorectal liver metastases and the primary colorectal tumor.

METHODS

This study involved 86 patients with synchronous colorectal liver metastases who underwent simultaneous resection of the primary colorectal tumor and the hepatic tumor. Postoperative mortality, morbidity, and other surgical outcomes, including survival and hospitalization, were assessed. Predictive factors for postoperative morbidity and for anastomotic leakage were evaluated.

RESULTS

Postoperative morbidity and anastomotic leakage were found in 55 (64%) and 18 (21%) patients. Predictive factors for postoperative morbidity and for anastomotic leakage were intraoperative blood loss and operation time >8 h, respectively. The overall 5-year survival rate was 45%.

CONCLUSIONS

The frequency of morbidity and that of anastomotic leakage seemed to be high after simultaneous resection for synchronous colorectal liver metastases, especially when intraoperative blood loss or operation time increased greatly. Staged resections should be considered in cases in which excessive surgical stress from simultaneous resection of synchronous colorectal liver metastases would be expected.

Surgical treatment of colorectal cancer liver metastases

Treatment strategies for patients with stage IV colorectal cancer have changed markedly in the last decade. Patients with colorectal cancer metastases to the liver have always been a fascinating group to consider biologically and for local-regional treatment strategies. In the late 1980s through the 1990s, resection was performed for a select subset of patients who had resectable disease. However, a high proportion of patients had bilobar unresectable disease and were treated with either 5-fluorouracil-based systemic chemotherapy or implanted hepatic arterial infusion pumps. The advent of the new millennium was associated with the availability of several new cytotoxic and biologic agents active in colorectal cancer. These agents have completely changed the approach to the treatment of patients with colorectal cancer liver metastases and thus have increased the complexity of the decision-making process for treatment of these patients.

Safety of hepatic resection for colorectal metastases in the era of neo-adjuvant chemotherapy

PURPOSE

The relationship between neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases and post-operative morbidity still has to be clarified.

METHODS

Data from 242 patients undergoing hepatectomy for colorectal liver metastases, judged resectable at first observation, were reviewed and their clinical outcome was related to neo-adjuvant chemotherapy (125 patients). Selection biases were outlined and properly handled by means of propensity score analysis.

RESULTS

Post-operative death was 1.2% and morbidity 40.9%. Pre-operative chemotherapy was only apparently related to higher morbidity (P = 0.021): multivariate analysis identified extension of hepatectomy and intra-operative blood loss as independent prognostic variables (P < 0.05). Patients receiving and not receiving neo-adjuvant chemotherapy were significantly different for several covariates, including extension of hepatectomy (P = 0.049). After propensity score adjustment, 94 patients were identified as having similar covariate distribution (standardized differences <|0.1|) except for neo-adjuvant treatment (47 patients for each group). In this matched sample, mortality was similar and post-operative complications were only slightly higher (hazard ratio = 1.38) in treated patients. A significantly higher need for fluid replacement was only observed in patients receiving neo-adjuvant chemotherapy (P = 0.038).

CONCLUSIONS

Neo-adjuvant chemotherapy showed a limited role in determining post-operative morbidity after hepatic resection and did not modify mortality.

[Surgical treatment of liver metastasis in patients with colorectal cancer]

Half of patients with colorectal cancer have liver metastasis during their illness. Surgical resection of metastases represents the only curative treatment with prolonged survival in more than 50 % of patients. The aim of liver resection is complete excision of the lesions with histological negative margins while preserving sufficient functional liver parenchyma. In patients with diffuse liver disease, the radiofrequency ablation of metastases may be associated with surgical resection. The use of portal vein remobilization and neoadjuvant chemotherapy can also increase the number of patients for curative treatment. Despite this progress, from 50 to 60 % of patients relapse after complete resection of MHCCR. Surgical treatment of recurrent aggressive and effective chemotherapy allows the prolonged survival of these patients. The modern treatment of liver metastasis of colorectal cancers can be envisaged as part of a multidisciplinary approach to increase the number of patients for curative treatment.

Ten-year survival after liver resection for colorectal metastases: systematic review and meta-analysis

Background. Liver resection in metastatic colorectal cancer is proved to result in five-year survival of 25–40%. Several factors have been investigated to look for prognostic factors stratifications such as resection margins, node involvement in the primary disease, and interval between the primary disease and liver metastases. Methods. We searched MEDLINE and EMBASE for studies that reported ten-year survival. Metaanalysis was performed to analyse the effect of recognised prognostic factors on cure rate for colorectal metastases. The meta-analysis was performed according to Ottawa-Newcastle method of analysis for nonrandomised trials and according to the guidelines of the PRISMA. Results. Eleven studies were included in the analysis, which showed a ten-year survival rate of 12–36%. Factors that have favourable impact are clear resection margin, low level of CEA, single metastatic deposit, and node negative disease. The only factor that excluded patients from cure is the positive status of the resection margin. Conclusion. Predicted ten-year survival after liver resection for colorectal metastases varies from 12 to 36%. Only positive resection margins resulted in no 10-year survivors. No patient can be excluded from consideration for liver resection so long the result is negative margins.

Effectiveness and cost-effectiveness of peri-operative versus post-operative chemotherapy for resectable colorectal liver metastases

BACKGROUND

The role of neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases is currently a matter of debate. The aim of the present study was to analyse life-expectancy, quality adjusted life-expectancy and cost-effectiveness of the two chemotherapeutic strategies.

METHODS

A Markov decision model was developed, on the basis of parameters derived from an extensive literature search of the last ten years, to compare outcomes of peri-operative versus post-operative chemotherapy.

RESULTS

Life-expectancy observed for peri-operative chemotherapy was 54.56months and 52.62months with post-operative chemotherapy only; the quality-adjusted life-expectancy with peri-operative chemotherapy was 39.33 quality-adjusted life-months (QALMs) and 37.84 QALMs with post-operative chemotherapy. Peri-operative chemotherapy results in an increase in total costs of 1180€ over ten years and in an incremental cost-effectiveness ratio (ICER) of 791.9€/QALM. The model was more sensitive to the expected 3-year recurrence-free survival (RFS) and cost of hepatic resection: with respect to an expected 3-year RFS⩽25% the peri-operative approach was more cost-effective than post-operative strategy but differences in average cost-effectiveness were small. The relationship between ICER and cost of hepatic resection was inverse because the higher the cost of hepatic resection, the higher the cost saving due to patients becoming unresectable during neo-adjuvant therapy.

CONCLUSIONS

In the treatment of resectable colorectal liver metastases, the addition of neo-adjuvant chemotherapy could be cost-effective because it makes it possible to avoid hepatic resection in patients who do not respond to the neo-adjuvant approach; however, the life-expectancy of the two strategies is very similar.

Colorectal liver metastases

The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.

The neoadjuvant therapy of colorectal hepatic metastases and the role of biologic sensitizing and resistance factors

Liver metastasis represents a common systemic complication of colorectal cancers (CRCs). Partial liver resection has been demonstrated to result in long-term survival in certain well-selected patients with otherwise well-controlled systemic disease. Neoadjuvant therapy has been demonstrated to result in improved resectability and potentially longer survival in patients with liver metastases from CRC. The addition of biologic agents to chemotherapy has been shown to improve response rates and overall survival in patients with metastatic CRC. Here, we are discussing the role of biologic agents in the treatment of patients with liver metastases from CRC. We also discuss the role of biomarkers for response and resistance to such novel therapies.

Evaluation of chemotherapy-associated liver injury in patients with colorectal cancer liver metastases using indocyanine green clearance testing

BACKGROUND

Systemic chemotherapy may render initially unresectable colorectal cancer liver metastases resectable. Histopathologic examinations of resected nontumoral liver tissue revealed chemotherapy-associated liver injuries, which was recognized to impair the function of the remnant liver. We therefore evaluated whether indocyanine green (ICG) plasma clearance helps to assess chemotherapy-induced liver damage.

METHODS

Data of 101 liver resections performed between 2006 and 2008 for colorectal liver metastases were analyzed for this study. Eighteen patients had liver resection without preoperative treatment, whereas 83 patients underwent neoadjuvant chemotherapy before surgery. ICG clearance was assessed by pulse densitometry before surgery.

RESULTS

Comparison of ICG retention clearances demonstrated that patients pretreated with systemic chemotherapy had a significantly lower plasma disappearance rate (ICG-PDR; 19.3 ± 5.9 vs. 23.1 ± 3.8%/min; P = 0.002) and a significantly elevated ICG retention rate at 15 min (7.9 ± 6.6 vs. 3.8 ± 1.9%; P < 0.001). The percentage of subjects with an abnormal ICG-PDR (≤18%/min) was significantly higher in the pretreated group (48.2% vs. 5.6%; P = 0.001). Patients with an ICG-PDR of ≤18 had a prolonged postoperative hospital stay and experienced four times more complications in their postoperative course.

CONCLUSIONS

ICG clearance helps to identify patients with impaired liver function after neoadjuvant chemotherapy and aids in the estimation of the postoperative risk of morbidity after liver resection for colorectal liver metastases.

[Oncosurgical strategies for metastatic liver cancer]

Patients with liver metastases from colorectal cancer (CRC) present a major public health challenge with approximately, 1,2 million cases of CRC occur yearly worldwide. Resection of colorectal liver metastases (CRLM) is the only treatment offering the possibility of cure and has been shown to provide clear survival benefits. However, only 10 to 20% of patients with CRLM are eligible for this procedure upfront. During the last decade, major advances in the management of CRLM have taken place involving three fields: oncology, interventional radiology, and surgery. These advances have increased the resectability rate to 20-30% of cases with a 5-year survival of 35-50%. Neoadjuvant treatment with chemotherapeutic agents such as irinotecan and oxaliplatin, and hepatic artery infusion combined with systemic therapy and biologic agents (bevacizumab, cetuximab) play an important role in increasing the number of patients eligible to secondary resection. However, with the progressive use of neoadjuvant chemotherapy further studies are necessary to answer questions such as the risk: benefit ratio in maximizing response rates versus vascular changes in the liver (current opinion still divided concerning their importance). These questions remain challenging and should not be underestimated. In this review, we have described the current oncosurgical strategies employed in patients with resectable and non resectable CRLM, their benefits, and future treatment strategies.

Is perioperative chemotherapy useful for solitary, metachronous, colorectal liver metastases?

BACKGROUND

Chemotherapy is increasingly used in colorectal liver metastases (CRLMs) even when they are initially resectable. The aim of our study was to address the still pending question of whether perioperative chemotherapy is really beneficial in patients developing solitary metastases at a distance from surgery of the primary.

METHODS

We analyzed a multicentric cohort of 1471 patients resected for solitary, metachronous, primarily resectable CRLMs without extrahepatic disease in the LiverMetSurvey International Registry over a 15-year period. Patients who received at least 3 cycles of oxaliplatin- or irinotecan-based chemotherapy before liver surgery (group CS, n = 169) were compared with those who were resected upfront (group S, n = 1302).

RESULTS

Patients of group CS were more frequently females (49% vs 36%, P = 0.001) and had larger metastases (≥5 cm, 33% vs 23%, P = 0.007); no difference was observed with regard to age, site of the primary tumour, time delay to occurrence of metastases, and carcinoembryonic antigen (CEA) levels at the time of diagnosis in the 2 groups. The rate of postoperative complications was significantly higher in group CS (37.2% vs 24% in group S, P = 0.006). At univariate analysis, preoperative chemotherapy did not impact the overall survival (OS) (60% at 5 years in both groups); however, postoperative chemotherapy was associated with better OS (65% vs 55% at 5 years, P < 0.01). At multivariate analysis, age 70 years or older (P = 0.05), lymph node positivity in the primary tumor (P = 0.02), a primary-to-metastases time delay of less than 12 months (P = 0.04), raised CEA levels of more than 5 ng/mL at diagnosis (P < 0.01), a tumor diameter of 5 cm or more (P < 0.01), noncurative liver resection (P < 0.01), and the absence of postoperative chemotherapy (P < 0.01) were independent prognostic factors of survival. The disease-free survival (DFS) was negatively influenced by CEA level of more than 5 ng/mL (P < 0.01), size of the metastases 5 cm or more (P = 0.05), and the absence of postoperative chemotherapy (P < 0.01). When patients with metastases of less than 5 cm in size were compared to those with metastases of size 5 cm or more, preoperative chemotherapy did not influence the OS or DFS in either group. Postoperative chemotherapy, on the other hand, improved OS and DFS in patients with metastases of size 5 cm or more but not in patients with metastases of less than 5 cm in size.

CONCLUSIONS

Although preoperative chemotherapy does not seem to benefit the outcome of patients with solitary, metachronous CRLM, postoperative chemotherapy is associated with better OS and DFS, mainly when the tumor diameter exceeds 5 cm.

Regenerative nodular hyperplasia of the liver related to chemotherapy: impact on outcome of liver surgery for colorectal metastases

Background

Regenerative nodular hyperplasia (RNH) represents the end-stage of vascular lesions of the liver induced by chemotherapy. The goal was to evaluate its incidence and impact on the outcome of patients resected for colorectal liver metastases (CLM).

Methods

Patients who underwent hepatectomy for CLM after six cycles or more of first-line chemotherapy, between January 1990 and November 2006, were included. Detailed histopathologic analysis of the nontumoral liver was performed according to a standard format.

Results

From a cohort of 856 resected patients at our institution, 771 (90%) received preoperative chemotherapy. Of these, 146 fulfilled the selection criteria and were included: 24 (16%) received 5-fluorouracil (5-FU) and leucovorin (LV) alone, 92 (63%) had 5-FU/LV and oxaliplatin, 18 (12%) had 5-FU/LV and irinotecan, and 12 (8%) were treated by 5-FU/LV, oxaliplatin, and irinotecan. RNH occurred in 22 of 146 patients (15%). Twenty of these patients (91%) received oxaliplatin, of whom six (30%) had chronomodulated therapy. Patients treated by oxaliplatin more often had RNH compared with oxaliplatin-naïve patients (22 vs. 4%). Although operative mortality was nil, the presence of RNH was associated with increased postoperative hepatic morbidity (50 vs. 29%). Elevated preoperative gamma-glutamyltransferase (GGT) (>80 U/L; >1N) and total bilirubin levels (>15 μmol/L; >1N) were independent predictors of RNH.

Conclusions

Patients with CLM who receive preoperative oxaliplatin have an increased risk of RNH and associated postoperative morbidity. Increased serum GGT and bilirubin are useful markers to predict the presence of RNH.

Advances in therapeutics for liver metastasis from colorectal cancer

The evolution of chemotherapeutic regimens that include targeted molecular agents has resulted in a breakthrough in the management of advanced colorectal liver metastasis (CLM), improving the progression-free survival after liver resection, and rendering initially unresectable liver tumors resectable, with reported resection rates ranging from 13% to 51%. In addition, the criteria used for selecting patients for hepatectomy have been expanding because of advances in surgical techniques and improvements in chemotherapy. However, the increasing use of chemotherapy has raised concern about potential hepatotoxicities such as steatosis, chemotherapy-associated steatohepatitis, and sinusoidal obstruction syndrome, and their deleterious effects on postoperative outcome. The present review focuses on the advantages and disadvantages of chemotherapy, strategies for the prevention and diagnosis of chemotherapy-associated liver injury, and the adoption of more aggressive surgical approaches, which have changed the traditional paradigm for CLM.

Consequences of chemotherapy on resection of colorectal liver metastases

The response rate of colorectal metastases to chemotherapy, ranging from 50 to 60%, has been shown to be a prognostic factor. Complete pathologic and radiological response rates are approximately 4 and 7%, respectively. Hepatotoxic effects of oxaliplatin and irinotecan on the non-tumoral liver parenchyma have been reported and are incriminated in vascular changes (sinusoidal obstruction syndrome [SOS]) and chemotherapy-associated steatohepatitis (CASH). Oxaliplatin-based regimens are associated with an increased risk of vascular lesions and irinotecan-based regimens are associated with increased risks of steatosis and steatohepatitis. SOS increases morbidity after major liver resection, mostly after administration of more than six cycles of neoadjuvant systemic chemotherapy. CASH increases morbidity and mortality rates after hepatectomy. Preliminary results have shown that the addition of targeted molecular therapy (bevacizumab or cetuximab) to conventional chemotherapy does not increase the postoperative morbidity or mortality rates after hepatectomy and does not create additional injury to the non-tumoral liver parenchyma. However, bevacizumab may impair regeneration of the future remnant. Chemotherapy may reduce the sensitivity of CT scan and PET scan in the detection of metastases.

Chemotherapy-associated liver injury: impact on surgical management of colorectal cancer liver metastases

Chemotherapy is integral to the management of patients with advanced colorectal cancer liver metastases. Due to their improved efficacy, modern regimens can sometimes convert unresectable disease to a resectable state. As chemotherapy is often administered prior to hepatic resection, adverse effects on the liver are increasingly being recognized. Investigators have identified a wide spectrum of effects on the underlying liver parenchyma, ranging from mild forms of steatosis to severe steatohepatitis and sinusoidal obstruction syndrome. As the histopathologic definitions of these changes evolve, studies have identified specific patterns of hepatic injury related to the various chemotherapeutic agents. The impact of these changes on perioperative outcome after partial hepatectomy remains controversial. Timing and duration of chemotherapy may play a key role and account for discrepancies in outcomes seen among studies. In this review, we provide an overview of the spectrum of chemotherapy-associated liver injury and discuss its relevance to perioperative management of patients undergoing hepatic resection of colorectal cancer liver metastases.

[Chemotherapy's hepatotoxicity: what is the impact on surgery?]

Hepatotoxic effect of oxaliplatin and irinotecan on the non-tumourous liver parenchyma has been reported. These two main drugs have been linked to injuries such as vascular changes (sinusoidal obstruction syndrome (SOS) and chemotherapy-associated steatohepatitis (CASH)). Oxaliplatin-based regimens have been associated with an increased risk of vascular lesions and irinotecan-containing regimens have been also associated with increased risks of steatosis and steatohepatitis. SOS increased morbidity after major liver resection, mostly after administration of more than six cycles of neoadjuvant systemic chemotherapy. CASH increased morbidity and mortality rates after hepatectomy. Preliminary results demonstrated that the addition of targeted molecular therapy (bevacizumab or cetuximab) to conventional chemotherapy does not increase the postoperative morbidity and mortality rates after hepatectomy. Furthermore, there was no additional injury to the non-tumorous liver parenchyma.

Pathological response grade of colorectal liver metastases treated with neoadjuvant chemotherapy

BACKGROUND

The complete resection of liver metastases from colorectal cancer is the major determinant of longterm survival. The effectiveness of current chemotherapy regimens has made treatment algorithms more flexible and resulted in many different options. Recently, the pathological response to chemotherapy has emerged as another important prognostic marker. Different systems have been used to grade the pathological response in these patients.

METHODS

This study prospectively evaluates the prognostic value of the pathological response grade (PRG) in liver metastases treated with neoadjuvant chemotherapy.

RESULTS

Between 2002 and 2006, 50 patients were treated with a sandwich chemotherapy regimen and underwent liver resection. Complete resection was achieved in 45 patients (90%). A strong pathological response to chemotherapy (<10% viable tumour cells in all lesions) was seen in 17 patients (34%). It was associated with a statistically significant longer overall survival (P= 0.019) and was also identified on multivariate analysis as an independent predictor of survival (odds ratio = 243).

CONCLUSIONS

This pilot study demonstrates the prognostic potential of the PRG, which could be used clinically to select patients for an aggressive multimodal adjuvant algorithm. Larger multicentre studies are required to validate this particular grading system. The keys to longterm survival are resectability and chemo-responsiveness.

[The role of perioperative chemotherapy in patients with resectable colorectal liver metastases]

Surgical resection remains the only treatment of colorectal liver metastases that can ensure long-term survival and cure in some patients, but only a minority of patients with liver metastases is directly amenable to surgery. Cancer relapse is observed in the majority of patients after resection of liver metastases despite progress in surgical technique and improved surgical skills. In order to decrease the risk of cancer relapse, it has been proposed to combine surgery and chemotherapy, which could be administered before, after or before and after surgery. It has been demonstrated that perioperative chemotherapy can reduce the risk of cancer relapse and should be considered as the standard of care for most patients with resectable colorectal liver metastases. However perioperative chemotherapy has also potential disadvantages. This review will summarize the current data on the rationale, benefits and potential disadvantages of perioperative chemotherapy in patients with resectable colorectal liver metastases.

Impact of neoadjuvant chemotherapy with FOLFOX/FOLFIRI on disease-free and overall survival of patients with colorectal metastases

STUDY AIMS

To determine if neoadjuvant FOLFOX/FOLFIRI is associated with improved disease-free survival (DFS) or overall survival (OS) in patients with colorectal metastases (CRM) to the liver.

METHODS

Ninety-nine patients (from 457 eligible) with CRM that underwent hepatic resection during 2000 to 2005 were included. Group 1 (n = 44) patients received neoadjuvant FOLFOX/FOLFIRI, and Group 2 (n = 55) did not receive neoadjuvant therapy.

RESULTS

There were 58% men. The median age for Group 1 was 58 and Group 2, 64 (p = 0.03). OS for Group 1 at 1, 3, and 5 years was 93%, 62%, and 51%, respectively, with a median OS of 5.8 years. In Group 2 survival at 1l, 3, and 5 years was 90%, 63%, and 45%, respectively, with a median OS of 3.7 years (HR 1.06, p = 0.87). The DFS for Group 1 at 1, 3, and 5 years was 51%, 20%, and 20%, with a median DFS of 1.1 years and Group 2 at 1, 3, and 5 years was 58%, 32%, and 32% (median DFS-1.2 years; HR = 1.24, p = 0.45).

CONCLUSIONS

Neoadjuvant FOLFOX/FOLFIRI was employed more frequently in younger patients with CRM; however, neoadjuvant chemotherapy for CRM was not significantly associated with an increase in OS or DFS, despite additional adjuvant therapy.

Systematic review of randomized and nonrandomized trials of the clinical response and outcomes of neoadjuvant systemic chemotherapy for resectable colorectal liver metastases

BACKGROUND

Neoadjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases (CLM) may facilitate the resectability of the liver lesions and treat occult metastasis but may also lead to hepatic parenchyma damage. There is argument over the oncologic benefit of this practice in patients who would already be suitable for a curative hepatectomy.

METHODS

Extensive literature search of databases (MEDLINE and PubMed) to identify published studies of preoperative systemic chemotherapy for resectable CLM was undertaken with clinical response to treatment and survival outcomes as the endpoints.

RESULTS

Twenty-three studies were reviewed: 1 phase III randomized control trial, 3 phase II studies, and 19 observational studies, comprising 3,278 patients. Objective (complete/partial) radiological response was observed in 64% (range 44-100%) [complete 4% (range 0-38%), partial 52% (range 10-90%)] of patients after neoadjuvant chemotherapy. Pathologically, a median of 9% (range 2-24%) and 36% (range 20-60%) had complete and partial response, respectively. Of patients, 41% (range 0-65%) had stable or progressive disease whilst on neoadjuvant chemotherapy. Median disease-free survival (DFS) was 21 (range 11-40) months. Median overall survival (OS) was 46 (range 20-67) months.

CONCLUSION

Current evidence suggests that objective response to neoadjuvant chemotherapy may be achieved with improvement in DFS in patients with resectable CLM. A prospective randomized trial of neoadjuvant therapy versus adjuvant therapy after liver resection is required to determine the optimal perisurgical treatment regimen.

Treatment for colorectal liver metastases: a review

INTRODUCTION

Over the past decade, the emergence of surgical adjuncts such as portal vein embolization, two-stage hepatectomy, and ablative therapies not only decreases mortality and morbidity after an extended hepatectomy but also broadens the indication for surgical treatment of liver metastasis from colorectal cancer. Combination chemotherapeutic regimens, namely 5-fluorouracil/folinic acid with irinotecan or oxaliplatin, and targeted monochromal antibodies can downsize the tumor burden to the extent that formerly unresectable metastases can sometimes be excised.

DISCUSSION

The 5-year survival rate following liver resection ranges between 25% and 58%. During the 5-fluorouracil/folinic acid with oxaliplatin and 5-fluorouracil/folinic acid with irinotecan treatment period, the patients who were deemed to be resectable should be considered as surgical candidates regardless of the associated adverse predictive factors. The emergence of epidermal growth factor receptor antibody agents, which act effectively in patients with Kras wild-type tumor, fosters treatment individualization.

CONCLUSION

The efficacy of the perioperative chemotherapy on survival benefit for resectable liver metastases has not been justified. However, the timing and indication of surgical treatment paradigm in colorectal liver metastasis, including for synchronous disease and extrahepatic disease, are dramatically changing with the development of chemotherapeutic agents.

The role of preoperative chemotherapy in patients with resectable colorectal liver metastases

BACKGROUND

Liver metastases develop in 40-50% of patients with colorectal cancer and represent the major cause of death in this disease. Surgical resection remains the only treatment procedure that can ensure long-term survival and provide cure when liver metastases can be totally resected with clear margins, when the primary cancer is controlled, and when there is no nonresectable extrahepatic disease. Five-year survival rate after surgical resection of colorectal metastases varies from 25% to 55%, but cancer relapse is observed in most patients.

AIM

To review the potential benefits and disadvantages of neoadjuvant chemotherapy administered before surgery to patients with initially resectable metastases.

RESULTS

European Organization for Research and Treatment of Cancer (EORTC) study 40983 has shown that neoadjuvant chemotherapy could reduce the risk of relapse by one-quarter, and allows to test the chemosensitivity of the cancer, to help to determine the appropriateness of further treatments, and to observe progressive disease, which contraindicates immediate surgery. Neoadjuvant chemotherapy can induce damage to the remnant liver. Oxaliplatin-based combination regimen is associated with increased risk of vascular lesions, whereas irinotecan-containing regimens have been associated with increased risks of steatosis and steatohepatitis. Analysis of EORTC study 40983 showed that administration of six cycles of neoadjuvant systemic chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) was associated with moderate increase of the risk of reversible complications after surgery, but mortality rate was below 1% and not increased. If patients are not overtreated, chemotherapy before surgery is well tolerated. The integration of novel targeted agents in combination with cytotoxic drugs is a promising way to improve outcome in patients with advanced colorectal cancer. Preliminary trials have shown that targeted agents combined with cytotoxic regimens can increase tumor response rates. Another impact of preoperative chemotherapy is that metastases that respond to treatment may no longer be visible on computed tomography (CT) scan or at surgery. Patients should be carefully monitored and receive surgery before metastases disappear.

CONCLUSION

Treatment of most patients with liver metastases-those with resectable metastases as well as those with initially unresectable metastases-should start with chemotherapy. If drugs are well chosen and the duration of treatment is monitored with care during multidisciplinary meetings, benefits largely outweigh potential disadvantages.

Is there a survival benefit to neoadjuvant versus adjuvant chemotherapy, combined with surgery for resectable colorectal liver metastases?

BACKGROUND

The benefits of adding chemotherapy to surgery in patients with hepatic colorectal metastases at moderate and high risk for recurrence and the optimal sequence of administration are undetermined.

METHODS

We followed the overall-survival and event-free survival rates after operation in patients with resectable colorectal metastases confined to the liver. The adjuvant patients first underwent surgery and then treatment, whereas the neoadjuvant patients underwent treatment, surgery, and re-treatment. Assignment was by oncologist and patient preferences. Chemotherapy was oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) based.

RESULTS

Fifty-six of 105 patients who underwent liver resections for colorectal metastases (2002-2005) are included. The two groups were comparable for demographics, characteristics of disease (including recurrence risk), treatment protocols, and follow-up. The respective 1-, 2-, and 3-year overall survival rates were 91%, 91%, and 84%, and the event-free survival rates were 63%, 49%, and 49% for the 19 adjuvant patients, and 95%, 91%, and 70%, and 94%, 50%, and 50% for the 37 neoadjuvant patients.

CONCLUSIONS

The midterm overall survival and disease-free survival rates in this group of patients with resectable colorectal metastases to the liver, who were treated with combination of resection and chemotherapy, were similar, regardless of the sequence of treatment.

Synchronous colorectal liver metastases: is it time to reconsider traditional paradigms of management?

BACKGROUND

Patients with synchronous colorectal liver metastases (CLM) are typically treated with initial colorectal resection followed by arbitrary and prolonged courses of chemotherapy. Partial hepatectomy is considered only for patients without interval disease progression. This review describes the rationale for this treatment approach and the recent developments suggesting that this management paradigm should be reconsidered.

RESULTS

Because asymptomatic colorectal cancer often does not lead to complications, and given the potential benefit of chemotherapy in downsizing unresectable to resectable liver disease, most patients with asymptomatic primary tumors and unresectable synchronous CLM should be first treated with chemotherapy. In contrast, initial hepatic resection should be considered for resectable synchronous CLM. Survival benefits from prehepatectomy chemotherapy have not been established. Several reports demonstrate morbidity after hepatic resection from extended durations of irinotecan- and/or oxaliplatin-based prehepatectomy chemotherapy. Although shorter treatment periods may not have these deleterious effects on subsequent hepatic resection, prospective studies reveal that most patients with supposedly aggressive disease with short treatment durations will not be identified. Moreover, a complete radiologic response to prehepatectomy chemotherapy is not only rare but also does not equate with a complete pathological response. Finally, several studies suggest that simultaneous colorectal and minor hepatic resections can performed safely with benefits in total morbidity when compared with traditional staged procedures.

CONCLUSIONS

The traditional treatment paradigm centering on the utility of prehepatectomy chemotherapy for resectable synchronous CLM should be reconsidered. Recent developments underscore the need for prospective randomized controlled trials evaluating the optimal timing of hepatectomy relative to chemotherapy.

'Close shave' in liver resection for colorectal liver metastases

INTRODUCTION

The optimal size of clear liver resection margin width in patients with colorectal liver metastases (CRLM) remains controversial. The aim of this study was to investigate the effects of margin width on long-term survival after liver resection for CRLM with a policy of standard neo-adjuvant chemotherapy.

METHODS

Consecutive patients (n=238) who underwent liver resection for CRLM were included over a ten-year period. All patients with synchronous or early (<2 years) metachronous tumours were treated with neo-adjuvant chemotherapy. Data were recorded prospectively.

RESULTS

Overall survival of the cohort at 1, 3 and 5 years were 90.3%, 68.1% and 56.1% respectively. The incidence of cancer involved resection margins (CIRM) was 5.8%. Patients with macroscopically involved resection margins had a poorer overall survival than those with microscopically involved margins (p=0.04). Involved resection margins had a poorer overall survival (p=0.002) than patients with clear margins. Width of clear resection margin did not affect long-term survival.

CONCLUSION

CIRM independently predicts poor outcome in patients with CRLM. Clear margin width does not affect survival. A standard policy of neo-adjuvant chemotherapy may be associated with a low incidence of CIRM and improved long-term outcome of sub-centimetre margin widths, resembling those with >1cm resection margins.

A phase II experience with neoadjuvant irinotecan (CPT-11), 5-fluorouracil (5-FU) and leucovorin (LV) for colorectal liver metastases

BACKGROUND

Chemotherapy may improve survival in patients undergoing resection of colorectal liver metastases (CLM). Neoadjuvant chemotherapy may help identify patients with occult extrahepatic disease (averting unnecessary metastasectomy), and it provides in vivo chemosensitivity data.

METHODS

A phase II trial was initiated in which patients with resectable CLM received CPT-11, 5-FU and LV for 12 weeks. Metastasectomy was performed unless extrahepatic disease appeared. Postoperatively, patients with stable or responsive disease received the same regimen for 12 weeks. Patients with progressive disease received either second-line chemotherapy or best supportive care. The primary endpoint was disease-free survival (DFS); secondary endpoints included overall survival (OS) and safety.

RESULTS

35 patients were accrued. During preoperative chemotherapy, 16 patients (46%) had grade 3/4 toxicities. Resection was not possible in 5 patients. One patient died of arrhythmia following surgery, and 1 patient had transient liver failure. During the postoperative treatment phase, 12 patients (55%) had grade 3/4 toxicities. Deep venous thrombosis (DVT) occurred in 11 patients (34%) at various times during treatment. Of those who underwent resection, median DFS was 23.0 mo. and median OS has not been reached. The overall survival from time of diagnosis of liver metastases was 51.6 mo for the entire cohort.

CONCLUSION

A short course of chemotherapy prior to hepatic metastasectomy may serve to select candidates best suited for resection and it may also direct postoperative systemic treatment. Given the significant incidence of DVT, alternative systemic neoadjuvant regimens should be investigated, particularly those that avoid the use of a central venous line.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00168155.

Nonresponse to pre-operative chemotherapy does not preclude long-term survival after liver resection in patients with colorectal liver metastases

BACKGROUND

Liver resection is the only curative treatment offering a chance of long-term survival in patients with colorectal liver metastases (CRM). Recent data indicated that liver resection in patients with tumor progression while receiving chemotherapy was associated with poor outcome. The aim of the study was to identify risk factors for poor outcome in patients with pre-operative chemotherapy of CRM.

METHODS

We analyzed 160 patients after liver resection for CRM with preoperative systemic. chemotherapy. Three groups of patients were identified: 44 patients (27.5%) had a tumor response, 20 (12.5%) showed stable disease, and 96 (60%) patients had tumor progression while on chemotherapy. Median follow-up was 2.4 years (range, 6 days-11.1 years). All available clinicopathologic variables possibly associated with outcome were evaluated.

RESULTS

Survival was 88%, 53%, and 37% at 1, 3, and 5 years. Noncurative resection, carcinoembryonic antigen levels >200 ng/ml, tumor grading, size of the largest tumor >5 cm, and number of metastases were associated with poor patient outcome. In the multivariate analysis, tumor free margin and tumor grading correlated with the outcome. Tumor progression while on chemotherapy had no influence on the long-term survival.

CONCLUSION

Liver resection offers a long-term survival benefit for patients with CRM, even when tumor growth proceeds during pre-operative chemotherapy.

Simultaneous versus staged resection for synchronous colorectal cancer liver metastases

BACKGROUND

The aim of this study was to compare postoperative outcomes of patients with synchronous colorectal liver metastases treated with either simultaneous or staged colectomy and hepatectomy.

STUDY DESIGN

From July 1997 to June 2008, a review of our 1,344-patient prospective hepato-pancreatico-biliary database identified 230 patients treated surgically for primary adenocarcinoma of the large bowel and synchronous hepatic metastasis. Clinicopathologic, operative, and perioperative data, complications, and grade of complications (grade 1, minor, to grade 5, death) were reviewed to evaluate selection criteria, operative methods, and perioperative outcomes. Chi-square and proportional hazard model were used to evaluate predictors of outcomes.

RESULTS

Seventy patients underwent simultaneous resection of colon primary and liver metastasis in a single operation; 160 patients underwent staged operations. Simultaneous resections were similar for size (median 4 cm versus 3.7 cm) and number (median 3 cm versus 3 cm) of liver metastases. Major liver resections (>or=3 Couinaud segments) were similar between staged and simultaneous (32% versus 33%, respectively), as was type of colectomy (p=0.2). Complication rates and severity were similar in both groups: 39 of 70 patients (56%) in the simultaneous group experienced 63 complications versus 88 of 160 patients (55%) with 162 complications in the staged group (p=0.24). Multivariate analysis identified blood transfusion as a predictor of complication (odds ratio 2.98, p=0.001). Patients having simultaneous resection required fewer days in the hospital (median 10 days versus 18 days, p=0.001).

CONCLUSIONS

By avoiding a second laparotomy, simultaneous colon and hepatic resection reduces overall hospital stay, with no difference in morbidity and mortality rates or in severity of complications, compared with staged resection. Simultaneous resection is an acceptable option in patients with resectable synchronous colorectal metastasis.

Response to chemotherapy predicts survival following resection of hepatic colo-rectal metastases in patients treated with neoadjuvant therapy

BACKGROUND

Prognosis of patients following resection of CRC metastases to the liver has traditionally been predicted by clinical risk factors. In the era of neoadjuvant chemotherapy, determination of new prognostic indicators of outcome are necessary.

METHODS

This retrospective study includes patients with CRC liver metastases, who received oxaliplatin or irinotecan based neoadjuvant chemotherapy and underwent R0 resection. Patients were followed by CT and PET-CT, before, during and after chemotherapy and surgery. The predictive value of the Memorial Sloan-Kettering Cancer Center Clinical Score (MSKCC-CS) and degree of response to chemotherapy (measured by CT and PET-CT), were analyzed by univariate and multivariate COX regression.

RESULTS

Included are 54 patients. Overall 1-, 2-, 3-year survival rates 88%, 70%, and 39%. Response to chemotherapy on CT was a significant predictor of survival on univariate (P = 0.03) and multivariate analysis (P = 0.03), whereas MSKCC-CS and response to chemotherapy on PET-CT were not. Multivariate analysis demonstrated response to chemotherapy as a predictor of time to recurrence on CT (P = 0.02) and PET-CT (P = 0.03), while the MSKCC-CS (P = 0.64) was not.

CONCLUSIONS

In this cohort of patients treated by neoadjuvant chemotherapy, the outcome was not predicted by the traditional clinical scoring system, but rather by response to chemotherapy as evaluated by CT and PET-CT.

The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.