Treatment for multiple bilobar liver metastases of colorectal cancer

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) does not affect proliferation, apoptosis, or angiogenesis as compared to standard liver resection for colorectal liver metastases

Background

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a novel two-stage strategy to induce rapid hypertrophy of the future liver remnant (FLR) when patients are in danger of postoperative liver failure due to insufficient FLR. However, the effects of ALPPS on colorectal liver metastases (CRLM) are not clear so far. The aim of our study was to determine whether ALPPS induces proliferation, apoptosis, or vascularization compared to standard (one-stage) liver resection.

Methods

Six patients who underwent ALPPS were matched with 12 patients undergoing standard liver resection regarding characteristics of the metastases (size, number), time of appearance (syn-/metachronous), preoperative chemotherapy, primary tumor (localization, TNM stage, grading), and patient variables (gender, age). The largest resected metastasis was used for the analyses. Tissue was stained for tumor cell proliferation (Ki67), apoptosis (TUNEL, caspase-3), vascularization (CD31), and pericytes (αSMA).

Results

Vascularization (CD31; p = 0.149), proliferation (Mib-1; p = 0.244), and αSMA expression (p = 0.205) did not significantly differ between the two groups, although a trend towards less proliferation and αSMA expression was observed in patients undergoing ALPPS. Concerning apoptosis, caspase-3 staining showed significantly fewer apoptotic cells upon ALPPS (p < 0.0001), but this was not confirmed by TUNEL staining (p = 0.7344).

Conclusions

ALPPS does not induce proliferation, apoptosis, or vascularization of CRLM when compared to standard liver resection.

Long-term results after in-situ split (ISS) liver resection

PURPOSE

In-situ split (ISS) liver resection is a novel method to induce rapid hypertrophy of the contralateral liver lobe in patients at risk for postoperative liver failure due to insufficient liver remnant. So far, no data about oncological long-term survival after ISS liver resection is available.

METHODS

We retrospectively analyzed our patients treated with ISS liver resection at the Department of Surgery of the University of Regensburg, the first center worldwide to perform ISS.

RESULTS

Between 2007 and 2014, ISS liver resection was performed in 16 patients. Two patients (12.5 %) were lost in early postoperative phase (90 days) and one was lost to follow-up. Thirteen patients with a follow-up period of more than 3 months were included into oncologically focused analyses. Median follow-up was 26.4 months (range 3.2-54.6). Seven patients had suffered from colorectal liver metastases (CRLM) and six from various other liver malignancies (non-CRLM). The ISS procedure had led to a median increase of 86.3 % of the left lateral liver lobe after a median of 9 days (range 4-28 days). Median disease-free survival (DFS) was 14.6 months and median overall survival (OS) was 41.7 months (26.4 months when including 90-days mortality). Three-year survival was calculated with 56.4 and 48.9 % when including perioperative mortality, respectively (CRLM 64.3 % vs. non-CRLM 50 %).

CONCLUSION

ISS liver resection can provide long-term survival of selected patients with advanced liver malignancies that otherwise are not eligible for liver resection due to insufficient liver remnant.

Cost-effectiveness of simultaneous resection and RFA versus 2-stage hepatectomy for bilobar colorectal liver metastases

BACKGROUND AND OBJECTIVES

The current healthcare climate demands evaluation of treatment modalities in terms of costs and benefits. We compared the cost-effectiveness of two different strategies for bilobar colorectal liver metastases (bCRLM).

METHODS

Patients with bCRLM treated with either resection/RFA or planned 2-stage hepatectomy at our institution between 1999 and 2011 were reviewed. A decision analysis model was populated with treatment probabilities, outcomes, survival, and costs (Medicare payment, 2011 US$).

RESULTS

Two hundred fourteen patients underwent resection/RFA. Eighty-two patients were treated with planned 2-stage hepatectomy; 26 (32%) patients never completed a 2nd resection. In the 2-stage cohort, 50 patients underwent portal vein embolization (PVE). Overall complication rate and 90-day mortality for resection/RFA was 36% and 3.7%, and for 2-stage hepatectomy (both procedures combined) was 44% and 7.3%, respectively. Cost-effectiveness analysis revealed that resection/RFA cost $37,120 for 46.2-month survival, while planned 2-stage resection cost $62,198 for 35.9-month survival. If, hypothetically, all 2-stage patients completed both stages of resection, the per-patient cost was $72,644 for 40.3-month survival.

CONCLUSIONS

Resection/RFA is associated with lower costs and longer survival when compared to 2-stage resection. This 1-stage approach for bCRLM should be viewed as an efficient use of resources for this challenging clinical scenario.

Hepatic resection for colorectal liver metastases

Colorectal adenocarcinoma remains the third most common cause of cancer death in the United States, with an estimated 146,000 new cases and 50,000 deaths annually. Survival is stage dependent, and the presence of liver metastases is a primary determinant in patient survival. Approximately 25% of new cases will present with synchronous colorectal liver metastases (CLM), and up to one-half will develop CLM during the course of their disease. The importance of safe and effective therapies for CLM cannot be overstated. Safe and appropriately aggressive multimodality therapy for CLM can provide most patients with liver-dominant colorectal metastases with extended survival and an improved quality of life.

Multimodal treatment options for bilobar colorectal liver metastases

Purpose

We evaluated individualized multimodal oncological strategies in patients with bilobular colorectal liver metastases (biCRC-LM) as well as their effect on R0 resection rates, disease-free survival (DFS), and overall survival (OS).

Methods

Between January 2001 and December 2008, 64 patients were assigned to straightforward or two-stage liver resection ± preoperative 5-fluorouracil (5FU)-based chemotherapy (CTx). Postoperative strategy after R0-resection was either “wait and see” or “adjuvant” therapy (3 cycles of CTx or anti-carcinoembryonic antigen (CEA)-radioimmunotherapy with ¹³¹I-labetuzumab in a dose of 40–50 mCi/m²).

Results

Forty-three initially unresectable patients received preoperative CTx for downsizing of their biCRC-LM. Straightforward or two-stage liver resection was intended in 40 and 24 patients, respectively. Histopathologically confirmed R0-liver resection could be achieved in 47 patients. Surgical morbidity and mortality rates were 33% and 1.5%, respectively. Postoperatively, 26 patients received anti-cancer therapy (5 × CTx, 21 × anti-CEA-radioimmunotherapy). After R0-liver resection, median OS was significantly better compared to R1/R2 resections followed by palliative 5FU-CTx (38 versus 19 months, p = 0.035). There was no significant difference in DFS (p = 0.650) and OS (p = 0.435) between straightforward and two-stage liver resection. Compared to “wait and see” strategy, the application of postoperative therapy in adjuvant intent was associated with a better OS (p = 0.048).

Conclusion

Extensive liver resection within multimodal treatment concepts is justified in patients with biCRC-LM when complete resection of all metastases seems to be achievable.

Nitric oxide reduces organ injury and enhances regeneration of reduced-size livers by increasing hepatic arterial flow

Background

Reduced-size livers suffer from portal hyperperfusion, diminished arterial blood flow and the risk of postoperative liver injury. The aim of this experimental study was to unravel the role of nitric oxide in this setting.

Methods

Rats underwent 85 per cent partial hepatectomy and either substitution of nitric oxide with molsidomine or inhibition of nitric oxide synthase (NOS) with NG-nitro-l-arginine methyl ester. Untreated hepatectomized animals served as controls and unresected animals as the sham group.

Results

Ultrasonic flowmetry following partial hepatectomy revealed a marked increase in portal venous inflow with a concomitant decrease in hepatic arterial inflow. Nitric oxide substitution counteracted the decline in hepatic arterial inflow and caused a significantly greater increase in cell proliferation after partial hepatectomy compared with control or NOS-inhibited animals. Hepatectomized animals further profited from nitric oxide substitution, as indicated by reduced aminotransferase release and improved liver function.

Conclusion

Nitric oxide improves the postoperative course of rats with reduced-size livers by modulating hepatic macrohaemodynamics and mediating regeneration and cytoprotection, but not by reducing hepatic hyperperfusion and the accompanying sinusoidal shear stress.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Two-stage Hepatectomy Approach for Initially Unresectable Colorectal Hepatic Metastases

Two-stage hepatectomy has been developed as a surgical strategy for extremely difficult cases of bilobar multinodular metastatic liver disease. This strategy is applied when it is impossible to resect all malignant lesions in a single procedure. The main principle of this approach is sequential resection by a two-staged hepatectomy. Its goal is to achieve a complete metastasectomy in those cases in which a complete resection with a single hepatectomy would have left a remnant postresection liver too small for patient survival. This article describes strategic surgical approaches to multinodular metastatic disease and provides decision guidelines for two-stage hepatectomies.

Liver regeneration: mechanisms, mysteries and more

BACKGROUND

Liver regeneration remains a fascinating topic, still partly clouded to many as to the exact cellular and molecular mechanisms that bring about this phenomenon. It is an area, therefore, of active research today. This review looks at the recent published reports that have led to a greater understanding of this process.

METHODS

A database search was carried out on Medline search using the terms liver regeneration with no linguistic limitations from 1966 to 2006.

RESULTS

There are two randomized controlled trials on the topic and most data and information have come from experimental studies in animals.

CONCLUSION

Liver regeneration is a complex, tightly controlled process involving many inflammatory cells growth factors and hormones. More information about it is awaited in studies on humans.