Long-term oncological outcomes after laparoscopic parenchyma-sparing redo liver resections for patients with metastatic colorectal cancer: a European multi-center study

Robotic Complete ALPPS (rALPPS)-First German Experiences

BACKGROUND

ALPPS leads to fast and effective liver hypertrophy. This enables the resection of extended tumors. Conventional ALPPS is associated with high morbidity and mortality. MILS reduces morbidity and the robot adds technical features that make complex procedures safe.

MATERIAL AND METHODS

The MD-MILS was screened for patients who underwent rALPPS. Demographic and perioperative data were evaluated retrospectively. Ninety days postoperative morbidity was scored according to the CD classification. The findings were compared with the literature.

RESULTS

Since November 2021, five patients have been identified. The mean age and BMI of the patients were 50.0 years and 22.7 kg/m2. In four cases, patients suffered from colorectal liver metastases and, in one case, intrahepatic cholangiocarcinoma. Prior to the first operation, the mean liver volume of the residual left liver was 380.9 mL with a FLR-BWR of 0.677%. Prior to the second operation, the mean volume of the residual liver was 529.8 mL with a FLR-BWR of 0.947%. This was an increase of 41.9% of the residual liver volume. The first and second operations were carried out within 17.8 days. The mean time of the first and second operations was 341.2 min and 440.6 min. The mean hospital stay was 27.2 days. Histopathology showed the largest tumor size of 39 mm in diameter with a mean amount of 4.7 tumors. The mean tumor-free margin was 12.3 mm. One complication CD > 3a occurred. No patient died during the 90-day follow up.

CONCLUSION

In the first German series, we demonstrated that rALPPS can be carried out safely with reduced morbidity and mortality in selected patients.

Matrix Stiffness Triggers Lipid Metabolic Cross-talk between Tumor and Stromal Cells to Mediate Bevacizumab Resistance in Colorectal Cancer Liver Metastases

Bevacizumab is an anti-VEGF monoclonal antibody that plays an important role in the combination treatment of advanced colorectal cancer. However, resistance remains a major hurdle limiting bevacizumab efficacy, highlighting the importance of identifying a mechanism of antiangiogenic therapy resistance. Here, we investigated biophysical properties of the extracellular matrix (ECM) related to metabolic processes and acquired resistance to bevacizumab. Evaluation of paired pre- and posttreatment samples of liver metastases from 20 colorectal cancer patients treated with combination bevacizumab therapy, including 10 responders and 10 nonresponders, indicated that ECM deposition in liver metastases and a highly activated fatty acid oxidation (FAO) pathway were elevated in nonresponders after antiangiogenic therapy compared with responders. In mouse models of liver metastatic colorectal cancer (mCRC), anti-VEGF increased ECM deposition and FAO in colorectal cancer cells, and treatment with the FAO inhibitor etomoxir enhanced the efficacy of antiangiogenic therapy. Hepatic stellate cells (HSC) were essential for matrix stiffness-mediated FAO in colon cancer cells. Matrix stiffness activated lipolysis in HSCs via the focal adhesion kinase (FAK)/yes-associated protein (YAP) pathway, and free fatty acids secreted by HSCs were absorbed as metabolic substrates and activated FAO in colon cancer cells. Suppressing HSC lipolysis using FAK and YAP inhibition enhanced the efficacy of anti-VEGF therapy. Together, these results indicate that bevacizumab-induced ECM remodeling triggers lipid metabolic cross-talk between colon cancer cells and HSCs. This metabolic mechanism of bevacizumab resistance mediated by the physical tumor microenvironment represents a potential therapeutic target for reversing drug resistance.

SIGNIFICANCE

Extracellular matrix stiffening drives bevacizumab resistance by stimulating hepatic stellate cells to provide fuel for mCRC cells in the liver, indicating a potential metabolism-based therapeutic strategy for overcoming resistance.

Real-time administration of indocyanine green in combination with computer vision and artificial intelligence for the identification and delineation of colorectal liver metastases

Introduction

Fluorescence guided surgery for the identification of colorectal liver metastases (CRLM) can be better with low specificity and antecedent dosing impracticalities limiting indocyanine green (ICG) usefulness currently. We investigated the application of artificial intelligence methods (AIM) to demonstrate and characterise CLRMs based on dynamic signalling immediately following intraoperative ICG administration.

Methods

Twenty-five patients with liver surface lesions (24 CRLM and 1 benign cyst) undergoing open/laparoscopic/robotic procedures were studied. ICG (0.05 mg/kg) was administered with near-infrared recording of fluorescence perfusion. User-selected region-of-interest (ROI) perfusion profiles were generated, milestones relating to ICG inflow/outflow extracted and used to train a machine learning (ML) classifier. 2D heatmaps were constructed in a subset using AIM to depict whole screen imaging based on dynamic tissue-ICG interaction. Fluorescence appearances were also assessed microscopically (using H&E and fresh-frozen preparations) to provide tissue-level explainability of such methods.

Results

The ML algorithm correctly classified 97.2 % of CRLM ROIs (n = 132) and all benign lesion ROIs (n = 6) within 90-s of ICG administration following initial mathematical curve analysis identifying ICG inflow/outflow differentials between healthy liver and CRLMs. Time-fluorescence plots extracted for each pixel in 10 lesions enabled creation of 2D characterising heatmaps using flow parameters and through unsupervised ML. Microscopy confirmed statistically less CLRM fluorescence vs adjacent liver (mean ± std deviation signal/area 2.46 ± 9.56 vs 507.43 ± 160.82 respectively p < 0.001) with H&E diminishing ICG signal (n = 4).

Conclusion

ML accurately identifies CRLMs from surrounding liver tissue enabling representative 2D mapping of such lesions from their fluorescence perfusion patterns using AIM. This may assist in reducing positive margin rates at metastatectomy and in identifying unexpected/occult malignancies.

Long-term oncological outcomes for HALS/Hybrid vs pure laparoscopic approach in colorectal liver metastases: a propensity score matched analysis

BACKGROUND

Studies comparing hand-assisted laparoscopic (HALS)/Hybrid and pure laparoscopic (PLS) resection for colorectal cancer liver metastasis have focused on short-term results, while long-term oncological outcomes remain understudied.

METHODS

We established a multi-institutional retrospective cohort study from four centers with experience in minimally invasive surgery between 2004 and 2020. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Other endpoints analyzed were intraoperative and postoperative outcomes. Propensity score matching (PSM) was used to minimize baseline differences.

RESULTS

A total of 219 HALS/Hybrid (57.8%) and 160 PLS (42.2%) patients were included. After PSM, 155 patients remained in each group. Operative time (182 vs. 248 min, p = 0.012), use of intraoperative ablation (12.3 vs. 4.5%, p = 0.024), positive resection margin (4.5 vs 13.2%, p = 0.012), and pringle time (21 vs. 37 min, p = 0.001) were higher in PLS group. DFS at 1, 3, 5, and 7 years in HALS/Hybrid and PLS groups were 65.4%, 39.3%, 37.5%, and 36.3% vs. 64.9%, 38.0%, 33.1%, and 33.1%, respectively (p = 0.84). OS at 1, 3, 5, and 7 years in HALS/Hybrid and PLS groups were 94.5%, 71.4%, 54.3%, and 46.0% vs. 96.0%, 68.5%, 51.2%, and 41.2%, respectively (p = 0.73).

CONCLUSION

Our study suggests no differences in long-term oncologic outcomes between the two techniques. We discovered that longer total operative, pringle time, higher rates of intraoperative ablation, and positive resection margins were associated with PLS. These differences in favor of HALS/Hybrid could be due to a shorter learning curve and a greater ability to control hemorrhage.

Laparoscopic parenchyma-sparing liver resection for large (≥ 50 mm) colorectal metastases

BACKGROUND

Traditionally, patients with large liver tumors (≥ 50 mm) have been considered for anatomic major hepatectomy. Laparoscopic resection of large liver lesions is technically challenging and often performed by surgeons with extensive experience. The current study aimed to evaluate the surgical and oncologic safety of laparoscopic parenchyma-sparing liver resection in patients with large colorectal metastases.

METHODS

Patients who primarily underwent laparoscopic parenchyma-sparing liver resection (less than 3 consecutive liver segments) for colorectal liver metastases between 1999 and 2019 at Oslo University Hospital were analyzed. In some recent cases, a computer-assisted surgical planning system was used to better visualize and understand the patients' liver anatomy, as well as a tool to further improve the resection strategy. The surgical and oncologic outcomes of patients with large (≥ 50 mm) and small (< 50 mm) tumors were compared. Multivariable Cox-regression analysis was performed to identify risk factors for survival.

RESULTS

In total 587 patients met the inclusion criteria (large tumor group, n = 59; and small tumor group, n = 528). Median tumor size was 60 mm (range, 50-110) in the large tumor group and 21 mm (3-48) in the small tumor group (p < 0.001). Patient age and CEA level were higher in the large tumor group (8.4 μg/L vs. 4.6 μg/L, p < 0.001). Operation time and conversion rate were similar, while median blood loss was higher in the large tumor group (500 ml vs. 200 ml, p < 0.001). Patients in the large tumor group had shorter 5 year overall survival (34% vs 49%, p = 0.027). However, in the multivariable Cox-regression analysis tumor size did not impact survival, unlike parameters such as age, ASA score, CEA level, extrahepatic disease at liver surgery, and positive lymph nodes in the primary tumor.

CONCLUSION

Laparoscopic parenchyma-sparing resections for large colorectal liver metastases provide satisfactory short and long-term outcomes.

Comparison Between Minimally Invasive Right Anterior and Right Posterior Sectionectomy vs Right Hepatectomy: An International Multicenter Propensity Score-Matched and Coarsened-Exact-Matched Analysis of 1,100 Patients

BACKGROUND

The role of minimally invasive right anterior and right posterior sectionectomy (MI-RAS/MI-RPS) for right-sided liver lesions remains debatable. Although technically more demanding, these procedures might result in faster recovery and lower postoperative morbidity compared with minimally invasive right hemihepatectomy.

STUDY DESIGN

This is an international multicenter retrospective analysis of 1,114 patients undergoing minimally invasive right hemihepatectomy, MI-RAS, and MI-RPS at 21 centers between 2006 and 2019. Minimally invasive surgery included pure laparoscopic, robotic, hand-assisted, or a hybrid approach. A propensity-matched and coarsened-exact-matched analysis was performed.

RESULTS

A total of 1,100 cases met study criteria, of whom 759 underwent laparoscopic, 283 robotic, 11 hand-assisted, and 47 laparoscopic-assisted (hybrid) surgery. There were 632 right hemihepatectomies, 373 right posterior sectionectomies, and 95 right anterior sectionectomies. There were no differences in baseline characteristics after matching. In the MI-RAS/MI-RPS group, median blood loss was higher (400 vs 300 mL, p = 0.001) as well as intraoperative blood transfusion rate (19.6% vs 10.7%, p = 0.004). However, the overall morbidity rate was lower including major morbidity (7.1% vs 14.3%, p = 0.007) and reoperation rate (1.4% vs 4.6%, p = 0.029). The rate of close/involved margins was higher in the MI-RAS/MI-RPS group (23.4% vs 8.9%, p < 0.001). These findings were consistent after both propensity and coarsened-exact matching.

CONCLUSIONS

Although technically more demanding, MI-RAS/MI-RPS is a valuable alternative for minimally invasive right hemihepatectomy in right-sided liver lesions with lower postoperative morbidity, possibly due to the preservation of parenchyma. However, the rate of close/involved margins is higher in these procedures. These findings might guide surgeons in preoperative counselling and in selecting the appropriate procedure for their patients.

Is There Indication for the Use of Biological Mesh in Cancer Patients?

Up to 28% of all patients who undergo open surgery will develop a ventral hernia (VH) in the post-operative period. VH surgery is a debated topic in the literature, especially in oncological patients due to complex management. We searched in the surgical database of the Hepatobiliary Unit of the National Cancer Institute of Naples “G. Pascale Foundation” for all patients who underwent abdominal surgery for malignancy from January 2010 to December 2018. Our surgical approach and our choice of mesh for VH repair was planned case-by-case. We selected 57 patients that fulfilled our inclusion criteria, and we divided them into two groups: biological versus synthetic prosthesis. Anterior component separation was used in 31 patients (54.4%) vs. bridging procedure in 26 (45.6%). In 41 cases (71.9%), we used a biological mesh while a synthetic one was adopted in the remaining patients. Of our patients, 57% were male (33 male vs. 24 female) with a median age of 65 and a mean BMI of 30.8. We collected ventral hernia defects from 35 cm² to 600 cm² (mean 205.2 cm²); 30-day complications were present in 24 patients (42.1%), no 30-day mortality was reported, and 21 patients had a recurrence of pathology during study follow-up. This study confirms VH recurrence risk is not related with the type of mesh but is strongly related with BMI and type of surgery also in oncological patients.

Roles of GFPT2 Expression Levels on the Prognosis and Tumor Microenvironment of Colon Cancer

Background

Recently, increasing evidence has suggested that Glutamine-fructose-6-phosphate transaminase 2 (GFPT2) is related to carcinogenesis. However, the potential roles of GFPT2 in colon cancer still need to be fully investigated.

Methods

We examined the protein levels of GFPT2 by immunohistochemistry (IHC) in tissues collected from 83 patients with colon cancer. We further detected GFBPT2 protein levels by Western Blot assay. We checked the relationship between GFPT2 expression levels and overall survival (OS), stromal and immune scores and immune components from The Cancer Gene Atlas (TCGA) database. GFBP2-related pathways were validated in the Cancer Cell Line Encyclopedia (CCLE) database. Expression of GFPT2 in single cell subpopulations was calculated from The Tumor Immune Single Cell Center (TISCH). The levels of GFPT2 and drug sensitivity data were performed from CellMiner dataset.

Results

GFPT2 was highly expressed and correlated with poor pathological features in 83 colon cancer patients. Moreover, increased GFPT2 expression was significantly associated with poorer OS in 329 colon adenocarcinoma (COAD) patients. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed the differentially expressed genes of GFPT2 were mostly enriched in focal adhesion, ECM receptor interaction, JAK/STAT signaling pathway and immune related pathways. In addition, GFPT2 expression was correlated with the tumor microenvironment (TME). GFPT2 expression was linked to cancer-associated fibroblasts (CAFs)-associated factors and epithelial-mesenchymal transition (EMT)-related factors. GFPT2 was positively correlated with immunosuppressive cells and regulated immunosuppressive factors and T-cell exhaustion. Finally, our data suggested that the expression of GFPT2 may be a judgment of the sensitivity of a certain class of drugs.

Conclusions

Our work reveals the roles of GFPT2 in tumorigenesis, particularly in immune response, TME and drug resistance, which are crucial for the development of customized cancer therapies.