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

Mortality of patients with metastatic colorectal cancer who received elective or emergent operation after exposure to bevacizumab: A nationwide database study

INTRODUCTION

Treatment guidelines for colorectal cancer (CRC) indicate that surgical intervention within 4 weeks or 8 weeks after bevacizumab therapy might increase the risk of postoperative complications and mortality, especially in patients who received emergent operation. Therefore, we aimed to assess the association between different surgical timings, emergent or elective surgery, and the risk of postoperative mortality.

MATERIALS AND METHODS

Using the Taiwan National Health Insurance Database and Taiwan Cancer Registry, we identified patients with metastatic colorectal cancer (mCRC) who underwent surgery within 1 year of receiving bevacizumab between January 2010 and December 2017. The primary outcomes were 30-day, 60-day, and in-hospital mortality; the secondary outcomes were hospital stay, 30-day readmission rate, and surgical complications. Multivariate analysis was used to adjust for confounders.

RESULTS

This study included 2,047 patients. In the multivariate analysis, patients who underwent emergent operation and had higher Charlson scores had a significantly higher mortality rate. Patients with a longer interval to surgery, more cycles of bevacizumab treatment, and distal metastectomy had the opposite result. In subgroup analysis, patients who received emergent operation within 28 days had the highest surgical mortality.

CONCLUSIONS

The interval to operation among mCRC patients who receive bevacizumab treatment should exceed 4 weeks to avoid additional risk of mortality whether patients receiving elective or emergent operation. Patients who received emergent operation within 28 days of bevcizumab infusion had the highest risk of mortality.

Bevacizumab exacerbates sinusoidal obstruction syndrome (SOS) in the animal model and increases MMP 9 production

Background

Thanks to modern multimodal treatment the ouctome of patients with colorectal cancer has experienced significant improvements. As a downside, agent specific side effects have been observed such as sinusoidal obstruction syndrome (SOS) after oxaliplatin chemotherapy (OX). Bevazicumab targeting VEGF is nowadays comprehensively used in combination protocols with OX but its impact on hepatotoxicity is thus far elusive and focus of the present study.

Results

After MCT administration 67% of animals developed SOS. GOT serum concentration significantly increased in animals developing SOS (p < 0.001). Subsequent to MCT administration 100% of animals treated with Anti-VEGF developed SOS. In contrast, animals receiving VEGF developed SOS merely in 40% while increasing the VEGF dose led to a further decrease in SOS development to 25%. MMP 9 concentration in animals developing SOS was significantly higher compared to controls (p < 0,001). Additional treatment with Anti-VEGF increased the MMP 9 concentration significantly (p < 0,05).

Conclusions

Preservation of liver function is a central goal in both curative and palliative treatment phases of patients with CRC. Thus, knowledge about hepatotoxic side effects of chemotherapeutic and biological agents is crucial. From the results it can be concluded that Anti-VEGF exacerbates SOS paralleled by MMP 9 production. Therefore, OX-Bevacizumab combination therapies should be administered with caution, especially if liver parenchyma damage is apparent.

Methods

Male Sprague-Dawley rats were gavaged Monocrotaline (MCT) to induce SOS. Recombinant VEGF or an Anti-VEGF antibody was administered to MCT-treated rats and the hepatotoxic effect monitored in defined time intervals. MMP 9 expression in the liver was measured by ELISA.

A Population-Based Study of Complications After Colorectal Surgery in Patients Who Have Received Bevacizumab

BACKGROUND

Patients receiving Bevacizumab, a vascular endothelial growth factor inhibitor used to treat metastatic colorectal cancer, may be at greater risk of complications after colorectal surgery because of impaired healing.

OBJECTIVE

The purpose of this study was to describe population-based rates of complications of colorectal surgery after Bevacizumab treatment and evaluate the relationship between time since last treatment and risk of complications.

DESIGN

This was a population-based retrospective cohort study using administrative and cancer registry data.

SETTINGS

The study was conducted in Ontario, Canada.

PATIENTS

Patients with metastatic colorectal cancer receiving Bevacizumab between January 2008 and December 2011 were followed for a year after treatment or until death.

MAIN OUTCOME MEASURES

Administrative data were used to identify patients who underwent colorectal surgery after initiation of Bevacizumab and to determine whether they experienced a complicated postoperative course. The relationship between time since last Bevacizumab treatment (≤28 d, 29 d to 3 mo, and >3 mo) and risk of postoperative complications was evaluated using logistic regression.

RESULTS

Of the 2759 patients who received Bevacizumab for the treatment of metastatic colorectal cancer, 265 underwent a colorectal procedure after exposure. The majority had a bowel resection or repair with no stoma (47.5%) and had emergency surgery (61.1%). Overall, 96 (36.2%) had a complicated postoperative course, including 20.4% readmission, 12.5% wound complications, and 7.9% mortality rate within 30 days of surgery. Adjusted multivariate analysis showed no difference in the likelihood of a complicated postoperative course among patients undergoing surgery within 28 days of receiving their last Bevacizumab dose compared with 29 days to 3 months (OR = 1.23 (95% CI, 0.53-2.84), or 3 to 12 months (OR = 0.98 (95% CI, 0.46-2.09) after receiving Bevacizumab.

LIMITATIONS

Reliance on administrative data to measure complications limited the scope of this study.

CONCLUSIONS

Patients with metastatic colorectal cancer requiring colorectal surgery after exposure to Bevacizumab experience substantial morbidity and mortality. The risk of complications is not detectably associated with time since exposure. See Video Abstract at http://links.lww.com/DCR/A474.

Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

Impact of Bevacizumab on parenchymal damage and functional recovery of the liver in patients with colorectal liver metastases

Background

Little is known about the safety of the anti-VEGF antibody bevacizumab in patients undergoing resection for colorectal liver metastases (CLM). This meta-analysis evaluates the impact of bevacizumab on parenchymal damage and functional recovery in patients undergoing resection for CLM.

Methods

The Medline, Embase and Cochrane Library were systematically searched for studies on preoperative chemotherapy with and without bevacizumab prior to resection of CLM. Studies that reported histological and/or clinical outcomes were eligible for inclusion. Meta-analyses were performed using a random effects model.

Results

A total of 18 studies with a total sample size of 2430 patients (1050 patients with bevacizumab) were found. Meta-analyses showed a significant reduction in sinusoidal obstruction syndrome (SOS) (Odds ratio 0.50 [95 % confidence interval 0.37, 0.67]; p < 0.001; I² = 0 %) and hepatic fibrosis (0.61 [0.4, 0.86]; p = 0.004; I² = 7 %) after preoperative chemotherapy with bevacizumab. The reduced incidence of posthepatectomy liver failure in patients with bevacizumab treatment just failed to reach statistical significance (0.61 [0.34, 1.07]; p = 0.08 I² = 6 %). While there was no difference in perioperative morbidity and mortality, the incidence of wound complications was significantly increased in patients who received bevacizumab (1.81 [1.12, 2.91]; p = 0.02 I² = 4 %).

Conclusions

The combination of bevacizumab with cytotoxic chemotherapy is safe but increases the incidence of wound complications after resection of CLM. The reduction of SOS and hepatic fibrosis warrant further investigation and may explain the inverse association of bevacizumab administration and posthepatectomy liver failure.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2095-6) contains supplementary material, which is available to authorized users.

Anti-angiogenic agents in metastatic colorectal cancer

Colorectal cancer (CRC) is a major public health concern being the third leading cause of cancer mortality in the United States. The availability of better therapeutic options has led to a decline in cancer mortality in these patients. Surgical resection should be considered in all stages of the disease. The use of conversion therapy has made surgery a potentially curative option even in patients with initially unresectable metastatic disease. In this review we discuss the role of various anti-angiogenic agents in patients with metastatic CRC (mCRC). We describe the mechanism of action of these agents, and the rationale for their use in combination with chemotherapy. We also review important clinical studies that have evaluated the safety and efficacy of these agents in mCRC patients. Despite the discovery of several promising anti-angiogenic agents, mCRC remains an incurable disease with a median overall survival of just over 2 years in patients exposed to all available treatment regimens. Further insights into tumor biology and tumor microenvironment may help improve outcomes in these patients.

Addition of bevacizumab to preoperative chemotherapy for colorectal liver metastases does not increase perioperative morbidity and mortality

AIM

Patients with colorectal liver metastases (CRLM) benefit from liver resection. Bevacizumab is commonly used in these patients resulting in a greater number of patients receiving an operation for a potentially curative liver resection, with initially unresectable liver metastases. Our purpose was to evaluate the effect of preoperative bevacizumab administration on perioperative complications in patients undergoing hepatic resection for CRLM.

METHODS

A retrospective analysis of patients undergoing hepatic resection for CRLM who received only neoadjuvant chemotherapy (chemotherapy group, n = 133), or neoadjuvant chemotherapy and bevacizumab (chemotherapy and bevacizumab group, n = 103). We compared surgical characteristics, perioperative complications and postoperative liver function.

RESULTS

The type of liver resection (minor vs major liver resection) was comparable in the two groups (major liver resection 52.6 vs 62.1%, p = 0.144). The addition of bevacizumab to preoperative chemotherapy does not affect the frequency (chemotherapy group vs chemotherapy and bevacizumab group, 35.3 vs 38.8%, p = 0.581), severity (major complications, 20.3 vs 19.4%, p = 0.487) and type of perioperative complications. Preoperative administration of bevacizumab was associated with a higher peak of postoperative alanine aminotransferase levels but did not affect functional recovery of the liver.

CONCLUSION

Neoadjuvant administration of bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection and did not affect the liver's functional recovery. Patients receiving more than eight cycles of bevacizumab are at an increased risk to develop perioperative complications.

Experimental histopathological study on retinal and renal cellular response to intravitreous antiangiogenic drugs

AIM

To evaluate histopathological retinal and renal response after one single dose of intravitreous injection of antiangiogenic drugs ranibizumab and bevacizumab in rats.

METHODS

Experimental study in 60d of life adults Wistar rats. Ten animals were included. Group 1 included 5 animals that were injected with 1 µL ranibizumab 1.25 mg in the right eye and with 1 µL of balanced salt solution (BSS) in the left eye, as control; Group 2 included 5 animals that were injected with 1 µL of bevacizumab in the right eye and with 1 µL of BSS in the fellow eye. All injections were performed with Hamilton syringes. After 15d of the interventions, all animals were sacrificed in CO2 chamber. Both eyes were enucleated and one kidney was removed, fixed and embedded in paraffin for histopathological analysis by optic microscopy. For statistical purposes the initial expected abnormal histopathological responses were defined as 0%.

RESULTS

Atypical histopathological retinal response was detected in 2 eyes injected with ranibizumab (40%) as well as in 2 control eyes in group 1. Same was detected in 1 eye injected with bevacizumab (20%) as well as in 1 control eye, in group 2. The noted atypical findings were lymphocytes and eosinophils in the vitreous posterior cavity and mild retinal inflammatory reaction with ganglion cell layer edema but without clinical significance. No atypical histopathological renal response was detected.

CONCLUSION

Unexpected atypical histopathological retinal response without clinical significance was observed in 3 eyes injected with antiangiogenic drugs (2 in group 1 and 1 in group 2) as well as in 3 control eyes (2 in group 1 and 1 in group 2). No atypical renal response was detected suggesting no extra ocular involvement of the intravitreous injected antiangiogenic drugs.

Comparative analysis of the incidence of surgical site infections in patients with liver resection for colorectal hepatic metastases after neoadjuvant chemotherapy

BACKGROUND

The aim of this study was to identify the incidence of surgical site infections (SSIs) and postoperative complications, as defined by the Clavien-Dindo classification, after hepatic resection for metastatic colorectal cancer in patients with and without associated neoadjuvant chemotherapy.

METHODS

A total of 181 patients were studied retrospectively. Patients were divided into two groups: the first group comprised patients with associated neoadjuvant chemotherapeutic treatment for liver metastases with a latency time <8 wk and the second group comprised patients without associated neoadjuvant chemotherapy.

RESULTS

Variables of duration of liver surgery, length of total hospital stay, and length of postoperative hospital stay seem to be correlated with SSIs and postoperative complications, P < 0.005 and P < 0.0001, respectively. Duration of surgery is a risk factor for SSIs, with an odds ratio of 1.15, and for complications according to the Clavien-Dindo classification, with an odds ratio of 1.35.

CONCLUSIONS

Neoadjuvant chemotherapy was not a significant risk factor for SSIs, whereas the total length of hospital stay, length of postoperative hospital stay, and duration of surgery were independent predictors of SSIs and complications according to the Clavien-Dindo classification.