Modern multimodality approach to hepatic colorectal metastases: solutions and controversies

Distinct role of tumor-infiltrating lymphocytes between synchronous and metachronous colorectal cancer

PURPOSE

Tumor-infiltrating lymphocytes (TILs) may influence the prognosis of colorectal liver metastasis (CRLM). We assessed the prognostic value of evaluating TILs in the primary and metastatic sites of synchronous CRLM as well as metachronous CRLM.

METHODS

We examined 90 patients who underwent curative primary and liver metastasis resection for colorectal cancer. CD8+ TILs (cytotoxic T cells) or CD45RO+ TILs (memory T cells) in both primary and metastatic sites were simultaneously evaluated by immunohistochemistry.

RESULTS

Fifty-one patients had synchronous CRLM, and 39 patients had metachronous CRLM. In synchronous cases, the overall survival (OS) was significantly worse in patients with low CD8+ or CD45RO+ TILs in a metastatic site than in those with high CD8+ or CD45RO+ TILs (P = 0.017 and P = 0.005, respectively). Multivariate analysis showed that age ≥ 65 years (P = 0.043), maximum tumor size ≥ 30 mm (P = 0.003), primary N2-3 (P = 0.019), and low CD8+ TILs in metastatic site (P = 0.046) were independent poor prognostic factors. In contrast, in metachronous cases, OS was significantly worse in patients with low CD45RO+ TILs in a primary site than in those with high CD45RO+ TILs (P = 0.021). CD45RO+ TILs in a primary site (P = 0.044) were determined to be independent prognostic factor on multivariate analysis.

CONCLUSIONS

The immune microenvironment between synchronous and metachronous CRLM might be different, and these differences may affect its prognosis.

AI Denoising Significantly Enhances Image Quality and Diagnostic Confidence in Interventional Cone-Beam Computed Tomography

(1) To investigate whether interventional cone-beam computed tomography (cbCT) could benefit from AI denoising, particularly with respect to patient body mass index (BMI); (2) From 1 January 2016 to 1 January 2022, 100 patients with liver-directed interventions and peri-procedural cbCT were included. The unenhanced mask run and the contrast-enhanced fill run of the cbCT were reconstructed using weighted filtered back projection. Additionally, each dataset was post-processed using a novel denoising software solution. Place-consistent regions of interest measured signal-to-noise ratio (SNR) per dataset. Corrected mixed-effects analysis with BMI subgroup analyses compared objective image quality. Multiple linear regression measured the contribution of “Radiation Dose”, “Body-Mass-Index”, and “Mode” to SNR. Two radiologists independently rated diagnostic confidence. Inter-rater agreement was measured using Spearman correlation (r); (3) SNR was significantly higher in the denoised datasets than in the regular datasets (p < 0.001). Furthermore, BMI subgroup analysis showed significant SNR deteriorations in the regular datasets for higher patient BMI (p < 0.001), but stable results for denoising (p > 0.999). In regression, only denoising contributed positively towards SNR (0.6191; 95%CI 0.6096 to 0.6286; p < 0.001). The denoised datasets received overall significantly higher diagnostic confidence grades (p = 0.010), with good inter-rater agreement (r ≥ 0.795, p < 0.001). In a subgroup analysis, diagnostic confidence deteriorated significantly for higher patient BMI (p < 0.001) in the regular datasets but was stable in the denoised datasets (p ≥ 0.103).; (4) AI denoising can significantly enhance image quality in interventional cone-beam CT and effectively mitigate diagnostic confidence deterioration for rising patient BMI.

Solitary colorectal liver metastasis: overview of treatment strategies and role of prognostic factors

The following is an overview of the treatment strategies and the prognostic factors to consider in the therapeutic choice of patients characterized by solitary colorectal liver metastasis. Liver resection is the only potential curative option; nevertheless, only 25% of the patients are considered to be eligible for surgery. To expand the potentially resectable pool of patients, surgeons developed multidisciplinary techniques like portal vein embolization, two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy. Moreover, mini-invasive surgery is gaining support, since it offers lower post-operative complication rates and shorter hospital stay with no differences in long-term outcomes. In case of unresectable disease, various techniques of local ablation have been developed. Radiofrequency ablation is the most commonly used form of thermal ablation: it is widely used for unresectable patients and is trying to find its role in patients with small resectable metastasis. The identification of prognostic factors is crucial in the choice of the treatment strategy. Previous works that focused on patients with solitary colorectal liver metastasis obtained trustable negative predictive factors such as presence of lymph-node metastasis in the primary tumour, synchronous metastasis, R status, right-sided primary colon tumor, and additional presence of extrahepatic tumour lesion. Even the time factor could turn into a predictor of tumour biology as well as further clinical course, and could be helpful to discern patients with worse prognosis.

Survival rates and prognostic factors in right- and left-sided colon cancer stage I-IV: an unselected retrospective single-center trial

PURPOSE

Colorectal cancer revealed over the last decades a remarkable shift with an increasing proportion of a right- compared to a left-sided tumor location. In the current study, we aimed to disclose clinicopathological differences between right- and left-sided colon cancer (rCC and lCC) with respect to mortality and outcome predictors.

METHODS

In total, 417 patients with colon cancer stage I-IV were analyzed in the present retrospective single-center study. Survival rates were assessed using the Kaplan-Meier method and uni/multivariate analyses were performed with a Cox proportional hazards regression model.

RESULTS

Our study showed no significant difference of the overall survival between rCC and lCC stage I-IV (p = 0.354). Multivariate analysis revealed in the rCC cohort the worst outcome for ASA (American Society of Anesthesiologists) score IV patients (hazard ratio [HR]: 16.0; CI 95%: 2.1-123.5), CEA (carcinoembryonic antigen) blood level > 100 µg/l (HR: 3.3; CI 95%: 1.2-9.0), increased lymph node ratio of 0.6-1.0 (HR: 5.3; CI 95%: 1.7-16.1), and grade 4 tumors (G4) (HR: 120.6; CI 95%: 6.7-2179.6) whereas in the lCC population, ASA score IV (HR: 8.9; CI 95%: 0.9-91.9), CEA blood level 20.1-100 µg/l (HR: 5.4; CI 95%: 2.4-12.4), conversion to laparotomy (HR: 14.1; CI 95%: 4.0-49.0), and severe surgical complications (Clavien-Dindo III-IV) (HR: 2.9; CI 95%: 1.5-5.5) were identified as predictors of a diminished overall survival.

CONCLUSION

Laterality disclosed no significant effect on the overall prognosis of colon cancer patients. However, group differences and distinct survival predictors could be identified in rCC and lCC patients.

Accuracy of 18F-FDG PET/CT in monitoring therapeutic response and detection of loco-regional recurrence and metastatic deposits of colorectal cancer in comparison to CT

Background

The study shows the role of PET/CT in monitoring response to therapy in colorectal cancer as well as detection of loco-regional recurrence and metastatic deposits hence guiding the clinician to the proper management strategy. Sixty patients (41male and 19 female) were included in our study. All patients are pathologically proven colorectal cancer. They had undergone 18F-FDG PET/CT for follow up post-therapeutic (operative, and/or chemotherapy and/or radiotherapy) follow up for metastatic or recurrent colorectal cancer during the period from September 2015 to August 2017.

Results

Our study demonstrated that FDG PET/CT is highly sensitive and specific in assessing local recurrence and distant metastasis in patient with pathologically proved colorectal cancer, with sensitivity 95.45%, specificity 97.3%, and accuracy 96.7% in detection of local recurrence; and sensitivity, specificity, and accuracy of 100% in detection of hepatic metastasis as well as in detection of nodal metastasis.

Conclusion

FDG PET/CT is an accurate modality in the treatment plan of cancer colon in monitoring therapeutic response as well as defining their local extent and distant metastatic disease thus provides valuable information that is very helpful in the clinical decision-making process.

Prediction of Histopathologic Growth Patterns of Colorectal Liver Metastases with a Noninvasive Imaging Method

OBJECTIVES

To predict histopathologic growth patterns (HGPs) in colorectal liver metastases (CRLMs) with a noninvasive radiomics model.

METHODS

Patients with chemotherapy-naive CRLMs who underwent abdominal contrast-enhanced multidetector CT (MDCT) followed by partial hepatectomy between January 2007 and January 2019 from two institutions were included in this retrospective study. Hematoxylin- and eosin-stained histopathologic sections of CRLMs were reviewed, with HGPs defined according to international consensus. Lesions were divided into training and validation datasets based on patients' sources. Radiomic features were extracted from pre- and post-contrast (arterial and portal venous) phase MDCT images, with review focusing on the segmented tumor-liver interface zones of CRLMs. Minimum redundancy maximum relevance and decision tree methods were used for radiomics modeling. Multivariable logistic regression analyses and ROC curves were used to assess the predictive performance of these models in predicting HGP types.

RESULTS

A total of 126 CRLMs with histopathologic-demonstrated desmoplastic (n = 68) or replacement (n = 58) HGPs were assessed. The radiomics signature consisted of 20 features of each phase selected. The 3 phases fused radiomics signature demonstrated the best predictive performance in distinguishing between replacement and desmoplastic HGPs (AUCs of 0.926 and 0.939 in the training and external validation cohorts, respectively). The clinical-radiomics combined model showed good discrimination (C-indices of 0.941 and 0.833 in the training and external validation cohorts, respectively).

CONCLUSIONS

A radiomics model derived from MDCT images may effectively predict the HGP of CRLMs, thus providing a basis for prognostic stratification and therapeutic decision-making.

Clinical significance of post-hepatectomy hepatic failure in patients with liver metastases from colorectal cancer

Backgrounds/Aims

This study attempted to identify risk factors for development of post-hepatectomy hepatic failure (PHF) and its effect on long-term survival of patients with liver metastases from colorectal cancer.

Methods

We carried out a retrospective study of 143 patients who had been diagnosed with liver metastases from colorectal cancer and who had undergone hepatectomy between 2003 and 2010. We allocated these patients to PHF and non-PHF groups, using the definition of the International Study Group of Liver Surgery, and compared the clinical factors of the two groups, using Cox regression and Kaplan-Meier analysis to evaluate the differences in overall survival (OS) and recurrence-free survival (RFS) between these groups.

Results

The PHF group comprised 19 patients (13.3%); all had Grade A PHF. Independent risk factors for development of PHF were metachronous liver metastases and major hepatectomy. The differences between the PHF and non-PHF groups in OS or RFS were not statistically significant; however, the PHF group tended to have a worse prognosis. Multivariate analysis revealed significant associations between OS and the factors of poor differentiation of the primary colorectal cancer, major hepatectomy, and positive resection margin.

Conclusions

Major hepatectomy is an important risk factor for PHF in patients with liver metastases from colorectal cancer. The pathological characteristics of the primary tumor are more important as predictors than is Grade A PHF.

Impact of Prior Hepatectomy History on Local Tumor Progression after Percutaneous Ablation of Colorectal Liver Metastases

PURPOSE

To test the hypothesis that, given the current resection eligibility criteria for colorectal liver metastasis (CLM), prior hepatectomy would be associated with improved local tumor control and survival after percutaneous ablation of CLMs.

MATERIALS AND METHODS

This single-institution retrospective study included 82 consecutive patients with 97 CLMs treated with ablation (radiofrequency ablation, microwave ablation, or cryoablation) from January 2005 to December 2014. Local tumor progression-free survival (LTPFS), recurrence-free survival (RFS) at any organ, and overall survival (OS) were calculated using the Kaplan-Meier method from the time of ablation and compared between patients with (n = 49) and without (n = 33) prior hepatectomy. Cox regression models were used to identify LTPFS predictors.

RESULTS

Median overall follow-up period was 28 months (range, 4.5-132 months). Three-year actuarial LTPFS (patient level: 73% vs 34%, P < .001) was significantly higher in patients with than without prior hepatectomy, respectively. Similarly, 3-year RFS (23% vs 9.1%, P = .026) and OS (78% vs 48%, P = .003) were improved in patients with prior hepatectomy. At multivariate analysis, predictors of worse LTPFS were: no prior hepatectomy (hazard ratio [HR] 2.35, 95% confidence interval [CI] 1.02-5.45; P = .045), minimal ablation margin < 5 mm (HR 2.4, 95% CI 1.18-4.87; P = .016), and RAS-mutant tumor (HR 2.65, 95% CI 1.18-5.94; P = .019).

CONCLUSIONS

Prior hepatectomy for CLMs is associated with improved local tumor control after percutaneous ablation of post-resection-developed CLMs.

Yttrium-90 Radioembolization for Metastatic Colorectal Cancer: Outcomes by Number of Lines of Therapy

Metastatic colorectal cancer represents the most common liver malignancy, and imparts a very poor prognosis for those who develop this disease. Unlike primary liver tumors such as hepatocellular carcinoma, which largely develops in patients with underlying cirrhosis, most metastatic liver tumor patients have normal underlying liver function. Owing to this, most will succumb to tumoral replacement of the liver rather than from underlying liver dysfunction. Radioembolization represents a treatment modality that can be used in multiple fashions to treat one or both lobes of the liver. Techniques depend on whether the procedure is used as first-line, second/third-line, or as salvage therapy. Outcomes and complications of radioembolization are presented in this article, as well as background information on colorectal cancer and systemic therapies.

Current status and future perspectives on treatment of liver metastasis in colorectal cancer (Review)

Liver metastasis is the most common site of colorectal cancer (CRC) metastasis. Approximately half of all colorectal cancer patients will develop liver metastases. Although radical surgery is the standard treatment modality, only 10-20% of patients are deemed eligible for resection. Despite advances in survival with chemotherapy, surgical resection is still considered the only curative option for patients with liver metastases. Much effort has been expended to address patients with metastatic liver disease. The majority of evidence stated a significant survival benefit with surgical resection to reach an overall 5-year survival rate of 35-55% after hepatic resection. However, still majority of patients will experience disease recurrence even after a successful resection. In this review, we describe current status and controversies related to treatment options for CRC liver metastases and its potential for enhancing oncologic outcomes and improving quality of life.

Process improvement for the safe delivery of multidisciplinary-executed treatments-A case in Y-90 microspheres therapy

PURPOSE

To develop a safe and robust workflow for yttrium-90 (Y-90) radioembolization procedures in a multidisciplinary team environment.

METHODS AND MATERIALS

A generalized Define-Measure-Analyze-Improve-Control (DMAIC)-based approach to process improvement was applied to a Y-90 radioembolization workflow. In the first DMAIC cycle, events with the Y-90 workflow were defined and analyzed. To improve the workflow, a web-based interactive electronic white board (EWB) system was adopted as the central communication platform and information processing hub. The EWB-based Y-90 workflow then underwent a second DMAIC cycle. Out of 245 treatments, three misses that went undetected until treatment initiation were recorded over a period of 21 months, and root-cause-analysis was performed to determine causes of each incident and opportunities for improvement. The EWB-based Y-90 process was further improved via new rules to define reliable sources of information as inputs into the planning process, as well as new check points to ensure this information was communicated correctly throughout the process flow.

RESULTS

After implementation of the revised EWB-based Y-90 workflow, after two DMAIC-like cycles, there were zero misses out of 153 patient treatments in 1 year.

CONCLUSIONS

The DMAIC-based approach adopted here allowed the iterative development of a robust workflow to achieve an adaptable, event-minimizing planning process despite a complex setting which requires the participation of multiple teams for Y-90 microspheres therapy. Implementation of such a workflow using the EWB or similar platform with a DMAIC-based process improvement approach could be expanded to other treatment procedures, especially those requiring multidisciplinary management.

Liver metastatic disease: new concepts and biomarker panels to improve individual outcomes

Liver cancer, one of the leading causes of all cancer related deaths, belongs to the most malignant cancer types. In fact, the secondary hepatic malignancies (liver metastases) are more common than the primary ones. Almost all solid malignancies can metastasise to the liver. It is well justified that the "treat and wait" approach in the overall management of the liver cancer is not up-to-date and so creation of complex individual patient profiles is needed. This review is specifically focused on the liver metastases originating from the colorectum, breast and prostate cancer. Innovative multilevel diagnostics may procure specific panels of validated biomarkers for predisposition, development and progression of metastatic disease. Creation of the patient specific "molecular portrait" is an essential part of the diagnostic strategy. Contextually, analysis of molecular and cellular patterns in blood samples as the minimally invasive diagnostic tool and construction of diagnostic windows based on individual patient profiling is highly recommended for patient cohorts predisposed to and affected by the liver metastatic disease. Summarised information on risk assessment, predictive and prognostic panels for diagnosis and treatments of the liver metastatic disease in colorectal, breast and prostate cancer is provided.

Liver resection for metastases from colorectal cancer in very elderly patients: New surgical horizons

INTRODUCTION AND AIM

Patients with colorectal cancer (CRC) may develop liver metastases. Surgical resection remains the best treatment of choice for colorectal liver metastases (CRLM) according to resectability criteria, with a long-term survival of 25% up to 41% after 5 years. Advanced age is associated with a higher incidence and co-morbidity, particularly cardiovascular disease, as well as deteriorating physiological reserves. The aim of this study was to analyse the overall and disease-free survival for patients with CRLM according to their chronological age.

METHODS

Patients with CRLM were enrolled in the study. Data on gender, age, co-morbidity, metastasis characteristics (number, size and total metastatic volume (TMV)), use of perioperative chemotherapy and operative and post-operative complications were collected. Then, according to recent World Health Organization (WHO) guidelines, the patients were grouped by age. Statistical analysis was performed using the software R (ver. 2.14.1).

RESULTS

Hepatic resection was performed in 149 patients (21 patients in the very elderly group, 79 in the elderly group and 49 in the younger group). The three groups were comparable in terms of operative duration, transfusion rate, length of high-dependency unit (HDU) stay and post-operative hospital stay. The very elderly group showed a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates increased with age without any significant statistically difference between the three groups (very elderly group 4.8% and 4.8%; elderly group: 2.5% and 3.8%; and younger group 0% and 2%). At 5 years, the overall survival was 28.6% for very elderly patients (≥75 years), 33.3% for elderly patients (≥65 to <75 years) and 43.5% for younger patients (≤65 years). The 1-, 3- and 5-year disease-free survival was similar across the groups.

CONCLUSIONS

Liver resection for CRLM in carefully selected patients above the age of 75 can be performed with acceptable morbidity and mortality rates, similar to those in younger patients. Moreover, the severity of CRLM in elderly patients is proven to be lesser than in younger patients. Thus, we can conclude that advanced chronological age cannot be considered a contraindication to hepatic resection for CRLM.

Biological and Prognostic Significance of the Morphological Types and Vascular Patterns in Colorectal Liver Metastases (CRLM): Looking Beyond the Tumor Margin

Patients with encapsulated colorectal liver metastases (CRLM) have a better prognosis than those without a capsule. The reason for the encapsulation is unknown. Hypoxia inducible factor-1α (HIF-1α) increases tumor angiogenesis and tumor tissue expression is associated with reduced survival. Our aim was to determine whether the good prognosis of encapsulated CRLM is associated with reduced HIF-1α expression by the cancer.The study selected only patients who had not undergone neoadjuvant chemotherapy prior to a potentially curative hepatectomy for CRLM. From 30 selected patients, serial sections were cut from a single randomly selected metastasis. Morphology was assessed following H&E staining. Tumor hypoxia, vascular endothelial growth factor (VEGF), proliferation, and microvascular density (MVD) were assessed by immunostaining for HIF-1α and carbonic anhydrase-9 (CA-9), VEGF, Ki67, and cluster of differentiation-31, respectively. MVD was calculated in the vascular hot spots. Pathology was reported without clinical outcome information. Actual long-term survival was recorded.Thirteen (43%) of the cancers were encapsulated CRLM containing glands which were large, complex, and cribriform. Thirteen (43%) were infiltrative CRLM and their glands were small, closely packed, and rounded with vessels in the interglandular fibrous tissue with no capsule; 3 (10%) had a mixed picture. Encapsulated CRLM had a higher expression of HIF-1α (58% vs 8%, P = 0.03), CA-9 (42% vs 0%, P = 0.04), and VEGF (92% vs 25%, P = 0.02). MVD was lower in the encapsulated CRLM group (37 mm vs 143 mm, P < 0.001). The median follow-up was 115 months. The encapsulated CRLM group had a better overall and 5-year survival (relative hazard: 0.58, P = 0.057 and hazard ratio: 0.52, P = 0.044).There are 2 main morphological appearances of CRLM which have very different long-term survival following liver resection surgery. The morphology is associated with differences in expression of HIF-1α, CA-9, VEGF, and angiogenesis.

Significant Shrinkage of Multifocal Liver Metastases and Long-Term Survival in a Patient With Rectal Cancer, After Trans-Arterial Chemoembolization (TACE): A Case Report

In this paper, we present the successful therapeutic approach of unresectable liver metastases in a patient with rectal cancer.A 63-year-old male underwent endoscopic polypectomy followed by rectosigmoid resection for an adenocarcinoma of the rectum diagnosed in pT2N0 stage. The angio-computed tomography (CT) revealed four metastatic hepatic nodules ranging from 12 to 130 mm in diameter. After one cure of trans-arterial chemoembolization (TACE) with lipiodol and 5-fluorouracil, combined with FOLFOX4 + capecitabine systemic chemotherapy, the diameter of all hepatic nodules decreased to half size, at 6 months after TACE. Further curative surgical hepatic metastasectomy was done and complete pathologic response was obtained. The patient is free of recurrences and metastases after 26 months of follow-up.This representative case shows that an efficient trans-disciplinary approach could lead to successful therapeutic management even in patients with advanced-staged colorectal carcinomas.

Tumour growth of colorectal rat liver metastases is inhibited by hepatic arterial infusion of the mTOR-inhibitor temsirolimus after portal branch ligation

Portal branch ligation (PBL) can be performed before major hepatic resection of colorectal liver metastases (mCRC) to increase the remnant liver mass. However, PBL may also stimulate mCRC growth through hepatic arterial hyperperfusion and growth factor release. Herein, we studied whether hepatic arterial infusion (HAI) of the mTOR-inhibitor temsirolimus (Tem) is capable of inhibiting the growth of colorectal liver metastases after PBL. WAG/Rij rats were randomized to four groups (n=6 each) and underwent subcapsular implantation of 5×10(5) CC531 cells into the left liver lobe. The animals of two groups underwent simultaneous PBL of the tumour bearing liver lobe. Ten days later animals underwent a HAI either of temsirolimus (Tem and PBL Tem) or saline solution (Sham and PBL Sham). Tumour size was analyzed at days 10 and 13 using three-dimensional ultrasound. In Sham controls tumour volume increased by 43%. After PBL Sham tumour volume increased by 52%. In contrast, in animals undergoing HAI of temsirolimus the tumour growth was not only completely inhibited, but tumour volume was found decreased, irrespective of PBL. After HAI of temsirolimus immunohistochemistry revealed an increased cleaved caspase-3 activity, indicating stimulation of apoptotic cell death. In parallel temsirolimus treatment was associated with a significant reduction of PECAM-1 positive cells within the tumour tissue, implying a reduced tumour vascularisation. HAI of temsirolimus is capable of inhibiting the growth of CC531 colorectal rat liver metastases also after PBL.

Y90 radioembolization of colorectal cancer liver metastases: response assessment by contrast-enhanced computed tomography with or without PET-CT guidance

PURPOSE

To compare various computed tomography (CT) parameters to the positron emission tomography with computed tomography (PET-CT) response, with or without PET guidance for the response assessment of colorectal cancer (CRC) metastases treated by Y90 radioembolization.

METHODS

Thirty-six CRC metastases were retrospectively evaluated on 18F-Fluoro-Deoxy-Glucose PET-CT and contrast-enhanced computed tomography (CECT) performed at baseline and 2-3 months after Y90 radioembolization.

RESULTS

Median SUVmax values decreased from 11.39 to 6.71 after radioembolization (P<.001), and 23/36 (64%) metastases were categorized metabolic responses according to European Organisation for Research and Treatment of Cancer criteria. Only a decrease of the mean attenuation in the structural (P<.001) and metabolic active volume (P<.001) was observed. The change in these criteria was correlated with the change of SUVmax.

Survival and tolerability of liver radioembolization: a comparison of elderly and younger patients with metastatic colorectal cancer

AIM

To evaluate the outcomes among elderly (≥70 years) and younger patients (<70 years) with liver-dominant metastatic colorectal cancer (mCRC) who received radioembolization (RE) as salvage therapy.

METHODS

A retrospective review of 107 consecutive patients with unresectable mCRC treated with RE after failing first- and second-line chemotherapy.

RESULTS

From 2002 to 2012, 44 elderly and 63 younger (<70 years) patients received RE. Patients had similar previous extensive chemotherapy and liver-directed interventions. Using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria, either a stable or a partial radiographical response was seen in 65.8% of the younger compared with 76.5% of the elderly patients. RE was equally well tolerated in both groups and common procedure-related adverse events were predominantly grade 1-2 and of short duration. No significant difference was found with regard to overall median survival between younger [8.4 months; 95% confidence interval (CI) = 6.2-10.6] or elderly patients (8.2 months; 95% CI = 5.9-10.5, P = 0.667). The presence of extrahepatic disease at the time of RE was associated with a significantly worse median survival in both groups.

CONCLUSION

Radioembolization appears to be as well tolerated and effective for the elderly as it is for younger patients with mCRC. Age alone should not be a discriminating factor for the use of radioembolization in the management of mCRC patients.

A systematic review on the safety and efficacy of yttrium-90 radioembolization for unresectable, chemorefractory colorectal cancer liver metastases

INTRODUCTION

The management of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM) is a clinical dilemma. Yttrium-90 (Y90) radioembolization is a potentially safe and effective treatment for patients with CRCLM who have failed conventional chemotherapy regimens.

METHODS

A systematic review of clinical studies before November 2012 was performed to examine the radiological response, overall survival and progression-free survival of patients who underwent Y90 radioembolization of unresectable CRCLM refractory to systemic therapy. The secondary objectives were to evaluate the safety profile of this treatment and identify prognostic factors for overall survival.

RESULTS

Twenty studies comprising 979 patients were examined. Patients had failed a median of 3 lines of chemotherapy (range 2-5). After treatment, the average reported value of patients with complete radiological response, partial response and stable disease was 0% (range 0-6%), 31% (range 0-73%) and 40.5% (range 17-76%), respectively. The median time to intra-hepatic progression was 9 months (range 6-16). The median overall survival was 12 months (range 8.3-36). The overall acute toxicity rate ranged from 11 to 100% (median 40.5 %). Most cases of acute toxicity were mild (Grade I or II) (median 39%; range 7-100%) which resolved without intervention. The number of previous lines of chemotherapy (≥ 3), poor radiological response to treatment, extra-hepatic disease and extensive liver disease (≥ 25%) were the factors most commonly associated with poorer overall survival.

CONCLUSION

Y90 radioembolization is a safe and effective treatment of CRCLM in the salvage setting and should be more widely utilized.

Irreversible electroporation ablation (IRE) of unresectable soft tissue tumors: learning curve evaluation in the first 150 patients treated

Background

Irreversible electroporation (IRE) is a novel technology that uses peri-target discrete probes to deliver high-voltage localized electric current to induce cell death without thermal-induced coagulative necrosis. “Learnability” and consistently effective results by novice practitioners is essential for determining acceptance of novel techniques. This multi-center prospectively-collected database study evaluates the learning curve of IRE.

Methods

Analysis of 150 consecutive patients over 7 institutions from 9/2010-7/2012 was performed with patients treated divided into 3 groups A (1^st 50 patients treated), B (2^nd 50) and C (3^rd 50 patients treated) chronologically and analyzed for outcomes.

Results

A total of 167 IRE procedures were performed, with a majority being liver(39.5%) and pancreatic(35.5%) lesions. The three groups were similar with respect to co-morbidities and demographics. Group C had larger lesions (3.9vs3cm,p=0.001), more numerous lesions (3.2vs2.2,p=0.07), more vascular invasion(p=0.001), underwent more associated procedures(p=0.001) and had longer operative times(p<0.001). Despite this, they had similar complication and high-grade complication rates(p=0.24). Attributable morbidity rate was 13.3%(total 29.3%) and high-grade complications were seen in 4.19%(total 12.6%). Pancreatic lesions(p=0.001) and laparotomy(p=0.001) were associated with complications.

Conclusion

The review represents that single largest review of IRE soft tissue ablation demonstrating initial patient selection and safety. Over time, complex treatments of larger lesions and lesions with greater vascular involvement were performed without a significant increase in adverse effects or impact on local relapse free survival. This evolution demonstrates the safety profile of IRE and speed of graduation to more complex lesions, which was greater than 5 cases by institution. IRE is a safe and effective alternative to conventional ablation with a demonstrable learning curve of at least 5 cases to become proficient.

Role of positron emission tomography-computed tomography in gastrointestinal malignancies

Positron emission tomography (PET) has proved itself to be valuable in the evaluation of patients with a wide array of gastrointestinal (GI) malignancies. Subsequent development of fusion imaging with PET and computed tomography (PET-CT) scanners has significantly advanced the capabilities of imaging by combining the functional data of the(18)F-labeled glucose analogue fluorodeoxyglucose (FDG) with the conventional anatomic data provided by CT. This article reviews the evolving role of FDG PET-CT imaging in the initial assessment and monitoring of GI tumors. Specific applications are discussed, and normal variants and benign findings frequently encountered during PET-CT of the GI tract are reviewed.

Recommendations of a group of experts for the pathological assessment of tumour regression of liver metastases of colorectal cancer and damage of non-tumour liver tissue after neoadjuvant therapy

Colorectal cancer (CRC) incidence has increased during the past decades in Spain, being the first malignant tumour in incidence. Observed mortality for CRC is mainly due to liver and lung metastases. The only curative treatment is surgery; new surgical techniques and neoadjuvant treatments have increased the number of surgery candidate patients. Patients should be managed with a multidisciplinary approach that includes imaging techniques, chemotherapy, surgery and pathological assessment. As an answer to this approach, a group of pathology experts interested on CRC liver metastases aimed to review the diagnosis and prognosis of liver mestastases and developed practical recommendations for its assessment. The expert group revised the current literature and prepared questions to be discussed based on available evidence and on their clinical practise. As a result, recommendations for the assessment of tumour regression of liver metastases are proposed, which could be implemented in oncology centres allowing assessment standardisation for these patients. Prospective multi-center studies to evaluate these recommendations validity will further contribute to improve the standard care of CRC liver metastases patients.

Adhesiolysis-related morbidity in abdominal surgery

OBJECTIVE

To determine the incidence of bowel injury in operations requiring adhesiolysis and to assess the impact of adhesiolysis on the incidence of surgical complications, postoperative morbidity, and costs.

BACKGROUND

Morbidity of adhesiolysis during abdominal surgery seems an important health care problem, but the direct impact of adhesiolysis on inadvertent organ damage, morbidity, and costs is unknown.

METHODS

In a prospective cohort study, detailed data on adhesiolysis were gathered by direct observation during elective abdominal surgery. Comparison was made between surgical procedures with and without adhesiolysis on the incidence of inadvertent bowel defects. Secondary outcomes were the effect of adhesiolysis and bowel injury on surgical complications, other morbidity, and costs.

RESULTS

A total of 755 (out of 844) surgeries in 715 patients were included. Adhesiolysis was required in 475 (62.9%) of operations. Median adhesiolysis time was 20 minutes (range: 1-177). Fifty patients (10.5%) undergoing adhesiolysis inadvertently incurred bowel defect, compared with 0 (0%) without adhesiolysis (P < 0.001). In univariate and multivariate analyses, adhesiolysis was associated with an increase of sepsis incidence [odds ratio (OR): 5.12; 95% confidence interval (CI): 1.06-24.71], intra-abdominal complications (OR: 3.46; 95% CI: 1.49-8.05) and wound infection (OR: 2.45; 95% CI: 1.01-5.94), longer hospital stay (2.06 ± 1.06 days), and higher hospital costs [$18,579 (15,204-21,954) vs $14,063 (12,471-15,655)]. Mortality after adhesiolysis complicated by a bowel defect was 4 out of 50 (8%), compared with 7 out of 425 (1.6%) after uncomplicated adhesiolysis (OR: 5.19; 95% CI: 1.47-18.41).

CONCLUSIONS

Adhesiolysis and inadvertent bowel injury have a large negative effect on the convalescence after abdominal surgery. The awareness of adhesion-related morbidity during reoperation and the prevention of postsurgical adhesion deserve priority in research and clinical practice.

Prognostic factors for survival in patients with colorectal liver metastases: experience of a single brazilian cancer center

CONTEXT

Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for 2/3 of deaths from this disease. There is considerable controversy among the data in the literature regarding the results of surgical treatment and prognostic factors of survival, and no analysis have been done in a large cohort of patients in Brazil.

OBJECTIVES

To characterize the results of surgical treatment of patients with colorectal liver metastases, and to establish prognostic factors of survival in a Brazilian population.

METHOD

This was a retrospective study of patients undergoing liver resection for colorectal metastases in a tertiary cancer hospital from 1998 to 2009. We analyzed epidemiologic variables and the clinical characteristics of primary tumors, metastatic disease and its treatment, surgical procedures and follow-up, and survival results. Survival analyzes were done by the Kaplan-Meier method and the log-rank test was applied to determine the influence of variables on overall and disease-free survival. All variables associated with survival with P<0.20 in univariate analysis, were included in multivariate analysis using a Cox proportional hazard regression model.

RESULTS

During the period analyzed, 209 procedures were performed on 170 patients. Postope-rative mortality in 90 days was 2.9% and 5-year overall survival was 64.9%. Its independent prognostic factors were the presence of extrahepatic disease at diagnosis of liver metastases, bilateral nodules and the occurrence of major complications after liver surgery. The estimated 5-year disease-free survival was 39.1% and its prognostic factors included R1 resection, extrahepatic disease, bilateral nodules, lymph node involvement in the primary tumor and primary tumors located in the rectum.

CONCLUSION

Liver resection for colorectal metastases is safe and effective and the analysis of prognostic factors of survival in a large cohort of Brazilian patients showed similar results to those pointed in international series. The occurrence of major postoperative complications appears to be able to compromise overall survival and further investigation in needed in this topic.

Cryoablation for salvage therapy of liver metastases: An analysis of 46 cases

AIM: To assess the efficacy and safety of cryoablation as a salvage therapy for liver metastases.

METHODS: The clinical data for 46 patients with liver metastases who underwent cryoablation as a salvage therapy were analyzed retrospectively. The maximum diameter of individual lesion ranged from 1.8 cm to 13.0 cm, with a mean value of 5.32 cm ± 2.5 cm. The short-term effective rate, 1-year survival rate, quality of life, and complications after argon-helium cryoablation were assessed.

RESULTS: The clinical effective rates at 1 mo, 3 mo and 6 mo were 82.60%, 75.56% and 69.77%, respectively. The 1-year survival rate was 76.08%, and the quality of life was significantly improved (P < 0.001). Main adverse effects, such as cryoshock, hepatic bleeding and renal insufficiency, were not observed in all patients.

CONCLUSION: Cryoablation is an effective, safe and minimally-invasive therapy for liver metastases. It is a good alternative to conventional treatments in patients with liver metastases who were not suitable for surgical removal or chemotherapy.

Defining resectability of colorectal liver metastases: how and why?

SUMMARY Treatment outcome in metastatic colorectal carcinoma has improved because of advancements in medical therapy and increased use of liver resections. In primary nonresectable disease, prognosis improves when a secondary resection is performed after successful downsizing by neoadjuvant systemic therapy. Which patient groups may profit from a secondary liver resection and which neoadjuvant systemic therapy has the optimal chance of conversion to resectability has not been defined because various patient groups were selected in different studies and there is a lack of consensus on resectability. This invalidates cross-study comparisons of resection rates and survival rates. Prospective trials in which secondary resection rate is a predefined end point are needed and will allow more insight into this topic.

Dose-finding study of hepatic arterial infusion of oxaliplatin-based treatment in patients with advanced solid tumors metastatic to the liver

BACKGROUND

Liver metastases in patients with cancer are associated with poor survival. We hypothesized that hepatic arterial infusion (HAI) of oxaliplatin combination therapy would have antitumor activity in these patients.

PATIENTS AND METHODS

Patients with advanced cancer and predominant liver metastases were treated on a phase I study of HAI oxaliplatin in combination with systemic bevacizumab, with or without HAI or systemic fluorouracil and/or leucovorin and/or cetuximab. Patients were divided into two treatment arms according to KRAS mutational status and physician choice. A "3 + 3" design was used.

RESULTS

Among 76 patients (median age 61 years; 34 women; median number of prior therapies 4), the most common cancer was colorectal (CRC) (n = 58). Overall, the only dose-limiting toxicity was Grade 3 diarrhea (n = 2). The most common treatment-related toxicities were hypertension (n = 40), nausea (n = 29), fatigue (n = 28), and transaminitis (n = 26). Of 76 patients, one (1 %) had a complete response (CR), 12 (16 %) had a partial response (PR), and 12 (16 %) had SD for ≥ 6 months (total CR/PR/SD ≥ 6 months 25/76 = 33 %). In CRC (n = 58), total CR/PR/SD ≥ 6 months was 31 % (n = 18). Both patients with pancreatic neuroendocrine tumors achieved a PR (24+ months) and a CR (6+ months). Time to treatment failure (TTF) on the current regimen was 3.5 versus 2.8 months on patients' prior systemic treatment (p = 0.37).

CONCLUSIONS

HAI oxaliplatin combination therapy with 5-fluorouracil, leucovorin, bevacizumab, and/or cetuximab was well tolerated and had antitumor activity in selected heavily pretreated patients with predominant liver disease.

Radioembolisation with Yttrium-90 microspheres: an effective treatment modality for unresectable liver metastases

PURPOSE

To compare the outcomes (survival and adverse events) of the authors' use of (90) Y microsphere radioembolisation in patients with chemotherapy-refractory liver metastases with published data from other groups using radioembolisation. To retrospectively evaluate the efficiency, in particular survival benefits, of radioembolisation in the treatment of liver metastases.

METHODS AND MATERIALS

Over 5 years, 339 patients underwent (90) Y microsphere radioembolisation for unresectable liver metastases and were evaluated for adverse events at the time of treatment and 1 and 3 months after treatment. Overall survival (OS) was calculated by the Kaplan-Meier method. The results from the present retrospective study were compared with a number of prospective and retrospective clinical trials which have addressed the use of (90) Y microspheres as a salvage treatment for liver metastases.

RESULTS

The OS time of the present study (12.0 months) compares favourably with survival times reported by other groups. The incidence of late grade 2 adverse events (e.g. duodenal or gastric ulceration, radiation-induced liver disease, gall bladder complications) is comparable to previous studies, with a lower prevalence of grade 2/3 ulcerations (3.7%) at our centre.

CONCLUSIONS

The survival results, together with the low acute and late toxicity observed in our data and previous studies, support the use of radioembolisation to aid in the local control of unresectable liver metastases in the salvage setting. The present study contributes to the growing evidence for efficiency, in particular survival gains, of radioembolisation in the treatment of liver metastases.

Resectable liver metastases from colorectal cancer: where we are now and where do we go from here?

SUMMARY Liver metastases from colorectal cancer represent a peculiar clinical scenario in everyday practice, since treatment should achieve long-term survival or even a cure in selected patients. Presentation may vary between single cases, ranging from easily resectable lesions to more advanced metastatic spreading for which surgery can only be considered after major tumor shrinkage. For resectable liver metastases, surgery remains the essential step in the curative approach to the disease, even though different ablative procedures may be considered as valuable alternatives in certain subsets. Postoperative or perioperative chemotherapy may further improve long-term outcome, even though treatment benefits and harms related to liver toxicity should be carefully balanced in each patient. A comprehensive multidisciplinary assessment of patient- and tumor-related features remains the key to complement the clinical aspects with the biological characterization in the framework of a personalized therapeutic approach.

Histopathological growth pattern, proteolysis and angiogenesis in chemonaive patients resected for multiple colorectal liver metastases

The purpose of this study was to characterise growth patterns, proteolysis, and angiogenesis in colorectal liver metastases from chemonaive patients with multiple liver metastases. Twenty-four patients were included in the study, resected for a median of 2.6 metastases. The growth pattern distribution was 25.8% desmoplastic, 33.9% pushing, and 21% replacement. In 20 patients, identical growth patterns were detected in all metastases, but in 8 of these patients, a second growth pattern was also present in one or two of the metastases. In the remaining 4 patients, no general growth pattern was observed, although none of the liver metastases included more than two growth patterns. Overall, a mixed growth pattern was demonstrated in 19.3% of the liver metastases. Compared to metastases with pushing, those with desmoplastic growth pattern had a significantly up-regulated expression of urokinase-type plasminogen activator receptor (P = 0.0008). Angiogenesis was most pronounced in metastases with a pushing growth pattern in comparison to those with desmoplastic (P = 0.0007) and replacement growth pattern (P = 0.021). Although a minor fraction of the patients harboured metastases with different growth patterns, we observed a tendency toward growth pattern uniformity in the liver metastases arising in the same patient. The result suggests that the growth pattern of liver metastases is not a random phenomenon.

Chemotherapy-associated liver injury in patients with colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

Chemotherapy-associated liver injury is a major cause for concern when treating patients with colorectal liver metastases. The aim of this review was to determine the pathological effect of specific chemotherapy regimens on the hepatic parenchyma as well as on surgical morbidity, mortality and overall survival.

METHODS

A systematic review of the published literature and a meta-analysis were performed. For each of the variables under consideration, the effects of different chemotherapy regimens were determined by calculation of relative risks by a random-effects model.

RESULTS

Hepatic parenchymal injury is regimen specific, with oxaliplatin-based regimens being associated with grade 2 or greater sinusoidal injury (number needed to harm 8; 95 % confidence interval [CI] 6.4-13.6), whereas irinotecan-based regimens associated with steatohepatitis (number needed to harm 12; 95 % CI 7.8-26). The use of bevacizumab alongside FOLFOX reduces the risk of grade 2 or greater sinusoidal injury (relative risk 0.34; 95 % CI 0.15-0.75).

CONCLUSIONS

Chemotherapy before resection of colorectal liver metastases is associated with an increased risk of regimen-specific liver injury. This liver injury may have implications for the functional reserve of the liver for patients undergoing major hepatectomy for colorectal liver metastases.

An update on chemotherapy of colorectal liver metastases

Surgical resection of liver metastases of colorectal cancer greatly improves the clinical outcome of patients with advanced disease. Developments in chemotherapeutic agents and strategies bring hope of a cure to patients with initially unresectable colorectal liver metastases (CLM). Perioperative chemotherapy significantly improves the survival time of patients who receive curative-intent hepatectomy. Even for unresectable CLM, recent studies demonstrated that active preoperative chemotherapy could achieve shrinkage of liver metastasis and thus render some for resection. Furthermore, an increase in tumor resection rate and prolonged survival time among patients with CLM has been observed following the application of monoclonal antibodies in recent years. However, the value of chemotherapy via hepatic arterial infusion is still unclear. More trials should be conducted in patients with CLM in order to improve survival.

Liver metastases from colorectal cancer: how to best complement medical treatment with surgical approaches

Colorectal liver metastases (CLM) represent a major challenge for oncologists and surgeons. In fact, in this setting, the optimal treatment of patients can achieve a long-term survival and sometimes a definitive cure of disease. In recent years, improvements in both medical therapies and surgical approaches have led to an increased rate of patients considered amenable for surgery on CLM. New perspectives in the management of CLM underline the need for a comprehensive assessment of patient and tumor characteristics, to integrate technical and prognostic issues into an individualized therapeutic strategy in different patient subgroups. The multidisciplinary evaluation from the onset and during treatment remains the key element to maximizing the benefit of more intensive treatment modalities.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver, with five-year survival rates up to 58% in selected cases. However, only a minority are resectable at the time of diagnosis. Continuous research in this field aims at increasing the percentage of patients eligible for resection, refining the indications and contraindications for surgery, and improving overall survival. The use of surgical innovations, such as staged resection, portal vein embolization, and repeat resection has allowed higher resection rates in patients with bilobar disease. The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection. Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Current management of colorectal liver metastases requires a multidisciplinary approach, which should be individualized in each case.

Phase I clinical trial of hepatic arterial infusion of paclitaxel in patients with advanced cancer and dominant liver involvement

PURPOSE

The survival of patients with liver metastases from solid tumors is poor. We conducted a phase I study of hepatic arterial infusion (HAI) paclitaxel in patients with advanced cancer and predominant liver involvement.

METHODS

Patients were treated with HAI paclitaxel 150-275 mg/m(2) (and 15,000 IU heparin intraarterially) every 28 days. A "3 + 3" study design was used.

RESULTS

Twenty-six patients were treated (median age, 59 years). Diagnoses were colorectal cancer (n = 10), breast cancer (n = 7), and other (n = 9). The median number of prior therapies was four (range, 0-10). The maximum tolerated dose (MTD) was HAI paclitaxel 225 mg/m(2). Dose-limiting toxicities (DLTs) included Grade 3 neuropathy (1 of 5 patients) at HAI paclitaxel 275 mg/m(2) and Grade 4 thrombocytopenia and neutropenia, and Grade 3 mucositis (1 of 4 patients) at 250 mg/m(2). None of the eight patients treated with HAI paclitaxel 225 mg/m(2) experienced a DLT. The most common toxicities were nausea and peripheral neuropathy. Of 22 patients evaluable for response, 3 (13.6%) patients had SD for ≥4 months (colorectal cancer, n = 1; thyroid cancer, n = 1; and hepatocellular carcinoma, n = 1; duration of response was 4 months, 7.1 months, and 22.2+ months, respectively).

CONCLUSION

The MTD of HAI paclitaxel was 225 mg/m(2). This regimen was well tolerated and had antitumor activity in selected patients.

A phase 1 study of hepatic arterial infusion of oxaliplatin in combination with systemic 5-fluorouracil, leucovorin, and bevacizumab in patients with advanced solid tumors metastatic to the liver

BACKGROUND

Liver metastases in patients with cancer are associated with poor survival. The authors of this report conducted a phase 1 study of hepatic arterial infusion (HAI) oxaliplatin combination therapy in patients with advanced cancer and liver metastases.

METHODS

Treatment consisted of escalating doses of HAI oxaliplatin 60 mg/m(2) to 175 mg/m(2) and intra-arterial heparin 3000 IU (Day 1); leucovorin 200 mg/m(2) intravenously (iv) and 5-fluorouracil 300 mg/m(2) bolus plus 600 mg/m(2) iv (Days 1 and 2); and bevacizumab 10 mg/kg iv (Day 3). A conventional "3 + 3" design was used.

RESULTS

Fifty-seven patients were treated, including 30 women and 27 men. The median age was 57 years, and the patients had received a median of 3 prior therapies (range, 1-7 prior therapies). The most common cancer was colorectal (n = 29). Overall, 204 cycles were administered (median per patient, 2 cycles; range, 1-17 cycles). The maximum tolerated dose (MTD) of HAI oxaliplatin was 140 mg/m(2). Dose-limiting toxicities were grade 4 thrombocytopenia (n = 1) and grade 4 hypokalemia (n = 1) at 150 mg/m(2) (n = 5). Thirty-three patients (58%) had no toxicity greater than grade 1. The most common toxicities were thrombocytopenia (n = 19), fatigue (n = 15), nausea/vomiting (n = 6), constipation (n = 6), and diarrhea (n = 4). Of 55 patients who were evaluable for response (according to Response Evaluation Criteria in Solid Tumors), 4 patients (7%) had a partial response (PR), and 32 patients (58%) had stable disease (SD), including 15 patients (48%) who had SD for >/=4 months. Of 28 patients with colorectal cancer, 3 patients (11%) had a PR, and 9 patients (32%) had SD for >/=4 months.

CONCLUSIONS

HAI oxaliplatin combined with systemic 5-fluorouracil, leucovorin, and bevacizumab had antitumor activity in patients with advanced cancer and liver metastases, and the current results indicated that this combination warrants further study. Cancer 2010. (c) 2010 American Cancer Society.

Role of FDG-PET/CT in detection of recurrent disease in colorectal cancer

BACKGROUND

One-third of patients with colorectal cancer (CRC) are likely to have a recurrence within the first 1-2 years. Conventional imaging modalities have limitations in detecting recurrent disease early. The purpose of this study was to assess the usefulness of fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in the detection of recurrence in patients with CRCs.

METHODS

One hundred and eighty-three patients, who were earlier treated with surgery and/or chemotherapy/radiotherapy, underwent 269 PET/CT studies for the detection of recurrence. The final diagnosis was made on the basis of histological analysis or clinical and imaging follow-up.

RESULTS

The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value in detecting recurrent CRC using F-FDG-PET/CT were 87, 90, 88, 93, and 80%, respectively. PET/CT was found to have limitations in detecting microscopic disease and small-sized lesions. The common cause of false-positive PET/CT results was infective and inflammatory pathology in our setup.

CONCLUSION

PET/CT showed high sensitivity, specificity, and accuracy for the detection of recurrent disease in patients, who were earlier treated for CRC. PET/CT can be considered as a useful diagnostic tool in these patients.

Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone in unresectable, chemotherapy refractory colorectal liver metastases

BACKGROUND

This multi-centre phase II clinical trial is the first prospective evaluation of radioembolisation of patients with colorectal liver metastases (mCRC) who failed previous oxaliplatin- and irinotecan-based systemic chemotherapy regimens.

METHODS

Eligible patients had adequate hepatic, haemopoietic and renal function, and an absence of major hepatic vascular anomalies and hepato-pulmonary shunting. Gastroduodenal and right gastric arteries were embolised before hepatic arterial administration of yttrium-90 resin microspheres (median activity, 1.7 GBq; range, 0.9-2.2).

RESULTS

Of 50 eligible patients, 38 (76%) had received > or =4 lines of chemotherapy. Most presented with synchronous disease (72%), >4 hepatic metastases (58%), 25-50% replacement of total liver volume (60%) and bilateral spread (70%). Early and intermediate (>48 h) WHO G1-2 adverse events (mostly fever and pain) were observed in 16 and 22% of patients respectively. Two died due to renal failure at 40 days or liver failure at 60 days respectively. By intention-to-treat analysis using Response Evaluation Criteria in Solid Tumours, 1 patient (2%) had a complete response, 11 (22%) partial response, 12 (24%) stable disease, 22 (44%) progressive disease; 4 (8%) were non-evaluable. Median overall survival was 12.6 months (95% CI, 7.0-18.3); 2-year survival was 19.6%.

CONCLUSION

Radioembolisation produced meaningful response and disease stabilisation in patients with advanced, unresectable and chemorefractory mCRC.

Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy

PURPOSE

Liver dissemination is a major cause of mortality among patients with advanced colorectal cancer. Hepatic intra-arterial injection of the beta-emitting isotope yttrium-90 ((90)Y) bound to resin microspheres (radioembolization) delivers therapeutic radiation doses to liver metastases with minimal damage to adjacent tissues.

PATIENTS AND METHODS

We conducted a prospective, multicenter, randomized phase III trial in patients with unresectable, chemotherapy-refractory liver-limited metastatic CRC (mCRC) comparing arm A (fluorouracil [FU] protracted intravenous infusion 300 mg/m(2) days 1 through 14 every 3 weeks) and arm B (radioembolization plus intravenous FU 225 mg/m(2) days 1 through 14 then 300 mg/m(2) days 1 through 14 every 3 weeks) until hepatic progression. The primary end point was time to liver progression (TTLP). Cross-over to radioembolization was permitted after progression in arm A.

RESULTS

Forty-six patients were randomly assigned and 44 were eligible for analysis (arm A, n = 23; arm B, n = 21). Median follow-up was 24.8 months. Median TTLP was 2.1 and 5.5 months in arms A and B, respectively (hazard ratio [HR] = 0.38; 95% CI, 0.20 to 0.72; P = .003). Median time to tumor progression (TTP) was 2.1 and 4.5 months, respectively (HR = 0.51; 95% CI, 0.28 to 0.94; P = .03). Grade 3 or 4 toxicities were recorded in six patients after FU monotherapy and in one patient after radioembolization plus FU treatment (P = .10). Twenty-five of 44 patients received further treatment after progression, including 10 patients in arm A who received radioembolization. Median overall survival was 7.3 and 10.0 months in arms A and B, respectively (HR = 0.92; 95% CI, 0.47 to 1.78; P = .80).

CONCLUSION

Radioembolization with (90)Y-resin microspheres plus FU is well tolerated and significantly improves TTLP and TTP compared with FU alone. This procedure is a valid therapeutic option for chemotherapy-refractory liver-limited mCRC.

Thermoablation of colorectal liver metastasis

Thermoablation is a local therapy that is effective in in situ destruction of colorectal liver metastasis while preserving surrounding normal liver tissue. It is less invasive compared to surgery, easy to use, and can be repeated. The therapy provides local control of unresectable disease and is an alternative therapy for small resectable lesions in patients with insufficient hepatic reserve after resection or coexistent comorbid conditions. It can artificially increase the resection margin thus increasing the number of patient candidate for resection. When used in conjunction with liver resection it clears the liver of multiple lesions that are surgically inaccessible or unresectable. Main limitations of the treatment are local recurrence of the disease, treatment-related complications, and questionable impact on patient. Outcome of therapy can be improved when used as part of multimodality treatment.