Advances in neoadjuvant therapy for colorectal cancer with liver metastases

Hepatic Artery Infusion Chemotherapy for Primary and Secondary Malignancies of the Liver: State of the Art and Current High-Level Evidence

BACKGROUND

Hepatic artery infusion chemotherapy (HAI) has been proposed as a valuable adjunct for multimodal therapy of primary and secondary liver malignancies. This review provides an overview of the currently available evidence of HAI, taking into account tumor response and long-term oncologic outcome.

SUMMARY

In colorectal liver metastases (CRLM), HAI in combination with systemic therapy leads to high response rates (85-90%) and conversion to resectablity in primary unresectable disease in up to 50%. HAI in combination with systemic therapy in CRLM in the adjuvant setting shows promising long-term outcomes with up to 50% 10-year survival in a large, non-randomized single-center cohort. For hepatocellular carcinoma patients, response rates as high as 20-40% have been reported for HAI and long-term outcomes compare well to other therapies. Similarly, survival for patients with unresectable intrahepatic cholangiocarcinoma 3 years after treatment with HAI is reported as high as 34%, which compares well to trials of systemic therapy where 3-year survival is usually below 5%. However, evidence is mainly limited by highly selected, heterogenous patient groups, and outdated chemotherapy regimens. The largest body of evidence stems from small, often non-randomized cohorts, predominantly from highly specialized single centers.

KEY MESSAGE

In well-selected patients with primary and secondary liver malignancies, HAI might improve response rates and, possibly, long-term survival. Results of ongoing randomized trials will show whether a wider adoption of HAI is justified, particularly to increase rates of resectability in advanced malignant diseases confined to the liver.

Intraarterial Chemotherapy for Liver Metastases

Colorectal cancer (CRC) is one of the leading cancers globally in terms of both incidence and cancer-related mortality. Liver metastatic disease is the main prognostic driver for patients with CRC. The management options for liver metastatic CRC continue to evolve, particularly with the incorporation of locoregional therapies into the treatment paradigm. Hepatic arterial infusion (HAI) chemotherapy is one such liver directed approach used with the goal of converting patients to liver resection, reducing the risk of recurrence, treating recurrent disease, and most importantly improving overall survival. This article summarizes the role of HAI chemotherapy in the treatment of liver metastatic CRC.

HBV infection may reduce the risk of metachronous liver metastasis in postoperative pathological stage 2 colorectal cancer

PURPOSE

To analyze whether HBV infection can reduce the risk of colorectal liver metastasis (CRLM) in stage 2 colorectal cancer (CRC).

METHODS

The data of postoperative pathological stage 2 CRC patients treated at the Sixth Affiliated Hospital of Sun Yat-sen University between 2013 and 2015 were analyzed. The patients were divided into an infection group (group A) and a non-infection group (group B). The correlations between HBV infection and CRLM, 5-year liver disease-free survival, and 5-year overall survival were compared.

RESULTS

A total of 884 patients who met the inclusion criteria were included in the study. Group A included 297 patients (33.60%), and 5 patients (1.68%) had CRLM. Group B included 587 patients (66.40%), and 31 patients (5.28%) had CRLM. The results of correlation analysis and logistic regression analysis showed that HBV infection (P = 0.013, HR = 0.29, 95% CI 0.11-0.77) was a protective factor for CRLM, while CEA > 5 ng/ml (P = 0.002, HR = 3.12, 95% CI 1.51-6.47) and hypertension (P = 0.010, HR = 3.50, 95% CI 1.34-9.09) were risk factors for CRLM. Group A had a significantly better 5-year liver disease-free survival than group B (P = 0.011, HR = 0.31, 95% CI 0.16-0.63), but there was no significant difference in the 5-year overall survival (P = 0.433).

CONCLUSION

HBV infection may reduce the risk of metachronous liver metastasis in stage 2 colorectal cancer.

The Results of the Combine Treatment of Patients with Liver Bilobar Metastases from Colorectal Cancer Using Radiofrequency Ablation

Colorectal cancer (CRC) is the third most common cancer worldwide. The mortality from CRC remains very high. The main cause of such a high mortality is a disseminate process with the appearance of distant metastases. In this regard, the treatment of metastatic lesions is recognized as an important trend in modern oncology. The program of study included 176 patients with colorectal cancer after primary tumor removal with the malignant progression-multiple (more than 4) bilobar liver metastases. The research was organized in Samara Regional Oncology Centre from 2001 to 2014. By the treatment method, patients were divided into two groups. Main group got the combined (chemotherapy + radiofrequency ablation (RFA)) treatment (n = 98). In control group, only chemotherapy was applied (n = 78). One-, two-, and three-year OS were 73.5, 25.1, and 7.2% in the main group and 39.6, 6.3, and 2.1% in the control group. The RFA application allowed us to reach the index of 4-year survival 1.8% in the main group, while we received only 2.1 of 3-year survival in the control group. The OS median reached 18 months in the main group and 11 months in the control group. So, the OS curves in two comparing groups were significantly different according to statistics (log-rank test 3.77, р = 0.000). The application of RFA in combination with chemotherapy in the treatment of bilobar metastasis colorectal cancer allows to improve the performance of disease-free survival and overall survival significantly, compared with the group of patients who received only chemotherapy.

LiMAx Test Improves Diagnosis of Chemotherapy-Associated Liver Injury Before Resection of Colorectal Liver Metastases

BACKGROUND

Chemotherapy of colorectal liver metastases (CLMs) prior to liver resection implies the risk of chemotherapy-associated liver injury, leading to increased postoperative morbidity and mortality OBJECTIVE: The aim of this study was to evaluate the LiMAx (liver maximum capacity) test for diagnosis of chemotherapy-associated liver injury.

METHODS

This was a retrospective analysis of patients with CLMs, prior to liver resection. We performed preoperative assessment of liver function using biochemical parameters and the LiMAx test. The individual history of chemotherapy within 12 months, including regimen, number of cycles, and therapy-free interval were collected, and histopathological evaluation of tumor-free liver tissue was performed in resected patients.

RESULTS

A total of 204 patients were included, of whom 127 (62%) had received previous chemotherapy. The LiMAx test was worse after chemotherapy (340 ± 95 vs. 391 ± 82 µg/kg/h; p < 0.001). Impaired LiMAx results (<315 µg/kg/h) were determined in 49% of patients after chemotherapy, and no effects of chemotherapy, liver steatosis or fibrosis on biochemical parameters were observed. LiMAx impairment was dependent on the number of oxaliplatin cycles, the therapy-free interval, and obesity in multivariate analysis. In addition, the LiMAx test was worse in patients with relevant steatosis, fibrosis and steatohepatitis. Patients with an impaired LiMAx showed sufficient regeneration during chemotherapy cessation when surgery was postponed (272 ± 57 - 348 ± 72 µg/kg/h; p = 0.003).

CONCLUSION

The LiMAx test enables non-invasive preoperative diagnosis of chemotherapy-associated liver injury. Preoperative performance of the LiMAx test can augment surgical strategy and timing of surgery after previous chemotherapy, thus avoiding increased postoperative morbidity.

Relevance of CEA and LDH in relation to KRAS status in patients with unresectable colorectal liver metastases

BACKGROUND

While the significance of carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH), and Kirsten rat sarcoma (KRAS) status as individual prognostic factors for patients with metastatic colorectal cancer has been addressed, the relationship and interdependence between these prognostic factors on survival is limited.

METHODS

Patients with unresectable colorectal liver metastases with known KRAS status, and with baseline CEA and LDH levels who were treated with hepatic arterial infusion and systemic chemotherapy were identified. Patients were divided into two groups: hepatic-only disease and extra-hepatic disease.

RESULTS

A total of 193 patients were included: 121 with hepatic-only and 72 with extra-hepatic disease. In the hepatic-only group, median overall survival (OS) was 55 months. On multivariate analysis, KRAS mutated tumors (HR 1.7, P < 0.05), LDH >200 U/L (HR 2.0, P < 0.05), and prior chemotherapy (HR 2.1, P < 0.05) had lower OS. In patients with extra-hepatic disease, median OS was 32 months. On multivariate analysis, baseline CEA >200 ng/mL (HR 2.1, P = 0.051), LDH >200 U/L (HR 3.8, P < 0.05), and right-sided tumors (HR 2.8, P < 0.05) had lower OS.

CONCLUSIONS

This analysis verifies two distinct patterns in terms of biomarkers in patients with unresectable colorectal liver metastases. In patients with hepatic-only disease, KRAS mutation and elevated LDH negatively influenced survival. In patients with extra-hepatic disease, elevated LDH negatively impacted survival.

Differential diagnosis between hepatic metastases and benign focal lesions using DWI with parallel acquisition technique: a meta-analysis

We aim to investigate the diagnostic capability of diffusion-weighted imaging using parallel acquisition technique for the differentiation between hepatic metastases and benign focal lesions with a meta-analysis. The meta-analysis included a total of 858 hepatic metastases and 440 benign liver lesions from nine studies. The pooled sensitivity and specificity of diffusion-weighted imaging (DWI) were 0.87 (95% CI, 0.84-0.89) and 0.90 (95% CI, 0.87-0.93), respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 8.50 (95% CI, 4.97-14.52) and 0.17 (95% CI, 0.11-0.26), respectively. The P value for χ (2) heterogeneity for all pooled estimates was <0.05. From the fitted summary receiver operating characteristics (SROC), the area under the curve (AUC) and Q* index were 0.95 and 0.88, respectively. Publication bias is not present (t = -0.76, P = 0.471). The meta-regression analysis indicated that evaluated covariates included patient number, patient population, mean age, maximum of b factor, number of cysts, number of hemangiomas, and field were not sources of heterogeneity (all P value >0.05). Diffusion-weighted imaging was useful for differentiation between hepatic metastases and benign focal lesions. The diffusion characteristics of the benign hepatocellular lesions, including cases of focal nodular hyperplasia (FNH) and adenoma, have rarely been reported and need further studies. The diagnostic capability of DWI with parallel acquisition technique for differentiation between metastases and benign hepatic focal lesions might be overestimated.

Can diffusion-weighted magnetic resonance imaging (DW-MRI) alone be used as a reliable sequence for the preoperative detection and characterisation of hepatic metastases? A meta-analysis

PURPOSE

To perform a meta-analysis of all available studies of the diagnostic performance of diffusion-weighted magnetic resonance imaging (DW-MRI) in patients with hepatic metastases.

METHODS

Databases including MEDLINE and EMBASE were searched for relevant original articles published from January 2000 to February 2012. We determined sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR-), diagnostic odds ratio (DOR) and constructed summary receiver operating characteristic curves using hierarchical regression models.

RESULTS

Across 11 studies (537 patients), DW-MRI sensitivity was 0.87 (95%confidence interval (CI), 0.80, 0.91) and specificity was 0.90 (95%CI, 0.86, 0.93). Overall, LR+ was 8.52 (95%CI, 6.17, 11.77), LR- was 0.15 (95%CI, 0.10, 0.22) and DOR was 57.36 (95%CI, 38.29, 85.93). In studies in which both DW-MRI and contrast-enhanced magnetic resonance imaging (CE-MRI) were performed, the comparison of DW-MRI performance with that of CE-MRI suggested no major differences against these two methods (p>0.05). DW-MRI combined CE-MRI had higher sensitivity and specificity than DW-MRI alone (97% versus 86% and 91% versus 90%, respectively) (p<0.05). The subgroup in which DW-MRI examinations were performed with a 3.0 Tesla (T) device had higher pooled specificity (0.91, 95%CI, 0.88-0.95) than the subgroup of DW-MRI with 1.5 T device (0.81, 95%CI, 0.67, 0.94) (p<0.05). Average lesion size (≤ 1.5 cm versus >1.5cm) did not influence the diagnostic accuracy of the test (p>0.05).

CONCLUSION

Our results demonstrate DW-MRI has good diagnostic performance in the overall evaluation of hepatic metastases and equivalent to CE-MRI. Combination of CE-MRI and DW-MRI can improve the diagnostic accuracy of magnetic resonance (MR) imaging. Our study further confirms that DW-MRI can accurately detect hepatic metastases regardless of the lesion size. It is suggested to perform DW-MRI by 3.0 T devices, which might have high specificity to identify liver metastases.

Synergistic anticancer effect of rAd/P53 combined with 5-fluorouracil or iodized oil in the early therapeutic response of human colon cancer in vivo

Exogenous wild-type p53 (wt-p53) tumor suppression increases the sensitivity of tumor cells to radiotherapy and chemotherapy. An iodized oil emulsion was used as a p53 vector for intra-arterial gene delivery to treat hepatic tumors. Whether the chemotherapeutic agent or the iodized oil affects exogenous wt-p53 activity remains poorly understood. In the present study, the early therapeutic response of rAd/p53, combined with 5-fluorouracil (5-FU) or with iodized oil, was observed in a human colon cancer model. Allograft models in 82 nude mice with human colon carcinoma SW480 were divided randomly into four groups and administered with physiologic saline, rAd/p53, rAd/p53+5-FU, and rAd/p53+iodized oil by intratumoral injection. At 24, 48, 72, 120, and 168 h after treatment, p53 expression, the Ki-67 index (KI), and the degree of tumor necrosis were assessed. The p53 expression and tumor necrosis in the therapeutic groups were higher than those in the control group. p53 expression reached its peak at 120 h in the rAd/p53 group, at 72 h in the rAd/p53+5-FU group, and at 48 h in the rAd/p53+iodized oil group. The p53 expression in the rAd/P53+5-FU group and the iodized oil group was significantly higher than those in the rAd/P53 group at 24 and 48 h. The results revealed that tumor necrosis is positively correlated with p53 expression. The KI of the rAd/p53+5-FU group increased significantly at 24 h. 5-FU and iodized oil increase the anticancer effect of rAd/p53, and 5-FU combined with rAd/p53 has a synergistic anticancer effect.

Repeat hepatectomy for metastatic colorectal cancer is safe but marginally effective

BACKGROUND

Although hepatectomy for metastatic colorectal cancer (mCRC) offers prolonged survival in up to 40% of people, recurrence rates are high, approaching 70%. Many patients experience recurrent disease in the liver after initial hepatectomy. We examined our experience with repeat hepatectomy for mCRC.

METHODS

After Institutional Review Board approval, we reviewed the records of all patients at a single institution who underwent hepatectomy for mCRC. Repeat hepatectomy was defined as partial liver resection any time after the initial hepatectomy for recurrent mCRC. We estimated time to recurrence and survival by using the Kaplan-Meier method and compared outcomes between groups by using the log-rank test.

RESULTS

From 1998 to 2008, 405 patients underwent hepatectomy for mCRC, and 215 (53%) experienced disease recurrence at a median of 13 months. Of 150 patients with liver-only or liver-predominant recurrence, 52 (35%) underwent repeat hepatectomy. The median time to recurrence after repeat hepatectomy was 10 months, and median overall survival was 19 months. There was one (1.9%) perioperative death, and there were 14 (27%) major complications. The median overall survival in the repeat hepatectomy group from the time of recurrence after initial hepatectomy was 22 months, compared with 15 months in the 98 patients with liver recurrence who were not selected for repeat hepatectomy (P=0.02).

CONCLUSIONS

Repeat hepatectomy for mCRC is feasible in highly selected patients, with acceptable perioperative morbidity and mortality. Although repeat hepatectomy should be considered, recurrence rates are high. Although the initial hepatectomy for mCRC is potentially curative, recurrence of metastatic disease in the liver is unlikely to be cured.

Glycine and taurine equally prevent fatty livers from Kupffer cell-dependent injury: an in vivo microscopy study

BACKGROUND

IRI still is a major problem in liver surgery due to warm ischemia and organ manipulation. Steatosis is not only induced by diabetes, hyperalimentation, alcohol and toxins, but also chemotherapy given before resection. Since steatotic livers are prone to Kupffer cell-dependent IRI, protection of steatotic livers is of special interest. This study was designed to compare the effect of taurine and glycine on IRI in steatotic livers.

MATERIALS AND METHODS

Steatosis was induced with ethanol (7 g/kg b.w.; p.o.) in female SD rats. Ten minutes after inactivation of Kupffer cells with taurine or glycine (300 mM; i.v.), left liver lobes underwent 60 minutes of warm ischemia. Controls received the same volume of valine (300 mM; i.v.) or normal saline. After reperfusion, white blood cell-endothelial interactions and latex-bead phagocytosis by Kupffer cells were investigated. Liver enzymes were measured to estimate injury. For statistical analysis, ANOVA and Student's t-test were used.

RESULTS

Glycine and taurine significantly decreased leukocyte- and platelet-endothelium interactions and latex-bead phagocytosis (p < 0.05). Liver enzymes were significantly lower after glycine and taurine (p < 0.05).

CONCLUSIONS

This study shows that preconditioning with taurine or glycine is equally effective in preventing injury to fatty livers most likely via Kupffer cell-dependent mechanisms.

Advances in regional chemotherapy of the liver

INTRODUCTION

Primary and secondary liver tumors resemble some of the most common causes of cancer and represent a major clinical problem owing to the poor prognosis. First-line therapeutic concepts are mainly based on surgical resection and/or systemic chemotherapy (SCT). However, many patients are not suitable for surgery or have failed SCT, although the total tumor load is still limited, which makes a regional therapy approach appealing.

AREAS COVERED

This review focuses on different types of transarterial instillation of chemotherapy, which encompasses conventional and drug-eluting transarterial chemoembolization (TACE), hepatic arterial infusion (HAI) chemotherapy and isolated hepatic perfusion (ILP).

EXPERT OPINION

TACE can be regarded as the treatment of choice in patients with multinodular hepatocellular carcinoma, but it should still be performed as a lipiodol-based regimen, while the value of doxorubicin-eluting beads needs to be exploited in further randomized controlled trials (RCTs). For patients with colorectal liver metastases, HAI chemotherapy has been challenged by the advent of more effective SCT, but encouraging results have been observed for the combination of the most recent, active drugs given by means of HAI with SCT. Nevertheless, data from RCTs comparing SCT with this transarterial regional therapy approach, as well as with TACE and ILP, are urgently needed.

Milestones in the evolution of hepatic surgery

This paper describes the rapid evolution of modern liver surgery, starting in the middle of the twentieth century. Claude Couinaud studied and described the segmental anatomy of the liver, Thomas Starzl performed the first liver transplantations, and Henri Bismuth introduced the concept of anatomical resections. Hepatic surgery has developed significantly since those early days. To date, innovative techniques are applied, using cutting-edge technologies: Intraoperative ultrasound, techniques of vascular exclusion of the liver, new devices for performing homeostasis and dissection, laparoscopy for resections, and new drugs that allow the resection of previously unresectable tumors. The next stage in liver surgery will probably be the implementation of a multidisciplinary holistic approach to the liver-diseased patient that will ensure the best and most efficient treatments in the future.

Diagnosis of liver metastases: value of diffusion-weighted MRI compared with gadolinium-enhanced MRI

OBJECTIVE

The full diagnostic value of diffusion-weighted (DW) MRI in the evaluation of liver metastases remains uncertain. The aim of the present study was to assess the diagnostic accuracy of DW-MRI and contrast-enhanced MRI (CE-MRI) using extracellular gadolinium chelates, with the reference standard established by consensus interpretation of confirmatory imaging and histopathologic data.

METHODS

MR examinations of 51 patients with extrahepatic malignancies were retrospectively reviewed by two independent observers who assessed DW-MRI and CE-MRI for detection of liver metastases.

RESULTS

By reference standard, 93 liver lesions (49 metastases and 44 benign lesions) were identified in 27 patients, 11 patients had no liver lesions, and 13 patients had innumerable metastatic and/or benign lesions. There was no difference in diagnostic performance between the two methods for either observer for the diagnosis of metastatic lesions per patient. For per-lesion analysis, sensitivity of DW-MRI was equivalent to CE-MRI for observer 1 (67.3% vs. 63.3%, p = 0.67), but lower for observer 2 (65.3% vs. 83.7%, p = 0.007). By pooling data from both observers, the sensitivity of DW-MRI was 66.3% (65/98) and 73.5% (72/98) for CE-MRI, with no significant difference (p = 0.171).

CONCLUSION

DW-MRI is a reasonable alternative to CE-MRI for the detection of liver metastases.

Comparison of optimally resected hepatectomy and peritonectomy patients with colorectal cancer metastasis

BACKGROUND

Hepatectomy is the standard of care for patients with colorectal liver metastases (CRLM) but cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) are still not widely accepted as the definitive treatment for patients with peritoneal carcinomatosis of colorectal origin (CRPC). We analyzed our data to compare survival outcomes for patients in these two groups who achieved optimal resection.

METHODS

We examined our prospectively collected database for CRLM and CRPC patients who underwent hepatectomy or peritonectomy from 1995 to 2008.

RESULTS

We identified 46 CRPC patients who achieved CCR-0/CCR-1 and 237 CRLM patients had a margin-negative hepatectomy. CRS patients had 1-, 2-, 3-, 5-year overall survival rates of 83.6%, 65.4%, 51.4%, and 32.1%, respectively. Comparatively, CRLM patients had 1-, 2-, 3-, 5-year overall survival rates of 88.1%, 69.4%, 51.9%, and 33.3%, respectively. Median survival for the two groups were 37.0 months (1-72) for CRPC patients and 37.0 months (0-120) for CRLM patients. There was no statistical significance in overall survival (P = 0.792).

CONCLUSIONS

There was no significant difference in survival outcomes for CRLM and CRPC patients who achieved optimal resection. Selected CRPC patients with potentially resectable disease should be considered for CRS and PIC.