Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy

Safety of laparoscopic compared to open right hepatectomy after portal vein occlusion: results from a multicenter study

BACKGROUND

Concerns have been expressed about the feasibility of laparoscopic right hepatectomy (Lap-RH) after portal vein occlusion (PVO), because of its technical difficulty. The aim of this study is to assess the safety and feasibility of lap-RH after PVO.

METHODS

Retrospective analysis of prospectively collected data from high-volume HPB centers was performed. The peri-operative outcomes of lap-RH were compared to open-RH. Propensity score matching (PSM) was used to mitigate the influence of selection bias. Both one-stage and two-stage procedures were considered.

RESULTS

Between 01/2010 and 12/2020, 284 patients underwent RH or extended RH after PVO. The laparoscopic approach was used in 63 (22%) cases. Overall, surgeries were mainly performed for colorectal metastases (68.6%). Two-stage procedures were required in one-third of the cases for both groups. After PSM, 126 patients of the open-RH group were matched with 63 patients of the lap-RH group. In the lap-RH group, compared to open-RH, median FLR% post-PVO was larger (39.4% vs 38.5%, p = 0.037), median operation time was longer (360 vs 264 min, p < 0.001), pedicle clamping was used more frequently (79.4% vs 38.9%, p > 0.001), and median blood loss was higher (250 cc vs 200 cc, p = 0.024). Severe intraoperative incidents seldom occurred in both groups (6.3% lap-RH vs 1.6% open-RH, p = 0.208). The overall and severe complication rates were comparable. ISGLS liver failure grade B/C was rare in both groups (3.2% lap-RH vs 4.8% open-RH, p = 0.721). 90-day mortality was 1.6% following either lap-RH or open-RH. Lap-RH allowed a shorter median hospital stay (6 vs 8 days, p = 0.001). R1 resection rate was lower after lap-RH (3.2% vs 16%, p = 0.008).

CONCLUSION

Lap-RH after PVO is safe, although it is technically more demanding than open-RH. This study also suggests some potential benefits of the laparoscopic approach, in terms of a shorter hospital stay and increased rate of radical resections.

Artificial Intelligence-Driven Patient Selection for Preoperative Portal Vein Embolization for Patients with Colorectal Cancer Liver Metastases

PURPOSE

To develop a machine learning algorithm to improve hepatic resection selection for patients with metastatic colorectal cancer (CRC) by predicting post-portal vein embolization (PVE) outcomes.

MATERIALS AND METHODS

This multicenter retrospective study (2000-2020) included 200 consecutive patients with CRC liver metastases planned for PVE before surgery. Data on radiomic features and laboratory values were collected. Patient-specific eigenvalues for each liver shape were calculated using a statistical shape model approach. After semiautomatic segmentation and review by a board-certified radiologist, the data were split 70%/30% for training and testing. Three machine learning algorithms predicting the total liver volume (TLV) after PVE, sufficient future liver remnant (FLR%), and kinetic growth rate (KGR%) were trained, with performance assessed using accuracy, sensitivity, specificity, area under the curve (AUC), or root mean squared error. Significance between the internal and external test sets was assessed by the Student t-test. One institution was kept separate as an external testing set.

RESULTS

A total of 114 (76 men; mean age, 56 years [SD± 12]) and 37 (19 men; mean age, 50 years ± [SD± 11]) patients met the inclusion criteria for the internal validation and external validation, respectively. Prediction accuracy and AUC for sufficient FLR% or liver growth potential (KGR%> 0%) were high in the internal testing set-85.81% (SD ± 1.01) and 0.91 (SD ± 0.01) or 87.44% (SD ± 0.10) and 0.66 (SD ± 0.03), respectively. Similar results occurred in the external testing set-79.66% (SD ± 0.60) and 0.88 (SD ± 0.00) or 72.06% (SD ± 0.30) and 0.69 (SD ± 0.01), respectively. TLV prediction showed discrepancy rates of 12.56% (SD ±4.20%; P = .86) internally and 13.57% (SD ± 3.76%; P = .91) externally.

CONCLUSIONS

Machine learning-based models incorporating radiomics and laboratory test results may help predict the FLR%, KGR%, and TLV as metrics for successful PVE.

Future liver remnant volumetry: an E-AHPBA international survey of current practice among liver surgeons

BACKGROUND

Accurate assessment of the future liver remnant (FLR) is crucial for predicting the risk of post-hepatectomy liver failure (PHLF). This survey aims to evaluate the current practices of liver surgeons regarding FLR volumetry and its clinical use.

METHODS

A cross-sectional survey was conducted among 212 liver surgeons to assess their use of FLR volumetry and associated methodologies. The survey consisted of 40 questions distributed in five sections covering multiple aspects of FLR volumetry.

RESULTS

Ninety percent of respondents utilize preoperative FLR volumetry. However, there is significant variability in the methods used for FLR calculation and the thresholds for safe liver resection, which deviate from the proposed 20/30/40 % rule. Before right hepatectomy, 21 % of respondents indicated that they rarely or never utilise volumetry. Extended resections are the surgical procedures in which volumetry is most frequently employed. Furthermore, the kinetic growth rate is not widely adopted in clinical decision making.

CONCLUSION

This survey highlights the widespread use of FLR volumetry, but also reveals substantial variation in its application. This demonstrates a lack of evidence or guidelines regarding the appropriate use of FLR volumetry.

Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments

The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.

Impact of the future liver remnant volume before major hepatectomy

INTRODUCTION

Following major liver resection, posthepatectomy liver failure (PHLF) is associated with a high mortality rate. As there is no therapy for PHLF available, avoidance remains the main goal. A sufficient future liver remnant (FLR) is one of the most important factors to reduce the risk for PHLF; however, it is not known which patients benefit of volumetric assessment prior to major surgery.

METHODS

A retrospective, bi-institutional cohort study was conducted including all patients who underwent major hepatectomy (extended right hepatectomy, right hepatectomy, extended left hepatectomy and left hepatectomy) between 2010 and 2023.

RESULTS

A total of 1511 major hepatectomies were included, with 29.4 % of patients undergoing FLR volume assessment preoperatively. Overall, PHLF B/C occurred in 9.8 % of cases. Multivariate analysis identified diabetes mellitus, extended right hepatectomy, perihilar cholangiocarcinoma (pCCA), gallbladder cancer (GBC) and cirrhosis as significant risk factors for PHLF B/C. High-risk patients (with one or more risk factors) had a 15 % overall incidence of PHLF, increasing to 32 % with a FLR <30 %, and 13 % with an FLR of 30-40 %. Low-risk patients with a FLR <30 % had a PHLF rate of 21 %, which decreased to 8 % and 5 % for FLRs of 30-40 % and >40 %, respectively. For right hepatectomy, the PHLF rate was 23 % in low-risk and 38 % in high-risk patients with FLR <30 %.

CONCLUSION

Patients scheduled for right hepatectomy and extended right hepatectomy should undergo volumetric assessment of the FLR. Volumetry should always be considered before major hepatectomy in patients with risk factors such as diabetes, cirrhosis, GBC and pCCA. In high-risk patients, a FLR cut-off of 30 % may be insufficient to prevent PHLF, and additional liver function assessment should be considered.

Right hepatectomy compared with left hepatectomy for resectable Klatskin tumor: A systematic review across tumor types

BACKGROUND

The prognosis of Klatskin tumors is poor, and radical surgery with disease-free surgical margins (R0) represents the treatment capable of ensuring the best long-term outcomes. In patients with Klatskin tumors, both right hepatectomy and left hepatectomy might achieve R0 surgical margins. This systematic review concentrated on a comparative investigation between left hepatectomy and right hepatectomy, aiming to furnish clinical evidence and to aid in surgical decision-making for Klatskin tumor depending on its spread within the bile duct tree.

METHODS

The eligible articles in the study were obtained from PubMed, Medline, and Scopus databases, following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis, and they were categorized according to the type of Klatskin tumor treated with right hepatectomy or left hepatectomy. The studies that analyzed the outcomes related to the 2 surgical techniques without focusing on the type of Klatskin tumor were included in a separate paragraph and table.

RESULTS

In total, 21 studies were included. Four studies reported outcomes of right hepatectomy or left hepatectomy for Klatskin type I/II tumor, 2 for Klatskin type II/IV tumor, 2 for Klatskin type III tumor, and 2 for Klatskin type IV. Eleven studies included the outcomes of right hepatectomy and left hepatectomy for hilar cholangiocarcinoma without specifying the type of Klatskin tumor. Although long-term oncologic outcomes seem comparable between right hepatectomy and left hepatectomy when achieving R0 resection for Klatskin type III/IV tumors, there may exist a marginal oncologic edge and reduced complication rates favoring left hepatectomy in individuals with Klatskin type I/II tumors.

DISCUSSION

Right hepatectomy traditionally has played a central role in treating Klatskin tumor, but recent studies have questioned its oncologic efficacy and surgical risks. Currently, there is a lack of evidence regarding the ideal surgical approach for each type of Klatskin tumor, and surgical strategy relies heavily on the individual surgeon's experience and technical skills. The management of Klatskin tumors necessitates specialized hepatobiliary surgical centers capable of conducting major hepatectomy with thorough lymphadenectomy, biliary, and vascular reconstructions. There is a need for studies with larger sample sizes to achieve a wide consensus about the superiority of one surgical technique over the other in cases in which both right hepatectomy and left hepatectomy can achieve an R0 margin.

Laparoscopic versus open right hepatectomy for colorectal liver metastases after portal vein embolization: international multicentre study

BACKGROUND

Laparoscopic liver surgery is increasingly used for more challenging procedures. The aim of this study was to assess the feasibility and oncological safety of laparoscopic right hepatectomy for colorectal liver metastases after portal vein embolization.

METHODS

This was an international retrospective multicentre study of patients with colorectal liver metastases who underwent open or laparoscopic right and extended right hepatectomy after portal vein embolization between 2004 and 2020. The perioperative and oncological outcomes for patients who underwent laparoscopic and open approaches were compared using propensity score matching.

RESULTS

Of 338 patients, 84 patients underwent a laparoscopic procedure and 254 patients underwent an open procedure. Patients in the laparoscopic group less often underwent extended right hepatectomy (18% versus 34.6% (P = 0.004)), procedures in the setting of a two-stage hepatectomy (42% versus 65% (P < 0.001)), and major concurrent procedures (4% versus 16.1% (P = 0.003)). After propensity score matching, 78 patients remained in each group. The laparoscopic approach was associated with longer operating and Pringle times (330 versus 258.5 min (P < 0.001) and 65 versus 30 min (P = 0.001) respectively) and a shorter length of stay (7 versus 8 days (P = 0.011)). The R0 resection rate was not different (71% for the laparoscopic approach versus 60% for the open approach (P = 0.230)). The median disease-free survival was 12 (95% c.i. 10 to 20) months for the laparoscopic approach versus 20 (95% c.i. 13 to 31) months for the open approach (P = 0.145). The median overall survival was 28 (95% c.i. 22 to 48) months for the laparoscopic approach versus 42 (95% c.i. 35 to 52) months for the open approach (P = 0.614).

CONCLUSION

The advantages of a laparoscopic over an open approach for (extended) right hepatectomy for colorectal liver metastases after portal vein embolization are limited.

Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis

BACKGROUND

In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

METHODS

A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted.

RESULTS

Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85).

DISCUSSION

ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).

Radiation Major Hepatectomy Using Ablative Dose Yttrium-90 Radioembolization in Patients with Hepatocellular Carcinoma 5 cm or Larger

PURPOSE

To evaluate the safety and effectiveness of ablative radioembolization for large hepatocellular carcinoma (HCC) while preserving a small future liver remnant (FLR).

MATERIALS AND METHODS

Twenty-five patients with large HCC of ≥5 cm requiring treatment for >60% of the total liver volume and having well-preserved liver function were treated with ablative glass microsphere radioembolization at a single institution from January 2017 to December 2021. Radioembolization was performed with a mean absorbed dose of >150 Gy, and the FLR per nontumor liver volume (NTLV) was set at >30%. Changes in liver function, adverse events, duration of response (DoR) in a treated area, time-to-progression (TTP), and overall survival (OS) were retrospectively investigated.

RESULTS

The largest tumor diameter and planned dose per treated volume were 11.4 cm ± 3.9 and 242.3 Gy ± 63.6 (169.4 Gy ± 45.9 per whole liver volume), respectively. All patients remained at Child-Pugh Class A for 90 days. No patient experienced Grade 3‒4 hyperbilirubinemia or new ascites. One patient (lung dose, 27.8 Gy) developed radiation pneumonitis requiring transient steroid treatment. According to the posttreatment dosimetry, the tumorous and nontumorous liver absorbed doses were 418.8 Gy ± 227.4 and 69.0 Gy ± 32.1, respectively. The median DoR in a treated area and TTP were 22.0 and 17.1 months, respectively. The 5-year OS rate was 83.2%.

CONCLUSIONS

Ablative radioembolization of large HCC of ≥5 cm can be performed safely and effectively in patients with preserved liver function when FLR/NTLV exceeds 30%.

Totally laparoscopic associating simultaneous bile duct and portal vein ligation for planned hepatectomy for primary liver cancer: a case report

BACKGROUND

Some patients with liver cancer lose the chance to have surgical treatment due to insufficient future remnant liver. To address this problem, individual or occlusion of both the portal vein and the bile duct was used to achieve quick hypertrophy. This is the first study reported in which simultaneous ligation of the portal vein and the bile duct was applied as the first step of planned hepatectomy of primary liver cancer.

CASE PRESENTATION

Here we report a case of a 38-year-old Asian male patient with hepatocellular carcinoma with tumor thrombus in the right anterior branch of the portal vein. Right hemihepatectomy can be curative, but patients face a high risk of liver failure because of the small volume of the remaining left liver lobe. Hence we developed a two-step liver resection strategy in which the patient underwent laparoscopic simultaneous bile duct and portal vein ligation of the right hepatic lobe prior to right hemihepatectomy under laparoscopy. Using this procedure, we achieved fast hypertrophy of the left liver lobe and successfully reversed the primary unresectability.

CONCLUSION

This case report demonstrates that simultaneous bile duct and portal vein ligation may be a feasible option for those patients with liver cancer who cannot get surgical treatment due to insufficient future remnant liver.

Prospective Study of Perioperative Circulating Tumor DNA Dynamics in Patients Undergoing Hepatectomy for Colorectal Liver Metastases

OBJECTIVE

To evaluate the association of perioperative ctDNA dynamics on outcomes after hepatectomy for CLM.

SUMMARY BACKGROUND DATA

Prognostication is imprecise for patients undergoing hepatectomy for CLM, and ctDNA is a promising biomarker. However, clinical implications of perioperative ctDNA dynamics are not well established.

METHODS

Patients underwent curative-intent hepatectomy after preoperative chemotherapy for CLM (2013-2017) with paired prehepatectomy/postoperative ctDNA analyses via plasma-only assay. Positivity was determined using a proprietary variant classifier. Primary endpoint was recurrence-free survival (RFS). Median follow-up was 55 months.

RESULTS

Forty-eight patients were included. ctDNA was detected before and after surgery (ctDNA+/+) in 14 (29%), before but not after surgery (ctDNA+/-) in 19 (40%), and not at all (ctDNA-/-) in 11 (23%). Adverse tissue somatic mutations were detected in TP53 (n = 26; 54%), RAS (n = 23; 48%), SMAD4 (n = 5; 10%), FBXW7 (n = 3; 6%), and BRAF (n = 2; 4%). ctDNA+/+ was associated with worse RFS (median: ctDNA+/+, 6.0 months; ctDNA+/-, not reached; ctDNA-/-, 33.0 months; P = 0.001). Compared to ctDNA+/+, ctDNA+/- was associated with improved RFS [hazard ratio (HR) 0.24 (95% confidence interval (CI) 0.1-0.58)] and overall survival [HR 0.24 (95% CI 0.08-0.74)]. Adverse somatic mutations were not associated with survival. After adjustment for prehepatectomy chemotherapy, synchronous disease, and ≥2 CLM, ctDNA+/- and ctDNA-/- were independently associated with improved RFS compared to ctDNA+/+ (ctDNA+/-: HR 0.21, 95% CI 0.08-0.53; ctDNA-/-: HR 0.21, 95% CI 0.08-0.56).

CONCLUSIONS

Perioperative ctDNA dynamics are associated with survival, identify patients with high recurrence risk, and may be used to guide treatment decisions and surveillance after hepatectomy for patients with CLM.

Portal vein embolization with absolute ethanol to induce hypertrophy of the future liver remnant

Background

Preoperative portal vein embolization (PVE) is widely used prior to major liver resection to reduce the risk of post-hepatectomy liver failure (PHLF). We evaluated the efficacy and safety of PVE using absolute ethanol.

Methods

Consecutive patients undergoing preoperative PVE between February 2003 and February 2020 at a high-volume tertiary institution were retrospectively reviewed. Hypertrophy of the future liver remnant (FLR) was determined by comparing volumetric data using semi-automated software on computed tomography or magnetic resonance imaging before and after PVE. Efficacy of absolute ethanol was evaluated by the percentage increase in the FLR volume and the ratio of the FLR to the total liver volume (TLV). Technical success and complications following PVE were evaluated. Feasibility of hepatectomy following PVE and the incidence of PHLF were determined.

Results

Sixty-two patients underwent preoperative PVE using absolute ethanol. The technical success rate was 95.2%. Median time interval between PVE and follow-up imaging was 34 days (range 6–144 days). The mean increase in FLR volume and ratio of the FLR to TLV were 43.6 ± 34.4% and 12.3 ± 7.7% respectively. Major adverse events occurred in 3 cases (4.8%) and did not preclude consideration of surgery. Forty-two patients (67.8%) proceeded to surgery for intended hepatectomy of which 36 patients (58.1%) underwent liver resection. Major post-operative complications occurred in 4 patients (11.1%) and there were no cases of PHLF.

Conclusion

Preoperative PVE with absolute ethanol is effective and safe in inducing hypertrophy of the FLR before partial hepatectomy to prevent PHLF.

Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

BACKGROUND

Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.

RESULTS

Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).

CONCLUSION

Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.

Aspiration thrombectomy for inferior vena cava tumor thrombus arising from hepatocellular carcinoma

Pharmacomechanical therapy and catheter-directed thrombolysis have been shown to be very effective in the treatment of venous thromboembolism; however, there is much less data regarding inferior vena cava thrombi. Tumor thrombi pose an even greater clinical challenge as anti-coagulation and thrombolysis are not effective. We present the case of a 61-year-old male who presented with an inferior vena cava thrombus emanating from an accessory right hepatic vein, treated with aspiration thrombectomy.

Current Perspectives on the Surgical Management of Perihilar Cholangiocarcinoma

Cholangiocarcinoma (CCA) represents nearly 15% of all primary liver cancers and 2% of all cancer-related deaths worldwide. Perihilar cholangiocarcinoma (pCCA) accounts for 50-60% of all CCA. First described in 1965, pCCAs arise between the second-order bile ducts and the insertion of the cystic duct into the common bile duct. CCA typically has an insidious onset and commonly presents with advanced, unresectable disease. Complete surgical resection is technically challenging, as tumor proximity to the structures of the central liver often necessitates an extended hepatectomy to achieve negative margins. Intraoperative frozen section can aid in assuring negative margins and complete resection. Portal lymphadenectomy provides important prognostic and staging information. In specialized centers, vascular resection and reconstruction can be performed to achieve negative margins in appropriately selected patients. In addition, minimally invasive surgical techniques (e.g., robotic surgery) are safe, feasible, and provide equivalent short-term oncologic outcomes. Neoadjuvant chemoradiation therapy followed by liver transplantation provides a potentially curative option for patients with unresectable disease. New trials are needed to investigate novel chemotherapies, immunotherapies, and targeted therapies to better control systemic disease in the adjuvant setting and, potentially, downstage disease in the neoadjuvant setting.

Parenchyma-sparing strategy and oncological prognosis in patients with colorectal cancer liver metastases

Background

Preliminary study results demonstrated parenchyma-sparing surgery (PSS) as an effective approach which allowed to remove colorectal cancer (CRC) metastatic lesions within the central liver cites and increased the probability of the liver re-resections.

Methods

The prospective analysis re-evaluation of the 185 CRC patients surgical treatment has been performed.

Results

An overall 5-year survival (OS) of the 185 enrolled patients was 43 ± 7%, and the mean and median value for OS was 48.7 ± 1.9% and 55.2 ± 5 (95% CI: 44.4–66.1) months. The 5-year OS for CRC patients whose metastatic lesions were predominantly located within peripheral and central liver segments was 56 ± 8% and 27 ± 9%, respectively (p = 0.08). A 5-year disease-free survival (DFS) rates of patients with peripheral and central liver cites metastatic lesions were 31 ± 7 % and 15 ± 7%, p = 0,12. And the DFS median was 34.2 and 46.5 months for R_1v and R0 cohorts, respectively, p = 0.62.

Conclusions

Parenchyma-sparing surgery should be a priority pathway for complex treatment of patients with deeply located lesions of the right liver lobe.

Trial registration

The study is registered in https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ed9f60863e9bf0016624456/, no. 5679.

Systemic Therapy and Its Surgical Implications in Patients with Resectable Liver Colorectal Cancer Metastases. A Report from the Western Canadian Gastrointestinal Cancer Consensus Conference

The Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) convened virtually on 4 November 2021. The WCGCCC is an interactive multi-disciplinary conference attended by health care professionals, including surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals from across four Western Canadian provinces, British Columbia, Alberta, Saskatchewan, and Manitoba, who are involved in the care of patients with gastrointestinal cancer. They participated in presentation and discussion sessions for the purpose of developing recommendations on the role of systemic therapy and its optimal sequence in patients with resectable metastatic colorectal cancer.

Gynura segetum-induced liver injury leading to acute liver failure: a case report and literature review

Background

Gynura segetum (GS) is widely used in medical care and in community settings in China as the herbal remedy. It is widely thought to have antiphlogistic properties and pain relief in traditional Chinese medicine. It has been reported that GS can cause chronic drug-induced liver injury (DILI), manifested as hepatic sinusoid obstruction syndrome (HOSO). But case reports of acute DILI developing acute liver failure (ALF) due to GS are extremely rare.

Case presentation

We report a case of a 63-year-old female patient with hepatolithiasis for more than 6 years. There were no deterioration of liver function and no history of viral liver disease, autoimmune liver disease, blood transfusion or surgical allergy before operation. ALF and grade II liver encephalopathy occurred after partial hepatectomy. To follow up the medical history, the patient has been taking GS (Tusanqi) for a year and a half. The causality assessment was done by the updated Roussel Uclaf Causality Assessment Method, and the possibility of DILI caused by GS as highly probable for the score was 6 points. Excluding other causes, a diagnosis of DILI-associated ALF was established. After symptomatic support and artificial liver support system (ALSS) treatment, the clinical symptoms and signs of the patients were significantly improved. After discharge, the liver function of the patients returned to normal.

Conclusions

Based on this rare case of severe liver injury, we recommend that timely prevention, identification, and appropriate management of DILI is essential for patients with a history of taking GS and other hepatotoxic drugs, and careful monitoring of liver function for patients with DILI could avoid ALF as far as possible.

Sarcopenia predicts reduced liver growth and reduced resectability in patients undergoing portal vein embolization before liver resection - A DRAGON collaborative analysis of 306 patients

BACKGROUND

After portal vein embolization (PVE) 30% fail to achieve liver resection. Malnutrition is a modifiable risk factor and can be assessed by radiological indices. This study investigates, if sarcopenia affects resectability and kinetic growth rate (KGR) after PVE.

METHODS

A retrospective study was performed of the outcome of PVE at 8 centres of the DRAGON collaborative from 2010 to 2019. All malignant tumour types were included. Sarcopenia was defined using gender, body mass and skeletal muscle index. First imaging after PVE was used for liver volumetry. Primary and secondary endpoints were resectability and KGR. Risk factors impacting liver growth were assessed in a multivariable analysis.

RESULTS

Eight centres identified 368 patients undergoing PVE. 62 patients (17%) had to be excluded due to unavailability of data. Among the 306 included patients, 112 (37%) were non-sarcopenic and 194 (63%) were sarcopenic. Sarcopenic patients had a 21% lower resectability rate (87% vs. 66%, p < 0.001) and a 23% reduced KGR (p = 0.02) after PVE. In a multivariable model dichotomized for KGR ≥2.3% standardized FLR (sFLR)/week, only sarcopenia and sFLR before embolization correlated with KGR.

CONCLUSION

In this largest study of risk factors, sarcopenia was associated with reduced resectability and KGR in patients undergoing PVE.

Improved Survival over Time After Resection of Colorectal Liver Metastases and Clinical Impact of Multigene Alteration Testing in Patients with Metastatic Colorectal Cancer

BACKGROUND

The past 20 years have seen advances in colorectal cancer management. We sought to determine whether survival in patients undergoing resection of colorectal liver metastases (CLM) has improved in association with three landmark advances: introduction of irinotecan- and/or oxaliplatin-containing regimens, molecular targeted therapy, and multigene alteration testing.

METHODS

Patients undergoing CLM resection during 1998-2014 were identified and grouped by resection year. The influence of alterations in RAS, TP53, and SMAD4 was evaluated and validated in an external cohort including patients with unresectable metastatic colorectal cancer.

RESULTS

Of 1961 patients, 1599 met the inclusion criteria. Irinotecan- and/or oxaliplatin-containing regimens and molecular targeted therapy were used for more than 50% of patients starting in 2001 and starting in 2006, respectively, so patients were grouped as undergoing resection during 1998-2000, 2001-2005, or 2006-2014. Liver resectability indications expanded over time. The 5-year overall survival (OS) rate was significantly better in 2006-2014, vs. 2001-2005 (56.5% vs. 44.1%, P < 0.001). RAS alteration was associated with worse 5-year OS than RAS wild-type (44.8% vs. 63.3%, P < 0.001). However, OS did not differ significantly between patients with RAS alteration and wild-type TP53 and SMAD4 and patients with RAS wild-type in our cohort (P = 0.899) or the external cohort (P = 0.932). Of 312 patients with genetic sequencing data, 178 (57.1%) had clinically actionable alterations.

CONCLUSION

OS after CLM resection has improved with advances in medical therapy and surgical technique. Multigene alteration testing is useful for prognostication and identification of potential therapeutic targets.

Role of CT in Two-Stage Liver Surgery

Complete resection is the only potentially curative treatment for primary or metastatic liver tumors. Improvements in surgical techniques such as conventional two-stage hepatectomy (TSH) with portal vein embolization and ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) promote hypertrophy of the future liver remnant (FLR), expanding resection criteria to include patients with widespread hepatic disease who were formerly not considered candidates for resection. Radiologists are essential in the multidisciplinary approach required for TSH. In particular, multidetector CT has a critical role throughout the various stages of this surgical process. The aims of CT before the first stage of TSH are to define the feasibility of surgery, assess the number and location of liver tumors in relation to relevant anatomy, and provide a detailed anatomic evaluation, including vascular and biliary variants. Volume calculation with CT is also essential to determine if the FLR is sufficient to avoid posthepatectomy liver failure. The objectives of CT between the first and second stages of TSH are to recalculate liver volumes (ie, assess FLR hypertrophy) and depict expected liver changes and complications that could modify the surgical plan or preclude the second stage of definitive resection. In this review, the importance of CT throughout different stages of TSH is discussed and key observations that contribute to surgical planning are highlighted. In addition, the advantages and limitations of MRI for detection of liver metastases and assessment of complications are briefly described. ^©RSNA, 2022.

Image-Guided Ablation for Colorectal Liver Metastasis: Principles, Current Evidence, and the Path Forward

Image-guided ablation can provide effective local tumor control in selected patients with CLM. A randomized controlled trial suggested that radiofrequency ablation combined with systemic chemotherapy resulted in a survival benefit for patients with unresectable CLM, compared to systemic chemotherapy alone. For small tumors, ablation with adequate margins can be considered as an alternative to resection. The improvement of ablation technologies can allow the treatment of tumors close to major vascular structures or bile ducts, on which the applicability of thermal ablation modalities is challenging. Several factors affect the outcomes of ablation, including but not limited to tumor size, number, location, minimal ablation margin, RAS mutation status, prior hepatectomy, and extrahepatic disease. Further understanding of the impact of tumor biology and advanced imaging guidance on overall patient outcomes might help to tailor its application, and improve outcomes of image-guided ablation.

Genomic Sequencing and Insight into Clinical Heterogeneity and Prognostic Pathway Genes in Patients with Metastatic Colorectal Cancer

BACKGROUND

An understanding of signaling pathways has not been fully incorporated into prognostication and therapeutic options. We evaluated the hypothesis that information about cancer-related signaling pathways can improve prognostic stratification and explain some of the clinical heterogeneity in patients with metastatic colorectal cancer.

STUDY DESIGN

We analyzed prognostic relevance of signaling pathways in patients undergoing resection of colorectal liver metastases (CLM) from 2004-2017, and clinical actionability of gene alterations in 7 signaling pathways: p53, Wnt, RTK-RAS, PI3K, TGFβ, Notch, and cell cycle. To assess the wide applicability, the results were validated in an external retrospective cohort including patients with unresectable metastatic colorectal cancer.

RESULTS

Of 579 patients, the numbers of patients with pathway alterations were as follows: p53, n = 420 (72.5%); Wnt, 340 (58.7%); RTK-RAS, 333 (57.5%); PI3K, 110 (19.0%); TGFβ, 65 (11.2%); Notch, 41 (7.1%); and cell cycle, 15 (2.6%). More than 80% of alterations in each pathway occurred in a single predominant gene TP53, APC, KRAS, PIK3CA, FBXW7, and RB1 in p53, Wnt, RTK-RAS, PI3K, Notch, and cell cycle pathways, respectively. Alterations of 4 pathways (p53, RTK-RAS, TGFβ, and Notch) and corresponding predominant genes (TP53, RAS/BRAF, SMAD4, and FBXW7) were significantly associated with worse overall survival (OS), and alterations of Wnt pathway (APC) were associated with better OS in the median follow-up duration of 3.8 years. Similarly, in the external cohort, alterations of p53 (TP53) and RTK-RAS (RAS/BRAF) were significantly associated with worse OS, whereas alteration of Wnt (APC) was associated with better OS in the median follow-up duration of 2.6 years.

CONCLUSIONS

Genomic sequencing provides insights into clinical heterogeneity and permits finer prognostic stratification in patients with metastatic colorectal cancer.

Contour prognostic model for predicting survival after resection of colorectal liver metastases: development and multicentre validation study using largest diameter and number of metastases with RAS mutation status

BACKGROUND

Most current models for predicting survival after resection of colorectal liver metastasis include largest diameter and number of colorectal liver metastases as dichotomous variables, resulting in underestimation of the extent of risk variation and substantial loss of statistical power. The aim of this study was to develop and validate a new prognostic model for patients undergoing liver resection including largest diameter and number of colorectal liver metastases as continuous variables.

METHODS

A prognostic model was developed using data from patients who underwent liver resection for colorectal liver metastases at MD Anderson Cancer Center and had RAS mutational data. A Cox proportional hazards model analysis was used to develop a model based on largest colorectal liver metastasis diameter and number of metastases as continuous variables. The model results were shown using contour plots, and validated externally in an international multi-institutional cohort.

RESULTS

A total of 810 patients met the inclusion criteria. Largest colorectal liver metastasis diameter (hazard ratio (HR) 1.11, 95 per cent confidence interval 1.06 to 1.16; P < 0.001), number of colorectal liver metastases (HR 1.06, 1.03 to 1.09; P < 0.001), and RAS mutation status (HR 1.76, 1.42 to 2.18; P < 0.001) were significantly associated with overall survival, together with age, primary lymph node metastasis, and prehepatectomy chemotherapy. The model performed well in the external validation cohort, with predicted overall survival values almost lying within 10 per cent of observed values. Wild-type RAS was associated with better overall survival than RAS mutation even when liver resection was performed for larger and/or multiple colorectal liver metastases.

CONCLUSION

The contour prognostic model, based on diameter and number of lesions considered as continuous variables along with RAS mutation, predicts overall survival after resection of colorectal liver metastasis.

The value of a combined radiological-surgical approach in allowing curative resection of a locally advanced type IIIa Klatskin tumor

We report the case of a 53-year-old patient subjected to percutaneous embolization of right and middle hepatic veins to induce liver segments 2–3 hypertrophy before extended right hepatic resection for a locally advanced type IIIa perihilar cholangiocarcinoma.

Hepatic vein embolization (HVE) was performed 3 weeks after surgical recanalization of left portal vein (severely narrowed at its origin due to tumor infiltration) interposing an internal jugular vein graft between main and distal left portal vein.

Nine days after HVE, future liver remnant volume increased from 395 to 501 cc, i.e. 25.1% of standardized total liver volume, allowing to perform a radical right hepatic trisectionectomy plus caudatectomy. He was discharged home on postoperative day 15th after an uneventful postoperative course, with no sign of posthepatectomy liver failure.

Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery

Background

Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure.

Purpose

The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates.

Conclusions

To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.

Alteration of FBXW7 is Associated with Worse Survival in Patients Undergoing Resection of Colorectal Liver Metastases

BACKGROUND

For patients undergoing resection of colorectal liver metastases (CLMs), the prognostic role of somatic gene alterations is increasingly recognized. F-box/WD repeat-containing protein 7 (FBXW7) is a tumor suppressor gene found in approximately 10% of patients with colorectal cancer. The aim of this study is to assess the association of FBXW7 with overall survival after CLM resection.

METHODS

Patients who underwent initial CLM resection during 2001-2016 and had genetic sequencing data were studied. Risk factors for overall survival (OS) were evaluated with Cox proportional hazards models using backward elimination.

RESULTS

Of 2045 patients who underwent CLM resection during the study period, 476 were included. The majority (90.5%) underwent prehepatectomy chemotherapy. A total of 27 patients (5.7%) had FBXW7 alteration, along with 240 (50.4%) RAS, 337 (70.8%) TP53, 51 (10.7%) SMAD4, and 27 (5.7%) BRAF. Cox proportional hazards model analyses including 5 somatic gene alteration status and 12 clinicopathologic factors revealed FBXW7(hazard ratio [HR] 1.99, P = 0.015), BRAF (HR 2.47, P = 0.023), RAS (HR 2.42, P < 0.001), TP53 (HR 2.00, P < 0.001), and SMAD4 alterations (HR 1.90, P = 0.004) as significantly associated with OS, together with three clinicopathologic factors, prehepatectomy chemotherapy > 6 cycles (HR 1.51, P = 0.021), number of CLM (HR 1.05, P = 0.007), and largest liver metastasis diameter (HR 1.07, P = 0.023). The covariate-adjusted 5-year OS was significantly lower in patients with FBXW7 alteration than in patients with FBXW7 wild-type (40.4% vs.59.4%, P = 0.015).

CONCLUSIONS

FBXW7 alterations are associated with worse survival after CLM resection. The information on multiple somatic gene alterations is imperative for risk stratification and patient selection for CLM resection.

Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments

The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.

The Advantages of Indocyanine Green Fluorescence Imaging in Detecting and Treating Pediatric Hepatoblastoma: A Preliminary Experience

Background: Currently, indocyanine green (ICG) fluorescence imaging enables radical surgical resection in hepatoblastoma (HB) and has beneficial uses; however, its usage in pediatric patients is still limited. Methods: From 2015 to 2019, 17 hepatoblastoma patients underwent 22 fluorescence-guided surgery using ICG. ICG (0.3 mg/kg) was intravenously injected 24-48 h before the operation. With ICG/NIR camera, intraoperative identification of biological structures and demarcation of mass were conducted. Results: ICG fluorescence-guided surgery was performed for hepatoblastoma in 22 cases: 16, 1, and 2 cases underwent anatomic resection, partial hepatectomy, and liver transplantation, respectively. Six patients accompanied lung metastasis at the time of surgery, and two patients underwent lung surgery using ICG. The median interval from ICG injection to surgery was 38.3 h (range, 20.5-50.3 h). The median tumor size was 36.5 mm (range, 2-132 mm). According to the pathologic finding, the median safety margin was secured for 6 mm (range, 0-11 mm) and there was no residual finding at the liver at the follow-up computed tomography (CT). Conclusions: ICG fluorescence imaging in children with HB was feasible and safe for tumor demarcation and enhancing the accuracy of radical tumor resection.

Quantitative magnetic resonance imaging predicts individual future liver performance after liver resection for cancer

The risk of poor post-operative outcome and the benefits of surgical resection as a curative therapy require careful assessment by the clinical care team for patients with primary and secondary liver cancer. Advances in surgical techniques have improved patient outcomes but identifying which individual patients are at greatest risk of poor post-operative liver performance remains a challenge. Here we report results from a multicentre observational clinical trial (ClinicalTrials.gov NCT03213314) which aimed to inform personalised pre-operative risk assessment in liver cancer surgery by evaluating liver health using quantitative multiparametric magnetic resonance imaging (MRI). We combined estimation of future liver remnant (FLR) volume with corrected T1 (cT1) of the liver parenchyma as a representation of liver health in 143 patients prior to treatment. Patients with an elevated preoperative liver cT1, indicative of fibroinflammation, had a longer post-operative hospital stay compared to those with a cT1 within the normal range (6.5 vs 5 days; p = 0.0053). A composite score combining FLR and cT1 predicted poor liver performance in the 5 days immediately following surgery (AUROC = 0.78). Furthermore, this composite score correlated with the regenerative performance of the liver in the 3 months following resection. This study highlights the utility of quantitative MRI for identifying patients at increased risk of poor post-operative liver performance and a longer stay in hospital. This approach has the potential to inform the assessment of individualised patient risk as part of the clinical decision-making process for liver cancer surgery.

Modern therapeutic approaches for the treatment of malignant liver tumours

Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.

Surgical Resection: Old Dog, Any New Tricks?

Patients with hepatocellular carcinoma (HCC) have many treatment options. For patients with surgical indication, consideration of future liver remnant and the surgical complexity of the procedure is essential. A new 3-level complexity classification categorizing 11 liver resection procedures predicts surgical complexity and postoperative morbidity better than reported classifications. Preoperative portal vein embolization can mitigate the risk of hepatic insufficiency. For small HCCs, both liver resection and ablation are effective. New medical treatment options are promising and perioperative use of these drugs may further improve outcomes for patients undergoing liver resection and lead to changes in current treatment guidelines.

Simultaneous portal and hepatic vein embolization before major liver resection

Background

Regenerative liver surgery expands the limitations of technical resectability by increasing the future liver remnant (FLR) volume before extended resections in order to avoid posthepatectomy liver failure (PHLF). Portal vein rerouting with ligation of one branch of the portal vein bifurcation (PVL) or embolization (PVE) leads to a moderate liver volume increase over several weeks with a clinical dropout rate of 20–40%, mostly due to tumor progression during the waiting period. Accelerated liver regeneration by the Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) was poised to overcome this limitation by reduction of the waiting time, but failed due increased perioperative complications. Simultaneous portal and hepatic vein embolization (PVE/HVE) is a novel minimal invasive way to induce rapid liver growth without the need of two surgeries.

Purpose

This article summarizes published results of PVE/HVE and analyzes what is known about its efficacy to achieve resection, safety, and the volume changes induced.

Conclusions

PVE/HVE holds promise to induce accelerated liver regeneration in a similar safety profile to PVE. The demonstrated accelerated hypertrophy may increase resectability. Randomized trials will have to compare PVE/HVE and PVE to determine if PVE/HVE is superior to PVE.

Postoperative liver regeneration does not elicit recurrence of colorectal cancer liver metastases after major hepatectomy

BACKGROUND AND OBJECTIVES

Recurrence is a frequent concern in curatively resected CRC liver metastases. Translational research suggests that regeneration upon hepatectomy may also alleviate metastatic recurrence; however, the significance in patients is unclear. We therefore sought to study the effect of liver regeneration on tumor recurrence in patients.

METHODS

In this retrospective cohort study, we included 58 out of 186 potentially eligible patients from our prospectively maintained database of CRC liver metastasis patients between 2001 and 2012 with a median follow-up of 42 months who underwent a formal right or left hemihepatectomy. Liver regeneration in CT volumetry was correlated with recurrence of CRC liver metastases and overall survival.

RESULTS

Liver regeneration increased up to 14 months to 21.0% for left and 122.6% for right hemihepatectomy, respectively, with comparable final volumes. Regeneration was independent of initial tumor stage, number of metastases, and preoperative chemotherapy. Patients with lower liver regeneration showed earlier recurrence of CRC liver metastases (p = 0.006). Overall survival did not differ in patients with weak versus strong liver regeneration.

CONCLUSIONS

The extent of liver regeneration after major hepatectomy does not impede overall survival. Therefore, our data encourage aggressive therapeutical regimes for CRC liver metastases involving major hepatectomies as part of a curative approach.

Innovation and Future Perspectives in the Treatment of Colorectal Liver Metastases

Technological advances and investigation into tumor biology have enhanced treatments of patients with colorectal liver metastases (CLM). This article briefly summarizes paradigm shifts in treatments of this disease in the following 4 sections. (1) Small metastases: The treatment of multiple and small CLM has evolved from anatomic resection to parenchyma-sparing hepatectomy. Survival after parenchyma-sparing hepatectomy was similar to or better than anatomic resection. The use of preoperative chemotherapy may cause tumor disappearance. However, the use of fiducial markers may aid in intraoperative localization. Post-resection completion ablation is a new useful treatment concept. It was defined as percutaneous ablation under cross-sectional imaging guidance to eradicate CLM which were intentionally unresected during latest surgery. (2) Bilateral (bilobar) metastases: Two-stage hepatectomy (TSH) is a well-established approach for treating multiple bilateral CLM. The use of hybrid operating room accelerates this sequence because it allows first-stage hepatectomy, portal vein embolization, and computed tomography in one hospitalization. This accelerated TSH sequence enables the second-stage hepatectomy within 4 weeks compared to 8 weeks using conventional TSH sequence. (3) Synchronous lung metastases: For patients with synchronous liver and lung metastases, simultaneous surgical approach is feasible. Specifically, a transdiaphragmatic approach enables simultaneous resection of liver and lung metastases via one abdominal incision. (4) Multiple mutation: Somatic gene mutation testing is increasingly used to evaluate tumor biology. Mutations in TP53, RAS, and SMAD4 affect prognosis through three different signaling pathways of colorectal carcinogenesis. This information can be used to change clinical decision-making regarding surveillance intensity and treatments for liver recurrence.

Surgical approach to synchronous colorectal liver metastases: staged, combined, or reverse strategy

An increasing number of patients with colorectal cancer (CRC) are presenting with synchronous disease to the liver. The optimal surgical approach for this complex patient group is controversial, but ultimately depends on individual patient characteristics and institutional practices. Surgical strategies include the traditional staged approach, a combined colorectal and liver resection, or a liver-first reverse approach. In this review, the authors will provide an overview of each strategy, including case examples demonstrating the benefits of the more recently described liver-first approach, while arguing for individualized planning and multidisciplinary discussion for every patient.

Gene mutation and surgical technique: Suggestion or more?

Advancements in chemotherapy and molecular targeted therapy have improved long-term outcomes for patients with resectable colorectal liver metastases (CLM). RAS mutation status was an original focus as a molecular biomarker as it predicted treatments response to anti-epidermal growth factor receptor agents. More recently, studies have incorporated somatic mutation data in analyses pertaining to surgical outcomes and prognosis. This evidenced-based review covers the implications of somatic mutations in patients undergoing resection of CLM.