Resection of nonresectable liver metastases from colorectal cancer after neoadjuvant chemotherapy

Perioperative complications after neoadjuvant chemotherapy with and without bevacizumab for colorectal liver metastases

PURPOSE

Bevacizumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Neoadjuvant bevacizumab is commonly used in patients undergoing liver resection. Our purpose was to evaluate whether bevacizumab is associated with increased rate of perioperative complications in patients undergoing hepatic resection for colorectal liver metastases (CRLM).

METHODS

Retrospective analysis of patients undergoing hepatic resection for CRLM who received chemotherapy and bevacizumab (group 1, n = 134), or chemotherapy alone (group 2, n = 57). We compared demographics, surgical characteristics, and perioperative course.

RESULTS

Perioperative complications developed in 35 % of patients in group 1, and 47 % in group 2 (p = 0.11). Of those complications, 15 (11.2 %) in group 1, and 5 (8.8 %) in group 2 were considered major (p = 0.617). Four patients, all of whom received preoperative bevacizumab, developed enteric leaks following combined liver and bowel resection. The rate of anastomotic leak in group 1 was 10 %, compared with 0 in group 2, p = 0.56.

CONCLUSION

Neoadjuvant chemotherapy along with bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection. Possible association of increased morbidity with simultaneous bowel and liver resections following bevacizumab administration was found and we recommend avoiding such treatment combination.

Defining resectability of colorectal liver metastases: how and why?

SUMMARY Treatment outcome in metastatic colorectal carcinoma has improved because of advancements in medical therapy and increased use of liver resections. In primary nonresectable disease, prognosis improves when a secondary resection is performed after successful downsizing by neoadjuvant systemic therapy. Which patient groups may profit from a secondary liver resection and which neoadjuvant systemic therapy has the optimal chance of conversion to resectability has not been defined because various patient groups were selected in different studies and there is a lack of consensus on resectability. This invalidates cross-study comparisons of resection rates and survival rates. Prospective trials in which secondary resection rate is a predefined end point are needed and will allow more insight into this topic.

Surgical management of colorectal cancer metastases to the liver: multimodality approach and a single institutional experience

Over the past 30 years, the treatment of metastatic colorectal cancer to the liver has undergone major changes. Once considered terminal and incurable, the prognosis of patients with colorectal hepatic metastases has seen dramatic improvements using modern multimodality therapy and now long-term survival and even cure are possible in some patients. Despite the advances seen in systemic therapy, hepatic resection offers the longest survival potential and remains the only curative option. Based on long-term outcomes and the improved safety of hepatic resection using modern operative techniques and critical care support, an aggressive locoregional approach to colorectal hepatic metastasis has become the standard of care. This article focuses on the management of colorectal hepatic metastases and highlights the importance of multimodality therapy. We also report our 18-year experience treating patients with hepatic resection for colorectal metastases.

Therapeutic strategies for hepatic metastasis of colorectal cancer: overview

To determine the treatment strategy for hepatic metastases of colorectal cancer, it is important to take into account whether metastases are still localized in the liver, or whether the tumor has metastasized throughout the body. For liver-limited metastasis, hepatectomy is the therapeutic strategy that offers the best prospect of improving a patient's prognosis if the case is deemed resectable. In cases when surgery is not indicated for hepatic metastases of colorectal cancer, chemotherapy is the first-choice treatment. Chemotherapy for colorectal cancer has made vast strides in recent years through advances such as the development of molecular targeted drugs. In cases where chemotherapy is effective and surgical resection becomes possible (conversion chemotherapy), the long-term prognosis may be good. The value of preoperative chemotherapy in resectable cases (neoadjuvant chemotherapy) has also been reported. The improvement in prognosis achieved by eradicating tiny latent metastases is important in conversion therapy, as well as in neoadjuvant chemotherapy. It will be important to achieve further improvements in the prognoses of patients with hepatic metastases of colorectal cancer through a combination of advances in diagnostic imaging, improvements in surgical techniques, and more effective chemotherapy treatments.

Risk of occult irresectable disease at liver resection for hepatic colorectal cancer metastases: a contemporary analysis

INTRODUCTION

Traditionally, rates of irresectable disease at laparotomy for colorectal liver metastases (CRLM) have ranged from 15 to 70%. Diagnostic laparoscopy has been shown to be effective at preventing nontherapeutic laparotomy in selected patients. The purpose of this study was to analyze the resectability rate and role of diagnostic laparoscopy in a contemporary cohort.

METHODS

Using a prospectively maintained database, we identified patients who were explored for presumed resectable CRLM. Clinical and pathologic data associated with the finding of irresectable disease were analyzed.

RESULTS

From 2008-2010, 455 patients were explored. Of these, 35 (7.7%) did not undergo a resection and/or ablation. Of the 35 patients with irresectable disease, 15 (43%) had disease limited to the liver, 17 (49%) had extrahepatic disease (EHD), and 3 (9%) had other reasons precluding resection. Of the whole cohort, 45 patients (9.9%) were found to have EHD, and 27 of these (60%) underwent complete resection or ablation. The only factor associated with irresectable disease was a prior history of EHD, which was present in 29% of those found irresectable versus 13% of those resected (p = 0.022). Diagnostic laparoscopy was performed in 55 patients. Four of these patients had irresectable disease, and three were spared unnecessary laparotomy. Therefore, the yield was 5% and the sensitivity 75%.

CONCLUSIONS

The finding of irresectable disease is a rare event with modern radiologic assessment and the expansion of indications for resection. Diagnostic laparoscopy has a low yield and should be considered if there is a history of EHD or suspicious findings on preoperative imaging.

Chemotherapy-associated liver injury in patients with colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

Chemotherapy-associated liver injury is a major cause for concern when treating patients with colorectal liver metastases. The aim of this review was to determine the pathological effect of specific chemotherapy regimens on the hepatic parenchyma as well as on surgical morbidity, mortality and overall survival.

METHODS

A systematic review of the published literature and a meta-analysis were performed. For each of the variables under consideration, the effects of different chemotherapy regimens were determined by calculation of relative risks by a random-effects model.

RESULTS

Hepatic parenchymal injury is regimen specific, with oxaliplatin-based regimens being associated with grade 2 or greater sinusoidal injury (number needed to harm 8; 95 % confidence interval [CI] 6.4-13.6), whereas irinotecan-based regimens associated with steatohepatitis (number needed to harm 12; 95 % CI 7.8-26). The use of bevacizumab alongside FOLFOX reduces the risk of grade 2 or greater sinusoidal injury (relative risk 0.34; 95 % CI 0.15-0.75).

CONCLUSIONS

Chemotherapy before resection of colorectal liver metastases is associated with an increased risk of regimen-specific liver injury. This liver injury may have implications for the functional reserve of the liver for patients undergoing major hepatectomy for colorectal liver metastases.

MicroRNAs: relevant tools for a colorectal surgeon?

Colorectal cancer is the third most common malignancy and cause of cancer-related deaths worldwide. Approximately half of the patients diagnosed with colorectal cancer ultimately die of the condition. Death from colorectal cancer can be prevented by early detection, but unfortunately presentation is often late, with a worse prognosis. Screening by fecal occult blood testing reduces disease-specific mortality, but there is a need for sensitive and specific noninvasive biomarkers to facilitate detecting the disease, staging it, and predicting the best therapeutic options. MicroRNAs (miRNAs) are short noncoding RNA sequences that have a crucial role in the regulation of gene expression. They have significant regulatory functions in basic cellular processes, such as cell differentiation, proliferation, and apoptosis. Evidence suggests that miRNAs may function as both tumor suppressors and oncogenes. The main mechanism for changes in the function of miRNAs in cancer cells is due to aberrant gene expression. Accurate discrimination of miRNA profiles between tumor and normal mucosa in colorectal cancer allows definition of specific expression patterns of miRNAs, giving good potential as diagnostic and therapeutic targets. MiRNAs expressed in colorectal cancers are also abundantly present and stable in stool and plasma samples. Their extraction from these three sources is feasible and reproducible. The ease and reliability of determining miRNA profiles in plasma or stool makes them potential molecular markers for colorectal cancer screening. This review summarizes the role miRNAs have in colorectal cancer, highlighting particularly the potential diagnostic, prognostic, and therapeutic implications in the future treatment of the disease.

Cost-effectiveness analysis of screening for KRAS and BRAF mutations in metastatic colorectal cancer

BACKGROUND

In 2009, the American Society of Clinical Oncology recommended that patients with metastatic colorectal cancer (mCRC) who are candidates for anti-epidermal growth factor receptor (EGFR) therapy have their tumors tested for KRAS mutations because tumors with such mutations do not respond to anti-EGFR therapy. Limiting anti-EGFR therapy to those without KRAS mutations will reserve treatment for those likely to benefit while avoiding unnecessary costs and harm to those who would not. Similarly, tumors with BRAF genetic mutations may not respond to anti-EGFR therapy, though this is less clear. Economic analyses of mutation testing have not fully explored the roles of alternative therapies and resection of metastases.

METHODS

This paper is based on a decision analytic framework that forms the basis of a cost-effectiveness analysis of screening for KRAS and BRAF mutations in mCRC in the context of treatment with cetuximab. A cohort of 50 000 patients with mCRC is simulated 10 000 times, with attributes randomly assigned on the basis of distributions from randomized controlled trials.

RESULTS

Screening for both KRAS and BRAF mutations compared with the base strategy (of no anti-EGFR therapy) increases expected overall survival by 0.034 years at a cost of $22 033, yielding an incremental cost-effectiveness ratio of approximately $650 000 per additional year of life. Compared with anti-EGFR therapy without screening, adding KRAS testing saves approximately $7500 per patient; adding BRAF testing saves another $1023, with little reduction in expected survival.

CONCLUSIONS

Screening for KRAS and BFAF mutation improves the cost-effectiveness of anti-EGFR therapy, but the incremental cost effectiveness ratio remains above the generally accepted threshold for acceptable cost effectiveness ratio of $100 000/quality adjusted life year.

Surgical resection after downsizing chemotherapy for initially unresectable locally advanced biliary tract cancer: a retrospective single-center study

BACKGROUND

Surgical resection is the only method for curative treatment of biliary tract cancer (BTC). Recently, an improved efficacy has been revealed in patients with initially unresectable locally advanced BTC to improve the prognosis by the advent of useful cancer chemotherapy. The aim of this study was to evaluate the effect of downsizing chemotherapy in patients with initially unresectable locally advanced BTC.

METHODS

Initially unresectable locally advanced cases were defined as those in which therapeutic resection could not be achieved even by proactive surgical resection. Gemcitabine was administered intravenously once a week for 3 weeks followed by 1 week's respite. Patients whose disease responded to chemotherapy were reevaluated to determine whether their tumor was resectable.

RESULTS

Chemotherapy with gemcitabine was provided to 22 patients with initially unresectable locally advanced BTC. Tumor was significantly downsized in nine patients, and surgical resection was performed in 8 (36.4%) of 22 patients. Surgical resection resulted in R0 resection in four patients and R1 resection in four patients. Patients who underwent surgical resection had a significantly longer survival compared with those unable to undergo surgery.

CONCLUSIONS

Preoperative chemotherapy enables the downsizing of initially unresectable locally advanced BTC, with radical resection made possible in a certain proportion of patients. Downsizing chemotherapy should be proactively carried out as a multidisciplinary treatment strategy for patients with initially unresectable locally advanced BTC with the aim of expanding the surgical indication.

Survival after liver resection in metastatic colorectal cancer: review and meta-analysis of prognostic factors

Background

Hepatic metastases develop in approximately 50% of colorectal cancer (CRC) cases. We performed a review and meta-analysis to evaluate survival after resection of CRC liver metastases (CLMs) and estimated the summary effect for seven prognostic factors.

Methods

Studies published between 1999 and 2010, indexed on Medline, that reported survival after resection of CLMs, were reviewed. Meta-relative risks for survival by prognostic factor were calculated, stratified by study size and annual clinic volume. Cumulative meta-analysis results by annual clinic volume were plotted.

Results

Five- and 10-year survival ranged from 16% to 74% (median 38%) and 9% to 69% (median 26%), respectively, based on 60 studies. The overall summary median survival time was 3.6 (range: 1.7–7.3) years. Meta-relative risks (95% confidence intervals) by prognostic factor were: node positive primary, 1.6 (1.5–1.7); carcinoembryonic antigen level, 1.9 (1.1–3.2); extrahepatic disease, 1.9 (1.5–2.4); poor tumor grade, 1.9 (1.3–2.7); positive margin, 2.0 (1.7–2.5); >1 liver metastases, 1.6 (1.4–1.8); and >3 cm tumor diameter, 1.5 (1.3–1.8). Cumulative meta-analyses by annual clinic volume suggested improved survival with increasing volume.

Conclusion

The overall median survival following CLM liver resection was 3.6 years. All seven investigated prognostic factors showed a modest but significant predictive relationship with survival, and certain prognostic factors may prove useful in determining optimal therapeutic options. Due to the increasing complexity of surgical interventions for CLM and the inclusion of patients with higher disease burdens, future studies should consider the potential for selection and referral bias on survival.

Inflammation-based prognostic system predicts survival after surgery for stage IV colorectal cancer

BACKGROUND

The aim of this study was to estimate whether the Glasgow prognostic score (GPS) is useful for predicting the survival of patients after surgery for stage IV colorectal cancer (CRC).

METHODS

The GPS was calculated on the basis of admission data as follows: patients with both an increased C-reactive protein (CRP) level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL) were allocated a score of 2, and patients showing one or none of these abnormalities were allocated a score of 1 or 0, respectively.

RESULTS

A total of 108 patients with stage IV CRC were enrolled. Although multivariate analyses showed that tumor pathology, subclass of stage IV CRC, and the GPS were associated with overall survival, the GPS could divide the patients into 3 independent groups showing significant differences in postoperative survival (P = .018).

CONCLUSIONS

The GPS is not only one of the most significant clinical characteristics associated with the overall survival of patients with stage IV CRC, but also a useful indicator that is capable of dividing such patients into 3 independent groups before surgery.

Surgical options for initially unresectable colorectal liver metastases

Although the frontiers of liver resection for colorectal liver metastases have broadened in recent decades, approximately 75% of these patients present with unresectable metastases at the time of their diagnosis. In the past, these patients underwent only palliative treatment, without the chance of a cure. In the previous two decades, several therapeutic strategies have been developed that render resectable those metastases that were initially unresectable, thus offering the chance of long-term survival and even a cure to these patients. The oncosurgical modalities that are available include liver resection following portal vein ligation/embolization, “two-stage” liver resection, one-stage ultrasonically guided liver resection, hepatectomy following conversion chemotherapy, and liver resection combined with thermal ablation. Moreover, in recent years, certain authors have recommended the revisiting of the concept of liver transplantation in highly selected patients with unresectable colorectal liver metastases and favorable prognostic factors. By employing such therapies, the number of patients with colorectal liver metastases who undergo a potentially curative treatment could increase to 40%. The safety profile of these approaches is acceptable (morbidity rates as high as 45%, mortality rates of less than 5%). Furthermore, the 5-year survival rates (approximately 30%) are significantly increased over those that were achieved with palliative treatment.

Identification of patients likely to benefit from metastasectomy in stage IV colorectal cancer

PURPOSE

The aim of the present study was to determine selection criteria for patients with stage IV colorectal cancer (CRC) who were likely to show survival benefits of metastasectomy.

METHODS

Clinicopathological data of 119 patients with stage IV CRC who underwent primary CRC resection were retrospectively reviewed. The prognostic factors were analyzed according to the disease resectability status, and patients likely to show survival benefits of metastasectomy were identified.

RESULTS

Metastasectomy was performed in 63 patients. Among these patients, R0 resection was reported in 55 patients, who comprised the curable group. The other 64 patients comprised the noncurable group. For the noncurable group, postoperative chemotherapy was identified as the only significant prognostic factor. In the curable group, T stage, histological type, elevated serum carcinoembryonic antigen (CEA) level and the presence of extra hepatic disease were identified as independent prognostic factors. Patients within the curable group were further classified into a low-risk group (zero to two prognostic factors) and a high-risk group (three or more prognostic factors). The overall survival (OS) of the high risk patients in the curable group was as poor as that of the patients in the noncurable group.

CONCLUSIONS

Stage IV CRC patients consisted of heterogeneous populations who had different prognostic factors, stratified by the disease resectability status. No prognostic benefit of metastasectomy was observed in high-risk patients undergoing curative metastasectomy. These results suggested that patients showing survival benefits of metastasectomy can be identified by considering the prognostic factors in patients undergoing curative metastasectomy.

Influence of preoperative chemotherapy on the intraoperative and postoperative course of liver resection for colorectal cancer metastases

BACKGROUND

Liver resection is a possibly curative treatment for colorectal cancer (CRC) liver metastases. Preoperative chemotherapy may make initially irresectable tumors resectable. The aim of this study was to compare perioperative course and short-term mortality after liver resection for CRC metastases between patients who were and were not treated with preoperative chemotherapy.

METHODS

Patients who had undergone liver resection for CRC metastases were included. A total of 97 patients treated with preoperative chemotherapy (group A) were compared with 136 who were not (group B). Intraoperative bleeding, operating time, complications, duration of stay, and mortality were compared using Pearson's χ(2) test, Fisher's exact test, and the Mann-Whitney U-test.

RESULTS

Mean intraoperative bleeding, duration of stay, and operating time were not significantly different. Complications occurred in 62.9% and 63.2% in groups A and B, respectively. The 30- and 90-day mortality rates were zero in group A, comparable to 1.5% in group B.

CONCLUSIONS

There were no significant differences in the perioperative course or postoperative mortality when comparing CRC patients with or without chemotherapy prior to liver resection. Consequently, this study suggests that preoperative chemotherapy before liver resection for CRC metastases does not negatively influence perioperative outcome and can therefore be applied if "downstaging" is indicated.

Novel insights of oligometastases and oligo-recurrence and review of the literature

Oligometastases and oligo-recurrence are among the most important notions of metastatic and recurrent cancer. The concept of oligometastases is related to the notion that cancer patients with 1–5 metastatic or recurrent lesions that could be treated by local therapy achieve long-term survival or cure, while the concept of oligo-recurrence is related to the notion that cancer patients with 1–5 metastatic or recurrent lesions that could be treated by local therapy have controlled primary lesions. Achievement of long-term survival or cure in patients with oligometastases and oligo-recurrence is cancer and organ specific. These facts rely on the seed and soil theory and multiple steps of cancer progression. Oligo-recurrence is considered to have a better prognosis than oligometastases. In patients with oligometastases and oligo-recurrence, the oligometastases and oligo-recurrence are sometimes cured with only local therapy, which is an example of the abscopal effect, previously described in relation to cure of lesions outside of the field of radiation therapy without systemic therapy. Oligometastases and oligo-recurrence can now be cured by less invasive local treatment methods combined with systemic therapy. The mechanisms of oligometastases and oligo-recurrence, as well as novel insights into these important concepts, are presented in this paper.

Management of rectal cancer and liver metastatic disease: which comes first?

In the last few decades there have been significant changes in the approach to rectal cancer management. A multimodality approach and advanced surgical techniques have led to an expansion of the treatment of metastatic disease, with improved survival. Hepatic metastases are present at one point or another in about 50% of patients with colorectal cancer, with surgical resection being the only chance for cure. As the use of multimodality treatment has allowed the tackling of more complicated cases, one of the main questions that remain unanswered is the management of patients with synchronous rectal cancer and hepatic metastatic lesions. The question is one of priority, with all possible options being explored. Specifically, these include the simultaneous rectal cancer and hepatic metastases resection, the rectal cancer followed by chemotherapy and then by the liver resection, and finally the “liver-first” option. This paper will review the three treatment options and attempt to dissect the indications for each. In addition, the role of laparoscopy in the synchronous resection of rectal cancer and hepatic metastases will be reviewed in order to identify future trends.

Methyl nomilinate from citrus can modulate cell cycle regulators to induce cytotoxicity in human colon cancer (SW480) cells in vitro

Limonoids are triterpenoids found in citrus and possess cancer preventive properties in in vitro and in vivo assays. Although several mechanisms for the chemopreventive properties of limonoids have been postulated, the specific mechanisms involved in the anti-cancer effects have not been explored. In the present study, limonoids, including methyl nomilinate, isoobacunoic acid, isolimonexic acid (ILNA), and limonexic acid (LNA), were purified, identified by LC-MS and NMR spectral data and evaluated for their biological effects on SW480 human colon adenocarcinoma cells. Methyl nomilinate was the most potent inhibitor of cell metabolic activity in MTT and EdU incorporation assays. These limonoids did not affect apoptotic markers such as caspase-3 and PARP, but methyl nomilinate treatment resulted in significant induction of G0/G1 cell cycle arrest. Furthermore, methyl nomilinate suppressed CDK4/6 and cyclin D3 and the expression of CDK inhibitors. Taken together, the results suggest inhibition of cell proliferation by methyl nomilinate occurs due to G1 cell cycle arrest, indicating that methyl nomilinate has potential as a chemopreventive agent.

Prognostic scoring system for stage IV colorectal cancer: is the AJCC sub-classification of stage IV colorectal cancer appropriate?

BACKGROUND

Stage IV colorectal cancer encompasses various clinical conditions. The aim of this study was to validate the utility of the recent AJCC stage IV colorectal cancer sub-classification, and to establish a prognostic scoring system using independent factors.

METHODS

We conducted a retrospective analysis using data from the multicenter registry. Factors affecting the curative resection and prognosis were analyzed in patients with stage IV colorectal cancer.

RESULTS

Of the 60,176 patients who received surgery for colorectal cancer, 9,624 (16.0 %) were classified as stage IV. The prognoses of patients with peritoneum-only metastasis were superior to those of patients with a stage IVB (P < 0.0001). Of the 11 independent prognostic factors identified, eight with a hazard ratio greater than 1.3 (depth of tumor invasion, regional lymph node metastasis, histologic grade, liver metastasis, lung metastasis, distant lymph node metastasis, peritoneal metastasis, and curative resection) were used in the prognostic scoring system. The scoring system gave one or two points for the presence of each prognosis risk factor, resulting in a total score ranging from 0 to 9. The 5-year overall survival rates of patients with a total score of 0-2, 3, 4, 5, and 6-9 were 50.4, 30.4, 17.7, 7.7, and 4.0 %, respectively (P < 0.0001).

CONCLUSION

Although the AJCC staging for patients with stage IV colorectal cancer reflected the prognosis, patients with peritoneum-only metastases should be classified as stage IVA. The prognostic scoring system using eight independent factors is useful in predicting the survival of patients with stage IV colorectal cancer.

Radiofrequency ablation for colorectal liver metastases: prognostic factors in non-surgical candidates

PURPOSE

To determine prognostic factors in patients with colorectal liver metastases who were not surgical candidates and received liver radiofrequency (RF) ablation.

MATERIALS AND METHODS

RF ablation was done for 141 colorectal liver metastases in 84 patients. There were 63 (75.0 %, 63/84) males and 21 (25.0 %, 21/84) females, with a mean age of 64.6 ± 10.3. The mean maximum tumor diameter was 2.3 ± 1.4 cm (range 0.5-9.0 cm). Extrahepatic metastases were associated at the time of liver RF ablation in 23 patients (27.4 %, 23/84), and 12 (14.3 %, 12/84) had lung metastases considered controllable by planned lung RF ablation. Prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

There was no procedure-related mortality. The 1-, 3-, and 5-year overall survival rates were 90.6 % (95 %CI, 83.9-97.2 %), 44.9 % (95 %CI, 31.8-57.9 %), and 20.8 % (95 %CI, 7.3-34.3 %), respectively, with a median survival of 34.9 months. The univariate analysis showed that tumor diameter larger than 3 cm, tumor multiplicity, uncontrollable extrahepatic disease, and previous chemotherapy history were significantly worse prognostic factors. The former three factors remained significant for worse prognosis in the multivariate Cox model. Extrahepatic disease was not a prognostic factor when it could be controlled.

CONCLUSION

Tumor size and number, and uncontrollable extrahepatic metastases were significant prognostic factors.

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.

A nomogram predicting disease-free survival in patients with colorectal liver metastases treated with hepatic resection: multicenter data collection as a Project Study for Hepatic Surgery of the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND/PURPOSE

The aim of this study was to create a nomogram to predict the disease-free survival of patients with colorectal liver metastases treated with hepatic resection.

METHODS

Perioperative factors were assessed in 727 hepatectomized patients with colorectal liver metastases between 2000 and 2004 at the 11 institutions of the "Project Committee of the Liver" in the Japanese Society of Hepato-Biliary-Pancreatic Surgery. A nomogram was developed as a graphical representation of a stepwise Cox proportional hazards regression model.

RESULTS

Perioperative mortality was 0.55%. Disease-free and overall survival rates were 31.2 and 63.8% at 3 years, 27.2 and 47.7% at 5 years, and 24.7 and 38.5% at 10 years, respectively. Six preoperative factors were selected to create the nomogram for disease-free survival: synchronous metastases, 3 points; primary lymph node positive, 3 points; number of tumors 2-4, 4 points and ≥5, 9 points; largest tumor diameter >5 cm, 2 points; extrahepatic metastasis at hepatectomy, 4 points, and preoperative carbohydrate antigen 19-9 level >100, 4 points. The estimated median disease-free survival time was easily calculated by the nomogram: >8.4 years for patients with 0 points, 1.9 years for 5 points, 1.0 years for 10 points, and the rates were lower than 0.6 years for patients with more than 10 points.

CONCLUSIONS

This nomogram can easily calculate the median and yearly disease-free survival rates from only 6 preoperative variables. This is a very useful tool to determine the likelihood of early recurrence and the necessity for perioperative chemotherapy in patients with colorectal liver metastases after hepatic resection.

Implications of clinical risk score to predict outcomes of liver-confined metastasis of colorectal cancer

OBJECTIVE/BACKGROUND

We investigated the usefulness of a clinical risk scoring system (CRS) for guiding management and defining prognosis for patients with colorectal liver met"astases (CLM).

METHOD

We retrospectively analyzed data about the correlation between outcomes and Fong's CRS from 1989 to 2010 for patients treated for CLM at the Severance Hospital.

RESULTS

Of 566 patients, 232 received adjuvant treatment after liver resection. Of these patients, 185 (81%) had a low CRS (0-2) and 47 (19%) had a high CRS (3-5). Stratification into high and low CRS allowed significant distinction between Kaplan-Meier curves for outcome. The 5-year survival rate was 88.5% and 11.5% among patients with a low and high CRS, respectively (P < 0.001). Seventy patients with initially unresectable CLM underwent liver resection after tumor downsizing by induction chemotherapy. Shifting of the CRS from high to low (8 patients; 11.4%) improved disease-free survival and overall survival.

CONCLUSION

High CRS is associated with worse survival after resection in resectable and unresectable disease. The CRS may be used for risk assessment when recommending oncological surgical timing in initially unresectable disease and treatment options for perioperative or adjuvant treatment in resectable disease.

Detailed liver-specific imaging prior to pre-operative chemotherapy for colorectal liver metastases reduces intra-hepatic recurrence and the need for a repeat hepatectomy

BACKGROUND

Neoadjuvant chemotherapy for colorectal liver metastases (CRLM) reduces the accuracy of liver imaging which may understage patients pre-operatively. Retrospective review of a prospective database to determine whether liver-specific magnetic resonance imaging (MRI) prior to pre-operative chemotherapy affects intra-hepatic recurrence and long-term outcome after hepatectomy.

PATIENTS AND METHODS

Between 2003 and 2009, 242 patients with CRLM underwent a hepatectomy after ≥3 cycles of oxaliplatin or irinotecan-based chemotherapy. All had a liver-specific MRI immediately pre-operatively. The outcome of patients who had a liver-specific MRI prior to chemotherapy (PCI group, n= 92) was compared with those who did not (non-PCI group, n= 150).

RESULTS

A liver-specific MRI pre-chemotherapy changed the staging in 56% of patients. At a median (range) follow-up of 55 (6-94) months, there was a higher incidence of intra-hepatic recurrence at a new site in the non-PCI group (65% vs. 48% in the PCI group, P= 0.041) and an increased rate of recurrence in patients with the same number of lesions pre- and post-chemotherapy [hazard ratio (HR) 2.02, 1:10-3.37, P= 0.024]. The non-PCI group underwent more repeat hepatectomies than the PCI group (24.7% vs. 13%, P= 0.034), achieving similar long-term survival.

CONCLUSIONS

A liver-specific MRI prior to chemotherapy reduces intra-hepatic recurrence and avoids a repeat hepatectomy.

Impact of preoperative targeted therapy on postoperative complications after resection of colorectal liver metastases

PURPOSE

The impact of chemotherapy (CTx) on morbidity after liver resection for colorectal metastases (CRC-LM) has been increasingly investigated during recent years. Biologic agents like bevacizumab (BEV) or cetuximab (CET) are now added as "targeted therapy" (TT), also in neoadjuvant settings. Initial series could demonstrate the safety of those regimens in liver resection but data are still scarce. We evaluated the impact of CTx with BEV or CET (CTx + TT) on perioperative morbidity and mortality.

METHODS

Two hundred thirty-seven patients who underwent liver resections for CRC-LM after chemotherapy before surgery since 1999 were included. One hundred eighty-five patients (78%) had preoperative CTx regimen without biologic agents (fluoropyrimidine-, oxaliplatin-, or irinotecan-based) and 52 (22%) had CTx + TT (39 BEV, 11 CET, 2 CET/BEV). After preoperative CTx + TT, a time interval of at least 4-6 weeks and a residual liver volume of >35% before surgery were required.

RESULTS

Hemihepatectomy or more was performed in about half of the patients. The median amount of intraoperatively transfused blood was 0 ml in both groups (p = 0.34). Overall mortality was 1.7% and slightly elevated in patients with CTx + TT (3.8% vs. 1.1%, p = 0.17). Any complication occurred in (CTx + TT vs. CTx) 52% and 46%, respectively (p = 0.47). The rates of liver failure (9.6% vs. 9.7%, p = 0.98), infectious complications such as wound infection (19% vs. 16%, p = 0.62) and abdominal abscess (8% vs. 6.5%, p = 0.71), as well as the rate of relaparotomies (11.5% vs. 7.0%, p = 0.29) showed no significant differences between the groups with TT or without. In multivariate analyses, neither type nor duration of CTx nor the time interval between CTx and surgery showed any influence on complication rates.

CONCLUSIONS

Our data confirm the safety of targeted therapy before liver resection for CRC-LM. This effect may in part be due to our treatment policy (time interval to resection and residual liver volume) after intensive preoperative CTx.

Evaluating agreement regarding the resectability of colorectal liver metastases: a national case-based survey of hepatic surgeons

BACKGROUND

The resectability of colorectal liver metastases is in part largely based on the surgeon's assessment of cross-sectional imaging. This process, while guided by principles, is subjective. The objective of the present study was to assess agreement between hepatic surgeons regarding the resectability of colorectal liver metastases.

METHODS

Forty-six hepatic surgeons across Canada were invited. A patient with biologically favourable disease was presented after having received neoadjuvant chemotherapy. The scenario was matched with 10 different scrollable abdominal CT scans representing a maximum response after six cycles of chemotherapy. Surgeons were asked to offer an opinion on resectability of liver metastases, and whether they would use adjunct modalities to hepatic resection.

RESULTS

Twenty-six surgeons participated. Twenty responses were complete. The median number of scenarios deemed resectable was 6/10 (range 3-8). Two control scenarios demonstrated perfect agreement. Agreement on resectability was poor for 4/8 test scenarios, of which one scenario demonstrated complete disagreement. Among resectable cases, the pattern of use of adjunct modalities was variable. A median ratio of 0.87 adjunct modality per resectable scenario per surgeon was used (range 0.25-1.75).

CONCLUSION

A significant lack of agreement was identified among surgeons on the resectability and use of adjunct modalities in the treatment of colorectal liver metastases.

General principles of hepatectomy in colorectal liver metastases

Hepatic resection for colorectal liver metastases remains the only therapeutic option that improves long-term survival and offers potential cure. By conventional resectability criteria, only a limited number of patients with metastatic disease can be subjected to surgical intervention. In the past decade, better understanding of the natural history of the disease, the introduction of new chemotherapy agents and the advances in surgical techniques have led to more patients being eligible for surgery. Neoadjuvant chemotherapy can reduce the size of the metastases, allowing operation on patients who were previously considered inoperable. Major resections can nowadays be safely performed with the development of new less-invasive techniques and with the use of supplementary tools like ablation techniques. Using portal vein embolization to induce hypertrophy of future liver remnant and combining it with two-staged hepatectomy allow more patients with advanced disease to undergo potentially curative surgery. Careful selection of patients and aggressive surgery in experienced centers improve survival rates.

Liver resection for colorectal metastases in older adults: a paired matched analysis

OBJECTIVES

To assess the safety and long-term results of hepatic resection of colorectal liver metastases (CLM) in older adults.

DESIGN

Case-control.

SETTING

Single liver and multivisceral transplant center.

PARTICIPANTS

Individuals with CLM: 32 aged 70 and older (older group) and 32 younger than 70 (younger group) matched in a 1:1 ratio according to sex, primary tumor site, liver metastases at diagnosis, number of metastases, maximum tumor size, infiltration of cut margin, type of hepatic resection, and hepatic resection timing.

MEASUREMENTS

Postoperative complications and survival rates.

RESULTS

There was no significant difference in preoperative clinical findings between the two study groups. The incidence of cumulative postoperative complications was similar in the older (28.1%) and younger (34.4%) groups (P = .10). One-, 3-, and 5-year disease-free survival rates were 57.6%, 32.9%, and 16.4%, respectively, in the younger group and 67.9%, 29.2%, and 19.5%, respectively, in the older group (P = .72). One-, 3-, and 5-year participant survival rates were 84.1%, 51.9%, and 33.3%, respectively, in the older group and 93.6%, 63%, and 28%, respectively, in the younger group (P = .50).

CONCLUSIONS

Resection of colorectal liver metastases in older adults can be performed with low mortality and morbidity and offers a long-time survival advantage to many of these individuals. Based on the results of this case-control study, older adults should be considered for surgical treatment whenever possible.

Curative strategies for liver metastases from colorectal cancer: a review

Colorectal cancer is a very common malignancy and frequently manifests with liver metastases, often without other systemic disease. Margin-negative (R0) resection of limited metastatic disease, in conjunction with systemic antineoplastic agents, is the primary treatment strategy, leading to long survival times for appropriately selected patients. There is debate over whether the primary tumor and secondaries should be removed at the same time or in a staged manner. Chemotherapy is effective in converting some unresectable liver metastases into resectable disease, with a correspondingly better survival outcome. However, the ideal chemotherapy with or without biological agents and when it should be administered in the course of treatment are uncertain. The role of neoadjuvant chemotherapy in initially resectable liver metastases is controversial. Local delivery of chemotherapy, with and without surgery, can lead to longer disease-free survival times, but it is not routinely used with curative intent. This review focuses on methods to maximize the disease-free survival interval using chemotherapy, surgery, and local methods.

Multi-modality treatment of colorectal liver metastases

Liver metastases synchronously or metachronously occur in approximately 50% of colorectal cancer patients. Multimodality comprehensive treatment is the best therapeutic strategy for these patients. However, the optimal pattern of multimodality therapy is still controversial, and it raises several significant concerns. Liver resection is the most important treatment for colorectal liver metastases. The definition of resectability has shifted to focus on the completion of R0 resection and normal liver function maintenance. The role of neoadjuvant and adjuvant chemotherapy still needs to be clarified. The management of either progression or complete remission during neoadjuvant chemotherapy is challenging. The optimal sequencing of surgery and chemotherapy in synchronous colorectal liver metastases patients is still unclear. Conversional chemotherapy, portal vein embolization, two-stage resection, and tumor ablation are effective approaches to improve resectability for initially unresectable patients. Several technical issues and concerns related to these methods need to be further explored. For patients with definitely unresectable liver disease, the necessity of resecting the primary tumor is still debatable, and evaluating and predicting the efficacy of targeted therapy deserve further investigation. This review discusses different patterns and important concerns of multidisciplinary treatment of colorectal liver metastases.

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.

Adenosine triphosphate-based chemotherapy response assay-guided chemotherapy in unresectable colorectal liver metastasis

BACKGROUND

This study aims to evaluate the effectiveness of adenosine triphosphate-based chemotherapy response assay (ATP-CRA)-guided neoadjuvant chemotherapy for increasing resectability in patients with unresectable colorectal liver metastasis.

PATIENTS AND METHODS

Patients were randomised into two groups: Group A was treated by conventional chemotherapy regimen and Group B was treated by chemotherapy regimen according to the ATP-CRA. Three chemotherapeutic agents (5-fluorouracil, oxaliplatin and irinotecan) were tested by ATP-CRA and more sensitive agents were selected. Either FOLFOX or FOLFIRI was administered. Between Group A and B, treatment response and resectability were compared.

RESULTS

Between November 2008 and October 2010, a total 63 patients were randomised to Group A (N=32) or Group B (N=31). FOLFOX was more preferred in Group A than in Group B (26 out of 32 (81.3%) vs 20 out of 31 (64.5%)). Group B showed better treatment response than Group A (48.4% vs 21.9%, P=0.027). The resectability of hepatic lesion was higher in Group B (35.5% vs 12.5%, P=0.032). Mean duration from chemotherapy onset to the time of liver resection was 11 cycles (range 4-12) in Group A and 8 cycles (range 8-16) in Group B.

CONCLUSION

This study showed that tailored-chemotherapy based on ATP-CRA could improve the treatment response and resectability in initially unresectable colorectal liver metastasis.

Inferior vena cava resection with hepatectomy: challenging but justified

OBJECTIVE

The aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours.

METHODS

From February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database.

RESULTS

Resections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients.

CONCLUSIONS

Aggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.

Radiofrequency ablation vs hepatic resection for solitary colorectal liver metastasis: A meta-analysis

AIM: To evaluate the comparative therapeutic efficacy of radiofrequency ablation (RFA) and hepatic resection (HR) for solitary colorectal liver metastases (CLM).

METHODS: A literature search was performed to identify comparative studies reporting outcomes for both RFA and HR for solitary CLM. Pooled odds ratios (OR) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.

RESULTS: Seven nonrandomized controlled trials studies were included in this analysis. These studies included a total of 847 patients: 273 treated with RFA and 574 treated with HR. The 5 years overall survival rates in the HR group were significantly better than those in the RFA group (OR: 0.41, 95% CI: 0.22-0.90, P = 0.008). RFA had a higher rate of local intrahepatic recurrence compared to HR (OR: 4.89, 95% CI: 1.73-13.87, P = 0.003). No differences were found between the two groups with respect to postoperative morbidity and mortality.

CONCLUSION: HR was superior to RFA in the treatment of patients with solitary CLM. However, the findings have to be carefully interpreted due to the lower level of evidence.

A systematic review of clinical response and survival outcomes of downsizing systemic chemotherapy and rescue liver surgery in patients with initially unresectable colorectal liver metastases

BACKGROUND

Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable after systemic chemotherapy. We reviewed the evidence of downsizing systemic chemotherapy followed by rescue liver surgery in patients with initially unresectable CLM.

METHODS

Literature search of databases (Medline and PubMed) to identify published studies of neoadjuvant chemotherapy followed by liver resection in patients with initially unresectable CLM was undertaken and focused on response rate of chemotherapy and survival outcomes.

RESULTS

Ten observational studies were reviewed. A total of 1,886 patients with initially unresectable CLM underwent systemic chemotherapy. An objective response was observed in 64% (range, 43-79%) of patients after systemic chemotherapy. Of these, 22.5% underwent macroscopically curative liver resection. Median overall survival was 45 (range, 36-60) months with 19% of patients alive and recurrence-free.

CONCLUSIONS

Current evidence suggests that downsizing systematic chemotherapy followed by rescue liver resection is safe and effective for selected patients with initially unresectable CLM. Further studies are required to examine response rates and secondary resectability using new targeted molecular therapy-based regimens.

Treatment advances in liver-limited metastatic colorectal cancer

Over the last several decades advances in the management and treatment of patients with liver metastases from colorectal cancer (CRC) has changed a disease with a dismal prognosis to one with a potential for cure in some patients. Advances have been made through coordinated management of patients by surgeons, medical oncologists, radiologists, and other health care professionals coupled with advances in treatment options. Although these advances have clearly impacted patient outcomes, it is clear that the benefit of traditional surgical approaches and the use of cytoxic chemotherapy are reaching a plateau. Continued research to develop new and more active therapies, including targeted or biologic agents, is needed. This review discusses the advances made in management of patients with liver-limited metastatic disease.

Liver resection for advanced or aggressive colorectal cancer metastases in the era of effective chemotherapy: a review

Liver surgery has been known to cure metastatic colorectal cancer in a small proportion of patients. However, advances in procedural technique and chemotherapy now allow more patients to have safe, potentially curative surgery. Here we review surgery for unresectable colorectal liver metastases using an expert multidisciplinary approach. With multidisciplinary management of patients with effective chemotherapy that can downstage metastases, more patients with previously inoperable disease can benefit from surgery. Portal vein embolization results in hypertrophy of the future liver remnant; on occasions, combining embolization with staged liver resection permits potentially curative surgery for patients previously unable to survive resection. However, increasing use of chemotherapy has raised awareness of potential hepatotoxicity and other deleterious effects of cytotoxic agents. Prolonged prehepatectomy chemotherapy therefore can reduce resectability even using a 2-stage procedure. Suitable timing of surgery for unresectable liver metastases during chemotherapy is critical. Because of advances in chemotherapy, colorectal cancer, like ovarian cancer, can now show survival benefit from maximum surgical debulking. Benefit from such maximum hepatic debulking surgery for metastatic colorectal disease is uncertain, but likely. Surgery in isolation may be approaching technical limits, but is now likely to help more patients because of the success of complementary strategies, particularly newer chemotherapy and targeted therapy. Expert individualized multidisciplinary treatment planning and problem-solving is essential.

Treatment recommendations for metastatic colorectal cancer

Metastatic colorectal cancer (CRC) represents an important health problem in which several biological predictive and prognostic factors have been identified, including clinical features and molecular markers that might influence the response to treatment. Actually, certain prognostic factors are considered key elements, along with disease extent, for deciding the therapeutic approach. However, a distinction between resectable/potentially resectable and unresectable patients must be made in order to establish an adequate therapeutic strategy. Different drugs and chemotherapy regimens are currently available, and their administration depends on patient characteristics, disease-related factors and the treatment objective. Moreover, special situations such as peritoneal carcinomatosis and local treatment of CRC in the setting of metastatic disease should be considered when deciding the most appropriate treatment strategy. This article reviews all the previously mentioned issues involved in the management of metastatic CRC and suggests some general recommendations for its treatment.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Recent advances in the curative treatment of colorectal liver metastases

Liver resection provides the basis for curative treatment of colorectal liver metastases (CLM), achieving 5-year survival rates as high as 58%. Use of this approach is limited by the number of patients whose CLM are resectable at the time of initial presentation and the risk of early recurrence after surgery, justifying development of modern perioperative chemotherapy regimens. Chemotherapy-associated hepatotoxicity led to development of standardized treatment strategies that balance the duration and timing of preoperative chemotherapy to minimize postoperative morbidity. The current challenge in the effort to offer curative treatment for CLM is selection of patients who will most benefit from an aggressive surgical approach. New end points of preoperative chemotherapy such as pathologic response and new radiologic response criteria have been evaluated as predictive factors for survival after liver resection and provide useful support in selecting patients for surgery.