Liver resection for colorectal metastases: the third hepatectomy

Recurrent Colorectal Liver Metastases: Upfront Local Treatment versus Neoadjuvant Systemic Therapy Followed by Local Treatment (COLLISION RELAPSE): Study Protocol of a Phase III Prospective Randomized Controlled Trial

PURPOSE

The objective of the COLLISION RELAPSE trial is to prove or disprove superiority of neoadjuvant systemic therapy followed by repeat local treatment (either thermal ablation and/or surgical resection), compared to repeat local treatment alone, in patients with at least one recurrent locally treatable CRLM within one year and no extrahepatic disease.

METHODS

A total of 360 patients will be included in this phase III, multicentre randomized controlled trial. The primary endpoint is overall survival. Secondary endpoints are distant progression-free survival, local tumour progression-free survival analysed per patient and per tumour, systemic therapy-related toxicity, procedural morbidity and mortality, length of hospital stay, pain assessment and quality of life, cost-effectiveness ratio and quality-adjusted life years.

DISCUSSION

If the addition of neoadjuvant systemic therapy to repeat local treatment of CRLM proves to be superior compared to repeat local treatment alone, this may lead to a prolonged life expectancy and increased disease-free survival at the cost of possible systemic therapy-related side effects.

LEVEL OF EVIDENCE

Level 1, phase III randomized controlled trial.

TRIAL REGISTRATION

NCT05861505. May 17, 2023.

Preoperative IL-8 levels as prognostic indicators of overall survival: an extended follow-up in a prospective cohort with colorectal liver metastases

INTRODUCTION

CRC with liver metastases is a major contributor to cancer-related mortality. Despite advancements in liver resection techniques, patient survival remains a concern due to high recurrence rates. This study seeks to uncover prognostic biomarkers that predict overall survival in patients undergoing curative hepatic resection for CRC liver metastases.

METHODS

Prospectively collected serum samples from a cohort of 49 patients who received curative hepatic resection for CRC liver metastases were studied. The patients are part of a cohort, previously analyzed for perioperative complications (see methods). Various preoperative serum markers, clinical characteristics, and factors were analyzed. Univariate and multivariate Cox regression analyses were conducted to determine associations between these variables and disease-free survival as well as overall survival.

RESULTS

For disease-free survival, univariate analysis highlighted the correlation between poor outcomes and advanced primary tumor stage, high ASA score, and synchronous liver metastases. Multivariate analysis identified nodal-positive primary tumors and synchronous metastases as independent risk factors for disease-free survival. Regarding overall survival, univariate analysis demonstrated significant links between poor survival and high preoperative IL-8 levels, elevated neutrophil-lymphocyte ratio (NLR), and presence of metastases in other organs. Multivariate analysis confirmed preoperative IL-8 and having three or more liver metastases as independent risk factors for overall survival. The impact of IL-8 on survival was particularly noteworthy, surpassing the influence of established clinical factors.

CONCLUSION

This study establishes preoperative IL-8 levels as a potential prognostic biomarker for overall survival in patients undergoing curative liver resection for CRC liver metastases. This study underscores the importance of incorporating IL-8 and other biomarkers into clinical decision-making, facilitating improved patient stratification and tailored treatment approaches. Further research and validation studies are needed to solidify the clinical utility of IL-8 as a prognostic marker.

Multimodal Management of Colorectal Liver Metastases: State of the Art

Liver is the most common site of colorectal cancer (CRC) metastases. Treatment of CRC liver metastases (CRLM) includes different strategies, prevalently based on the clinical and oncological intent. Valid approaches in liver-limited or liver-prevalent disease include surgery, percutaneous ablative procedures (radiofrequency ablation, microwave ablation), intra-arterial perfusional techniques (chemo-embolization, radio-embolization) as well as stereotactic radiotherapy. Systemic treatments, including chemotherapy, immunotherapy and other biological agents, are the only options for patients with no chance of locoregional approaches. The use of chemotherapy in other settings, such as neoadjuvant, adjuvant or conversion therapy of CRLM, is commonly accepted in the clinical practice, although data from several clinical trials have been mostly inconclusive. The optimal integration of all these strategies, when applicable and clinically indicated, should be ever considered in patients affected by CRLM based on clinical evidence and multidisciplinary experience. Here we revised in detail all the possible therapeutic approaches of CRLM focusing on the current evidences, the studies still in progress and the often contradictory data.

Value and prognostic factors of repeat hepatectomy for recurrent colorectal liver metastasis

BACKGROUND

More than 50% of patients with colorectal cancer develop liver metastases. Hepatectomy is the preferred treatment for resectable liver metastases. This review provides a perspective on the utility and relevant prognostic factors of repeat hepatectomy in recurrent colorectal liver metastasis (CRLM).

DATA SOURCES

The keywords "recurrent colorectal liver metastases", "recurrent hepatic metastases from colorectal cancer", "liver metastases of colorectal cancer", "repeat hepatectomy", "repeat hepatic resection", "second hepatic resection", and "prognostic factors" were used to retrieve articles published in the PubMed database up to August 2020. Additional articles were identified by a manual search of references from key articles.

RESULTS

Despite improvements in surgical methods and perioperative chemotherapy, recurrence remains common in 37%-68% of patients. Standards or guidelines for the treatment of recurrent liver metastases are lacking. Repeat hepatectomy appears to be the best option for patients with resectable metastases. The commonly reported prognostic factors after repeat hepatectomy were R0 resection, carcinoembryonic antigen level, the presence of extrahepatic disease, a short disease-free interval between initial and repeat hepatectomy, the number (> 1) and size (≥ 5 cm) of hepatic lesions, requiring blood transfusion, and no adjuvant chemotherapy after initial hepatectomy. The median overall survival after repeat hepatectomy ranged from 19.3 to 62 months, and the 5-year overall survival ranged from 21% to 73%. Chemotherapy can act as a test for the biological behavior of tumors with the goal of avoiding unnecessary surgery, and a multimodal approach involving aggressive chemotherapy and repeat hepatectomy might be the treatment of choice for patients with early recurrent CRLM.

CONCLUSIONS

Repeat hepatectomy is a relatively safe and effective treatment for resectable recurrent CRLM. The presence or absence of prognostic factors might facilitate patient selection to improve short- and long-term outcomes.

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.

Tumor biology reflected by histological growth pattern is more important than surgical margin for the prognosis of patients undergoing resection of colorectal liver metastases

INTRODUCTION

The histological growth pattern (HGP) of colorectal liver metastases (CRLMs) reflects tumor biology and local infiltrating behavior. In patients undergoing surgery for CRLMs, we investigated whether HGP and surgical margin status interact when influencing prognosis.

METHODS

Clinicopathological data, margin status, and HGP were reviewed in patients who underwent resection of CRLMs. R1 margin was defined when cancer cells were present at any point along the margin. HGPs were scored according to international guidelines, identifying patients with desmoplastic (DHGP) or non-desmoplastic (non-DHGP) CRLMs.

RESULTS

Among 299 patients, 16% had R1 resection and 81% had non-DHGP CRLMs. Non-DHGP was the only predictive factor for R1 resection (18.7% versus 7.4% in DHGP, p = 0.04). Poorer 5-year overall survival was observed in both R1 and non-DHGP groups in univariate analysis (27.6% in R1 versus 45.6% in R0, p = 0.026, and 37.2% in non-DHGP versus 59.2% in DHGP, p = 0.013), whereas non-DHGP but not R1 remained associated with worse prognosis in multivariate analysis. In patients with non-DHGP, R1 margin has no prognostic impact.

CONCLUSIONS

In patients undergoing resection of CRLMs, the prognostic value of poor tumor biology, such as in patients with non-DHGP, exceeds that of surgical radicality.

Cancer: slaying the nine-headed Hydra

Modern medicine continues to evolve, and the treatment armamentarium for various diseases grows more individualized across a breadth of medical disciplines. Cure rates for infectious diseases that were previously pan-fatal approach 100% because of the identification of the specific pathogen(s) involved and the use of appropriate combinations of drugs, where needed, to completely extinguish infection and hence prevent emergence of resistant strains. Similarly, with the assistance of technologies such as next-generation sequencing and immunomic analysis as part of the contemporary oncology armory, therapies can be tailored to each tumor. Importantly, molecular interrogation has revealed that metastatic cancers are distinct from each other and complex. Therefore, it is conceivable that rational personalized drug combinations will be needed to eradicate cancers, and eradication will be necessary to mitigate clonal evolution and resistance.

How to do repeat hepatectomy for remnant liver recurrence using diaphragmatic incision for right liver mobilization

In addition to difficulties with parenchymal resection reflecting anatomic disorientation arising from rotation of the liver remnant that accompanies regeneration, repeat resections typically involve difficult and protracted lysis of adhesions. We describe our technique for facilitating right liver mobilization even in the presence of severe adhesions. Lysis of dense retroperitoneal adhesions posterior to the right liver can be performed safely by incising the diaphragm to facilitate manipulations to mobilize the right liver.

Survival by Number and Sites of Resections of Recurrence after First Curative Resection of Colorectal Liver Metastases

BACKGROUND

Recurrence after curative hepatectomy for colorectal liver metastases (CRLM) is common. We sought to determine if number and sites of resections of recurrence after hepatectomy for CRLM impact survival.

METHODS

The study included patients who underwent resection of recurrence following complete curative-intent resection of CRLM during 1998-2016 at two academic medical centers in Houston, USA, and Rome, Italy. The survival impacts of number and sites of resections of recurrence were evaluated. Patients with synchronous extrahepatic disease at curative CRLM resection were excluded.

RESULTS

Among 2163 patients who underwent curative hepatectomy, 1456 (67.3%) developed a recurrence. Four hundred seventy-eight patients underwent one (322/478; 67.4%) or two or more (156/478; 32.6%) resections of recurrence. The 5-year overall survival (OS) rate was higher in patients with resected than unresected recurrence (70.2% vs. 24.0%; p < 0.001). In patients who underwent only one resection of recurrence, the 5-year OS rate differed by location (lung, 81.6%; liver, 64.3%; other, 54.1%). In patients who underwent two or more resections of recurrence, the 5-year OS rate was similar for liver-only resection (87.5%) and resection of liver and other sites (66.1%) (p = 0.223) and for liver-only resection and other-sites-only resection (80.7%) (p = 0.258); 5-year OS rate by site of first resection of recurrence did not differ between liver (78.5%) and lung (81.8%) (p = 0.502) but was worse for other sites (61.1%) than for lung (p = 0.045).

CONCLUSION

When recurrence after initial CRLM resection is resectable, the ability to undergo resection was associated with improved survival and can be considered as an option regardless of the number of recurrence and resection. Sites of resection of recurrence impact survival and should be considered.

Reconsideration of indications for third hepatectomy for colorectal liver metastases

BACKGROUND

It is unclear which patients with recurrence after a second hepatectomy will benefit from a third hepatectomy.

METHODS

Patients who underwent hepatectomy for colorectal liver metastasis (CRLM) between April 2005 and July 2021 were included. Factors affecting recurrence after each hepatectomy were analyzed.

RESULTS

Sixty-four of the 167 patients who had recurrence after the first hepatectomy underwent a second hepatectomy. Then, 46 patients had recurrence and 18 patients did not have recurrence after the second hepatectomy. Sixteen patients who underwent a third hepatectomy had better overall survival (OS) than those who did not (52 vs. 31 months, p = 0.043). However, the multivariate analysis demonstrated that only tumor size (>5 cm) during the second hepatectomy (p = 0.022) and carbohydrate antigen 19-9 (CA 19-9) level (>50 U/ml) (p = 0.041) at recurrence after the second hepatectomy were poor prognostic factors for OS.

CONCLUSION

While a third hepatectomy can be performed if it is technically and oncologically appropriate, tumor size >5 cm and CA 19-9 >50 U/ml should be considered in terms of long-term outcomes before proceeding to surgery.

Repeated hepatic resection for colorectal liver metastases: is this concept safe and feasible?

Background

The beneficial outcomes of hepatectomy in patients with colorectal metastases have encouraged the attempts of repeated hepatectomy in patients with recurrent disease. Although studies have provided encouraging results regarding perioperative outcomes and survival rates following repeated hepatectomy, it remains unclear whether the reported outcomes reflect the therapeutic results of redo hepatectomy or rather reflect the effect of selection bias. The aim of this study was to investigate differences among patients who underwent single and repeated hepatectomy and to hereby identify prognostic factors that contribute to the premises of repeated resection.

Methods

Patients who underwent hepatectomy due to colorectal metastases were listed in a retrospective database. Study participants were divided into a single partial hepatectomy group, a multiple partial hepatectomies group, and into subgroups of two or more than two hepatectomies.

Results

A total of 338 patients with 439 partial liver resections were included in the analysis. The overall survival rate after 1, 3, and 5 years was 89%, 56%, and 36%, respectively. The survival benefit in patients who underwent multiple partial liver resections versus those with a single partial resection was 10%, 16%, and 4% after 1, 3, and 5 years, respectively. Repeated hepatectomy was not associated with increased rates of surgical and non-surgical complications.

Conclusion

Beneficial outcomes have been found in terms of median overall survival and perioperative morbidity in patients with recurrence of colorectal hepatic metastases after partial and tissue-sparing repeated liver resections.

SOULMATE: the Swedish study of liver transplantation for isolated colorectal cancer liver metastases not suitable for operation or ablation, compared to best established treatment-a randomized controlled multicenter trial

Background

Around one fourth of patients with colorectal cancer present themselves with distant metastases at the time of diagnosis, and one additional one fifth of the patients will develop distant metastases during the disease, most commonly in the liver.

Surgical treatment such as liver resection or ablation, often combined with chemotherapy and targeted therapy, is the only treatment option with curative potential, but only about 20% of the patients with liver metastases are candidates for surgical intervention. Standard treatment for unresectable patients is palliative oncological therapy; however, less than 10% of these patients will achieve a 5-year survival.

Non-randomized studies indicate that liver transplantation could be an option for selected patients with colorectal liver metastases (CRLM), which are not suitable for operation or ablation due to surgical technical reasons such as massive tumor burden and small future liver remnant, or oncological reasons, for example, early relapse after liver surgery. Since there is a shortage of donated liver grafts, it is important to select the patient group that benefit most from the treatment. Although some studies present positive results from liver transplantation of CRLM, the results must be validated in a randomized controlled trial before this new indication for liver transplantation can be introduced as a clinical routine.

Methods

The SOULMATE study is a randomized study evaluating if liver transplantation with liver grafts, primarily from extended criteria donors, increases overall survival in patients with CRLM, not suitable for resection or ablation, in comparison with best established treatment.

Patients will be randomized to liver transplantation (LT)+ best established treatment (BET) or to best established treatment only.

In the SOULMATE trial, we will evaluate the use of livers from extended criteria donors to decrease the risk of prolonging waiting time for patients on the waiting list for LT.

Discussion

The SOULMATE study has the possibility to confirm the positive results of previous studies in a randomized setting. The use of extended criteria donors will make the results transferable globally, as most countries are struggling with organ shortage.

Trial registration

Clinical Trial number: NCT04161092 registered 13 November 2019.

Efficacy of laparoscopic repeat hepatectomy compared with open repeat hepatectomy: a single-center, propensity score matching study

Introduction

Laparoscopic repeat hepatectomy (LRH) is considered to be a technically challenging procedure which has not been widely applied. This study aimed to assess the accessibility and security of LRH for patients with hepatic tumor recurrence.

Methods

Between January 2010 and October 2020, we performed 48 LRHs and 31 open repeat hepatectomies (ORHs) for recurrent liver cancer. LRHs were matched to ORHs (1:1) using propensity score matching (PSM) created by comparing preoperative factors. The perioperative data of patients were retrospectively analyzed, including baseline data, operative time, intraoperative blood loss, pathology, days of postoperative stay, complication morbidity, and mortality within 30 days. Overall survival and recurrence-free survival rates with appropriate follow-up were obtained to evaluate the long-term outcomes.

Results

Compared with the ORH, LRH was related with shorter operative duration (169.9 versus 232.9 ml, p < 0.01), less intraoperative bleeding (100.0 versus 500.0 ml, p < 0.01), lower rate of blood transfusion (8.3% versus 58.1%, p < 0.01), and shorter hospitalization (5.0 versus 11.0 days, p < 0.01). The median follow-up was 31 months. The LRH 1-, 3-, and 5-year overall survival were 77.1%, 61.6%, and 46.2% versus 82.3%, 66.5%, and 29.5% for ORH (p = 0.77). The 1-, 3-, and 5-year disease-free survival rates of the two groups were 73.4%, 62.0%, and 44.3% versus 66.1%, 44.1%, and 14.7%, respectively (p = 0.22).

Conclusions

Laparoscopic repeated hepatectomy is safe and practicable with great short-term results for selected patients.

Repeat Resection for Advanced Colorectal Liver Metastases-Does it have the Potential for Cure?

BACKGROUND

Although surgical resection is the only potential treatment for patients with colorectal liver metastases (CLM), the actual cure is rare in patients with advanced CLM. Repeat resection (RR) is the most effective treatment in patients with recurrence; however, whether patients with initially advanced CLM achieve cure throughout RR or experience repeated recurrence even after RR remains unclear. In this study, we analyzed whether patients with advanced CLM achieve cure after RR.

METHODS

Consecutive patients who underwent initial hepatectomy with curative intent for CLM from January 1999 to August 2007 were included. Patients who were alive at 10 years from the initial hepatectomy without any evidence of recurrence were defined as cured. Cure rates were compared between patients with Fong's clinical risk score (CRS) of ≥ 3 and those with CRS of ≤ 2.

RESULTS

A total of 257 patients were included and followed up. Among them, 93 (36.2%) patients achieved actual cure postoperatively. The cure rate of patients with a CRS of ≥ 3 was 32.4% (33/102), which was not different from that of patients with a CRS of ≤ 2 (38.7% [60/155]; p = 0.299), although former patients had higher recurrence rate after the initial hepatectomy than latter ones (85.3% vs. 72.3%; p = 0.014). The cure rates after the initial, second, and third resections were 23.0% (59/257), 30.0% (24/80), and 22.5% (7/31), respectively. In multivariate analysis, RR was determined as an independent favorable factor of achieving cure.

CONCLUSIONS

RR had a potential to cure patients with advanced CLM, and one-third of them achieved cure.

Improved sensitivity and positive predictive value of contrast-enhanced intraoperative ultrasound in colorectal cancer liver metastasis: a systematic review and meta-analysis

BACKGROUND

Surgery is an effective treatment for improving the survival rate of patients with colorectal cancer liver metastases (CRLM). However, accurately determining the resection margin of liver lesions during surgery remains challenging. Therefore, this study aimed to evaluate the sensitivity and predictive value of intraoperative contrast-enhanced ultrasound (CE-IOUS) in CRLM patients undergoing surgery.

METHODS

We performed a literature search of the PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu databases using the following search terms: metastatic liver cancer, colorectal cancer, sensitivity, contrast-enhanced intraoperative ultrasound, CE-IOUS, colorectal liver metastases, and CRLM. The search period was set from the date of establishment of the database to September 2021. Quality assessment of diagnostic accuracy studies 2 (QUADAS-2) recommended by the Cochrane Collaboration was used to assess the methodological quality of the included studies, and network meta-analysis was performed using Stata 15.0 software.

RESULTS

A total of 10 articles met the inclusion criteria. The meta-analysis results showed that the overall sensitivity and specificity of CE-IOUS were 0.96 [95% confidence interval (CI), 0.95-0.97] and 0.75 (95% CI, 0.70-0.80), respectively. The overall sensitivity and specificity of IOUS were 0.84 (95% CI, 0.82-0.86) and 0.82 (95% CI, 0.77-0.87), respectively. The area under the summary receiving operating characteristic (SROC) curves (AUCs) of CE-IOUS and IOUS were 0.9753 and 0.8590, respectively. The odds ratio (OR) and 95% CI of CE-IOUS changed the surgical margin were 0.205 and 0.071-0.465, P=0.000, the difference was statistically significant.

DISCUSSION

Based on the results of this meta-analysis, CE-IOUS improved the sensitivity and predictive value of CRLM detection compared with IOUS, and is more suitable for intraoperative planning of surgical margins. At present, it is the most sensitive imaging method available, and is recommended for use during liver resection to provide doctors with more reliable information during surgery.

Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature

Recurrence following curative-intent hepatectomy for colorectal cancer liver metastasis, hepatocellular carcinoma, or cholangiocarcinoma is unfortunately common with a reported incidence as high as 75%. Various treatment modalities can improve survival following disease recurrence. A review of the literature was performed using PubMed. In addition to systemic therapy, liver-directed treatment options for recurrent liver disease include repeat hepatectomy, salvage liver transplantation, radiofrequency or microwave ablation, intra-arterial therapy, and stereotactic body radiation therapy. Repeat resection can be consider for patients with limited recurrent disease that meets resection criteria, as this therapeutic approach can provide a survival benefit and is potentially curative in a subset of patients. Salvage liver transplantation for recurrent hepatocellular carcinoma is another option, which has been associated with a 5-year survival of 50%. Salvage transplantation may be an option in particular for patients who are not candidates for resection due to underlying liver dysfunction but meet criteria for transplantation. Ablation is another modality to treat patients who recur with smaller tumors and are not surgical candidates due to comorbidity, liver dysfunction, or tumor location. For patients with inoperable disease, transarterial chemoembolization, or radioembolization with Yttrium-90 are liver-directed intra-arterial therapy modalities with relatively low risks that can be utilized. Stereotactic body radiation therapy is another palliative treatment option that can provide a response and local tumor control for smaller tumors.

Patient-centered developments in colon- and rectal cancer with a multidisciplinary international team: From translational research to national guidelines

Rarely, scientific developments centered around the patient as a whole are published. Our multidisciplinary group, headed by gastrointestinal surgeons, applied this research philosophy considering the most important aspects of the diseases “colon- and rectal cancer” in the long-term developments. Good expert cooperation/knowledge at the Comprehensive Cancer Center Ulm (CCCU) were applied in several phase III trials for multimodal treatments of primary tumors (MMT) and metastatic diseases (involving nearly 2000 patients and 64 centers), for treatment individualization of MMT and of metastatic disease, for psycho-oncology/quality of life involving the patients’ wishes, and for disease prevention. Most of the targets initially were heavily rejected/discussed in the scientific communities, but now have become standards in treatments and national guidelines or are topics in modern translational research protocols involving molecular biology for e.g., “patient centered individualized treatment”. In this context we also describe the paths we had to tread in order to realize our new goals, which at the end were highly beneficial for the patients from many points of view. This description is also important for students and young researchers who, with an actual view on our recent developments, might want to know how medical progress was achieved.

Repeat Local Treatment of Recurrent Colorectal Liver Metastases, the Role of Neoadjuvant Chemotherapy: An Amsterdam Colorectal Liver Met Registry (AmCORE) Based Study

This cohort study aimed to evaluate efficacy, safety, and survival outcomes of neoadjuvant chemotherapy (NAC) followed by repeat local treatment compared to upfront repeat local treatment of recurrent colorectal liver metastases (CRLM). A total of 152 patients with 267 tumors from the prospective Amsterdam Colorectal Liver Met Registry (AmCORE) met the inclusion criteria. Two cohorts of patients with recurrent CRLM were compared: patients who received chemotherapy prior to repeat local treatment (32 patients) versus upfront repeat local treatment (120 patients). Data from May 2002 to December 2020 were collected. Results on the primary endpoint overall survival (OS) and secondary endpoints local tumor progression-free survival (LTPFS) and distant progression-free survival (DPFS) were reviewed using the Kaplan-Meier method. Subsequently, uni- and multivariable Cox proportional hazard regression models, accounting for potential confounders, were estimated. Additionally, subgroup analyses, according to patient, initial and repeat local treatment characteristics, were conducted. Procedure-related complications and length of hospital stay were compared using chi-square test and Fisher's exact test. The 1-, 3-, and 5-year OS from date of diagnosis of recurrent disease was 98.6%, 72.5%, and 47.7% for both cohorts combined. The crude survival analysis did not reveal a significant difference in OS between the two cohorts (p = 0.834), with 1-, 3-, and 5-year OS of 100.0%, 73.2%, and 57.5% for the NAC group and 98.2%, 72.3%, and 45.3% for the upfront repeat local treatment group, respectively. After adjusting for two confounders, comorbidities (p = 0.010) and primary tumor location (p = 0.023), the corrected HR in multivariable analysis was 0.839 (95% CI, 0.416-1.691; p = 0.624). No differences between the two cohorts were found with regards to LTPFS (HR = 0.662; 95% CI, 0.249-1.756; p = 0.407) and DPFS (HR = 0.798; 95% CI, 0.483-1.318; p = 0.378). No heterogeneous treatment effects were detected in subgroup analyses according to patient, disease, and treatment characteristics. No significant difference was found in periprocedural complications (p = 0.843) and median length of hospital stay (p = 0.600) between the two cohorts. Chemotherapy-related toxicity was reported in 46.7% of patients. Adding NAC prior to repeat local treatment did not improve OS, LTPFS, or DPFS, nor did it affect periprocedural morbidity or length of hospital stay. The results of this comparative assessment do not substantiate the routine use of NAC prior to repeat local treatment of CRLM. Because the exact role of NAC (in different subgroups) remains inconclusive, we are currently designing a phase III randomized controlled trial (RCT), COLLISION RELAPSE trial, directly comparing upfront repeat local treatment (control) to neoadjuvant systemic therapy followed by repeat local treatment (intervention).

Perspectives for circulating tumor DNA in clinical management of colorectal cancer

Growing evidence has demonstrated that circulating tumor DNA (ctDNA) detection in colorectal cancer might be a promising approach to address current important clinical questions. During chemotherapy for metastatic colorectal cancer, tumor cells acquire potential resistance by generating additional somatic mutations related to therapeutic resistance. ctDNA can capture the tumor landscape, including heterogeneity, which might provide the opportunity for additional treatment options. Moreover, ctDNA detection is advantageous, because it can monitor tumor heterogeneity serially, in a non-invasive manner. ctDNA is considered valid for detecting minimal residual disease after a curable resection. By utilizing ctDNA detection, adjuvant chemotherapy for patients with stage II-III colorectal cancer might be omitted for patients at low risk of recurrence; or conversely, adjuvant chemotherapy might be highly recommended for patients at high risk, based on ctDNA findings. During multidisciplinary treatments for locally advanced rectal cancer, it is essential to monitor the responses to sequential treatments to make appropriate decisions. Currently, these decisions are mainly based on radiological or pathological findings. ctDNA can add value by providing the real-time status of locally advanced rectal cancer. In this review, we summarized the current evidence and discussed future strategies for using ctDNA in the treatment of colorectal cancer.

The current understanding on the impact of KRAS on colorectal cancer

KRAS (kirsten rat sarcoma viral oncogene) is a member of the RAS family. KRAS mutations are one of most dominant mutations in colorectal cancer (CRC). The impact of KRAS mutations on the prognosis and survival of CRC patients drives many research studies to explore potential therapeutics or target therapy for the KRAS mutant CRC. This review summarizes the current understanding of the pathological consequences of the KRAS mutations in the development of CRC; and the impact of the mutations on the response and the sensitivity to the current front-line chemotherapy. The current therapeutic strategies for treating KRAS mutant CRC, the difficulties and challenges will also be discussed.

Early Recurrence After Initial Hepatectomy for Colorectal Liver Metastases

Objective

This study investigated the frequency of early recurrence in patients who had undergone hepatectomy for colorectal cancer liver metastasis (CRLM) and assessed the indications for adjuvant chemotherapy in these patients.

Methods

This retrospective analysis included 133 consecutive patients who underwent initial hepatectomy for CRLM between April 2000 and May 2010 and have been followed more than 5 years.

Results

Of the 133 patients, 83 (62%) experienced tumor recurrence, with 14 of the 83 recurrences within 6 months after initial hepatectomy. Overall survival was significantly poorer in patients with recurrences within 6 months than those without any recurrence (P = 0.015). The frequency of adjuvant chemotherapy was significantly lower in patients with recurrences within 6 months than those without recurrences within 6 months. Multivariate analysis showed that H-2 classification was the only independent risk factor for recurrence within 6 months after hepatectomy (P = 0.002). Adjuvant chemotherapy improved prognosis in patients classified as H2.

Conclusions

Patients who experienced tumor recurrence within 6 months after initial hepatectomy for CRLM had a poorer prognosis than patients who experienced recurrence after 6 months. Patients with H2-classification of CRLM should receive preoperative adjuvant chemotherapy.

The Role of Neoadjuvant Chemotherapy in Repeat Local Treatment of Recurrent Colorectal Liver Metastases: A Systematic Review and Meta-Analysis

The additive value of neoadjuvant chemotherapy (NAC) prior to repeat local treatment of patients with recurrent colorectal liver metastases (CRLM) is unclear. A systematic search was performed in PubMed, Embase, Web of Science, and an additional search in Google Scholar to find articles comparing repeat local treatment by partial hepatectomy and/or thermal ablation with versus without NAC. The search included randomized trials and comparative observational studies with univariate/multivariate analysis and/or matching as well as (inter)national guidelines assessed using the AGREE II instrument. The search identified 21,832 records; 172 were selected for full-text review; 20 were included: 20 comparative observational studies were evaluated. Literature to evaluate the additive value of NAC prior to repeat local treatment was limited. Outcomes of NAC were often reported as subgroup analyses and reporting of results was frequently unclear. Assessment of the seven studies that qualified for inclusion in the meta-analysis showed conflicting results. Only one study reported a significant difference in overall survival (OS) favoring NAC prior to repeat local treatment. However, further analysis revealed a high risk for residual bias, because only a selected group of chemo-responders qualified for repeat local treatment, disregarding the non-responders who did not qualify. All guidelines that specifically mention recurrent disease (3/3) recommend repeat local treatment; none provide recommendations about the role of NAC. The inconclusive findings of this meta-analysis do not support recommendations to routinely favor NAC prior to repeat local treatment. This emphasizes the need to investigate the additive value of NAC prior to repeat local treatment of patients with recurrent CRLM in a future phase 3 randomized controlled trial (RCT).

Multimodal Treatment in Metastatic Colorectal Cancer (mCRC) Improves Outcomes-The University College London Hospital (UCLH) Experience

BACKGROUND

Despite notable advances in the management of metastatic colorectal cancer (mCRC) over the last two decades, treatment intent in the vast majority of patients remains palliative due to technically unresectable disease, extensive disease, or co-morbidities precluding major surgery. Up to 30% of individuals with mCRC are considered potentially suitable for primary or metastasis-directed multimodal therapy, including surgical resection, ablative techniques, or stereotactic radiotherapy (RT), with the aim of improving survival outcomes. We reviewed the potential benefits of multimodal therapy on the survival of patients with mCRC treated at the UCLH.

METHODS

Clinical data on baseline characteristics, multimodal treatments, and survival outcomes were retrospectively collected from all patients with mCRC receiving systemic chemotherapy between January 2013 and April 2017. Primary outcome was the impact of multimodal therapy on overall survival, compared to systemic therapy alone, and the effect of different types of multimodal therapy on survival outcome, and was assessed using the Kaplan-Meier approach. All analyses were adjusted for age, gender, and side of primary tumour.

RESULTS

One-hundred and twenty-five patients with mCRC were treated during the study period (median age: 62 years (range 19-89). The liver was the most frequent metastatic site (78%; 97/125). A total of 52% (65/125) had ≥2 lines of systemic chemotherapy. Of the 125 patients having systemic chemotherapy, 74 (59%) underwent multimodal treatment to the primary tumour or metastasis. Median overall survival (OS) was 25.7 months [95% Confidence Interval (CI) 21.5-29.0], and 3-year survival, 26%. Univariate analysis demonstrated that patients who had additional procedures (surgery/ablation/RT) were significantly less likely to die (Hazard Ratio (HR) 0.18, 95% CI 0.12-0.29, p < 0.0001) compared to those receiving systemic chemotherapy alone. Increasing number of multimodal procedures was associated with an incremental increase in survival-with median OS 28.4 m, 35.7 m, and 64.8 m, respectively, for 1, 2, or ≥3 procedures (log-rank p < 0.0001). After exclusion of those who received systemic chemotherapy only (n = 51), metastatic resections were associated with improved survival (adjusted HR 0.36, 95% CI 0.20-0.63, p < 0.0001), confirmed in multivariate analysis. Multiple single-organ procedures did not improve survival.

CONCLUSION

Multimodal therapy for metastatic bowel cancer is associated with significant survival benefit. Resection/radical RT of the primary and resection of metastatic disease should be considered to improve survival outcomes following multidisciplinary team (MDT) discussion and individual assessment of fitness.

Integrative Concepts for Liver Surgery

BACKGROUND

Surgery is the standard treatment for primary tumors and metastases. Due to improvements in surgical outcomes as well as the efficacy of systemic treatments, the role of surgery has changed in recent years.

SUMMARY

Liver surgery has become safe and efficient, with resectability being increased by multimodality concepts as well as staged liver resections and orthotopic liver transplantation. These concepts may be applied to primary liver tumors but also to selected patients with liver metastases from various diseases. In addition, even debulking surgery may be indicated for selected patients with endocrine metastases. While patient selection for liver resections was limited to clinical parameters in the past, histological and molecular characteristics have become increasingly important. Moreover, the response to regional or systemic chemotherapy has been demonstrated to be strong for a beneficial course of the disease even in advanced diseases.

KEY-MESSAGES

Due to the variety of available treatment options, optimal patient selection is crucial. Besides liver surgery, staged concepts as well as liver transplantation are curative tools for many patients.

Multidisciplinary treatment for colorectal liver metastases in elderly patients

BACKGROUND

Limited data describe the therapeutic practice and outcomes of colorectal liver metastases (CRLMs) in elderly patients. We aimed to evaluate the impact of age on multidisciplinary treatment for CRLMs.

METHODS

We reviewed treatment and outcomes for patients in different age groups who underwent initial hepatectomy for CRLMs from 2004 through 2012.

RESULTS

We studied 462 patients who were divided into three groups by age: ≤ 64 years (n = 265), 65-74 years (n = 151), and ≥ 75 years (n = 46). The rate of major hepatectomy and incidence of postoperative complications did not differ between groups. Adjuvant chemotherapy was used less in the ≥ 75-year group (19.6%) than that in the ≤ 64 (54.3%) or 65-74 age group (43.5%). Repeat hepatectomy for liver recurrence was performed less in the ≥ 75-year group (35%) than in the ≤ 64 (57%) or 65-74 (66%) age group. The 5-year disease-specific survival (DSS) rate of 44.2% in the ≥ 75-year group was lower than in the ≤ 64 (59.0%) or 65-74 (64.7%) age group. Multivariate analysis revealed age ≥ 75 years was an independent predictor of poor DSS.

CONCLUSIONS

Liver resection for CRLMs can be performed safely in elderly patients. However, repeat resection for recurrence are performed less frequently in the elderly, which may lead to the poorer disease-specific prognosis.

Predicting liver metastases growth patterns: Current status and future possibilities

Colorectal cancer is highly incident worldwide and presents a health burden with elevated mortality rate despite prevention, detection, and treatment, mainly due to metastatic liver disease. Histological growth patterns of colorectal cancer liver metastases have emerged as a reproducible prognostic factor, with biological implications and therapeutic windows. Nonetheless, the histological growth patterns of colorectal cancer liver metastases are only known after pathological examination of a liver resection specimen, thus limiting the possibilities of pre-surgical decision. Predicting the histological growth pattern of colorectal cancer liver metastases would provide valuable information for patient-tailored medicine. In this article, we perform a review of the histological growth patterns and their implications, with a focus on the possibilities for their prediction.

Stereotactic body radiotherapy (SBRT) can delay polymetastatic conversion in patients affected by liver oligometastases

PURPOSE

SBRT demonstrated to increase survival in oligometastatic patients. Nevertheless, little is known regarding the natural history of oligometastatic disease (OMD) and how SBRT may impact the transition to the polymetastatic disease (PMD).

METHODS

97 liver metastases in 61 oligometastatic patients were treated with SBRT. Twenty patients (33%) had synchronous oligometastases, 41 (67%) presented with metachronous oligometastases. Median number of treated metastases was 2 (range 1-5).

RESULTS

Median follow-up was 24 months. Median tPMC was 11 months (range 4-17 months). Median overall survival (OS) was 23 months (range 16-29 months). Cancer-specific survival predictive factors were having further OMD after SBRT (21 months versus 15 months; p = 0.00), and local control of treated metastases (27 months versus 18 months; p = 0.031). Median PFS was 7 months (range 4-12 months). Patients with 1 metastasis had longer median PFS as compared to those with 2-3 and 4-5 metastases (14.7 months versus 5.3 months versus 6.5 months; p = 0.041). At the last follow-up, 50/61 patients (82%) progressed, 16 of which (26.6%) again as oligometastatic and 34 (56%) as polymetastatic.

CONCLUSION

In the setting of oligometastatic disease, SBRT is able to delay the transition to the PMD. A proportion of patients relapse as oligometastatic and can be eventually evaluated for a further SBRT course. Interestingly, those patients retain a survival benefit as compared to those who had PMD. Further studies are needed to explore the role of SBRT in OMD and to identify treatment strategies able to maintain the oligometastatic state.

Repeat liver resection versus salvage liver transplant for recurrent hepatocellular carcinoma: A propensity score-adjusted and -matched comparison analysis

Backgrounds/Aims

Repeat liver resection (RLR) and salvage liver transplantation (SLT) are viable treatment options for recurrent hepatocellular carcinoma (HCC). With possibly superior survival outcomes than RLR, SLT is however, limited by liver graft availability and poses increased perioperative morbidity. In this study, we seek to compare the outcomes of RLR and SLT for patients with recurrent HCC.

Methods

Between 1999 and 2018, 94 and 16 consecutive patients who underwent RLR and SLT respectively were identified. Further retrospective subgroup analysis was conducted, comparing 16 RLR with 16 SLT patients via propensity-score matching.

Results

After propensity-score adjusted analyses, SLT demonstrated inferior short-term perioperative outcomes than RLR, with increased major morbidity (57.8% vs 5.4 %, p=0.0001), reoperations (39.1% vs 0, p<0.0001), renal insufficiency (30.1% vs 3%, p=0.0071), bleeding (19.8% vs 2.2%, p=0.0289), prolonged intensive care unit stay (median=4 vs 0 days, p<0.0001) and hospital stay (median=19.8 vs 7.1days, p<0.001). However, SLT showed significantly lower recurrence rate (15.4% versus 70.3%, p=0.0005) and 5-year cumulative incidence of recurrences (19.4% versus 68.4%, p=0.005). Propensity-matched subgroup analysis showed concordant findings.

Conclusions

While SLT offers potentially reduced risks of recurrence and trended towards improved long-term survival outcomes relative to RLR, it has poorer short-term perioperative outcomes. Patient selection is prudent amidst organ shortages to maximise allocated resources and optimise patient outcomes.

Circulating cell-free long DNA fragments predict post-hepatectomy recurrence of colorectal liver metastases

INTRODUCTION

Most patients with colorectal liver metastases, who undergo hepatectomy, experience recurrence. Although the prognosis is poorer for patients with early recurrence (within 6 months after hepatectomy) compared with later recurrence, no biomarker has been identified to predict early recurrence. Minimal residual disease (MRD) in patients who undergo curative surgery is the main cause of recurrence. In cancer patients, long fragment cell-free DNA is detected, and the presence of long fragments of cell-free DNA after surgery can indicate MRD. In this study, we developed a novel biomarker to predict early recurrence of colorectal liver metastases using cell-free DNA.

MATERIALS AND METHODS

Forty-one patients with colorectal liver metastases were enrolled. Peripheral blood samples were collected before and at 1 month after hepatectomy. Cell-free DNA was extracted from 1 ml plasma, and the long fragment/β-globin ratio, which can indicate MRD, was measured by real-time polymerase chain reaction.

RESULTS

Three of 21 patients (14.3%) with decreases in the long cell-free DNA fragment/β-globin ratio after hepatectomy developed early recurrence compared with twelve of 20 patients (60.0%) with an increased ratio (P = 0.002). Patients with a decreased long fragment/β-globin ratio after hepatectomy had significantly longer recurrence-free survival compared with patients with an increased ratio (366 vs 102 days, P < 0.001).

CONCLUSION

The cell-free DNA long fragment/β-globin ratio may serve as an effective biomarker of early recurrence in patients with colorectal liver metastases, who undergo hepatectomy.

Survival after repeat hepatectomy for recurrent colorectal liver metastasis: A review and meta-analysis of prognostic factors

BACKGROUND

Frequent recurrent hepatic metastasis after hepatic metastasectomy is a major obstacle in the treatment of colorectal liver metastasis (CRLM). We performed the present systematic review to evaluate the short- and long-term outcomes after repeat hepatectomy for recurrent CRLM and determine factors associated with survival in these patients.

DATA SOURCES

An electronic search of PubMed database was undertaken to identify all relevant peer-reviewed papers published in English between January 2000 and July 2018. Hazard ratios (HR) with 95% confidence interval (95% CI) were calculated for prognostic factors of overall survival (OS).

RESULTS

The search yielded 34 studies comprising 3039 patients, with a median overall morbidity of 23% (range 8%-71%), mortality of 0 (range 0-6%), and 5-year OS of 42% (range 17%-73%). Pooled analysis showed that primary T3/T4 stage tumor (HR = 1.94; 95% CI: 1.04-3.63), multiple tumors (HR = 1.49; 95% CI: 1.10-2.01), largest liver lesion ≥5 cm (HR = 1.89; 95% CI: 1.11-3.23) and positive surgical margin (HR = 1.80; 95% CI: 1.09-2.97) at initial hepatectomy, and high serum level of carcinoembryonic antigen (HR = 1.87; 95% CI: 1.27-2.74), disease-free interval ≤12 months (HR = 1.34; 95% CI: 1.10-1.62), multiple tumors (HR = 1.64; 95% CI: 1.32-2.02), largest liver lesion ≥5 cm (HR = 1.85; 95% CI: 1.34-2.56), positive surgical margin (HR = 2.25; 95% CI: 1.39-3.65), presence of bilobar disease (HR = 1.62; 95% CI: 1.19-2.20), and extrahepatic metastases (HR = 1.60; 95% CI: 1.23-2.09) at repeat hepatectomy were significantly associated with poor OS.

CONCLUSIONS

Repeat hepatectomy is a safe and effective therapy for recurrent CRLM. Long-term outcome is predicted mainly by factors related to repeat hepatectomy.

Gene mutation and surgical technique: Suggestion or more?

Advancements in chemotherapy and molecular targeted therapy have improved long-term outcomes for patients with resectable colorectal liver metastases (CLM). RAS mutation status was an original focus as a molecular biomarker as it predicted treatments response to anti-epidermal growth factor receptor agents. More recently, studies have incorporated somatic mutation data in analyses pertaining to surgical outcomes and prognosis. This evidenced-based review covers the implications of somatic mutations in patients undergoing resection of CLM.

Highlights, limitations and future challenges of laparoscopic resection for colorectal liver metastases

The liver is the most common site for metastatic colorectal cancer (CRLM). Despite advances in oncologic treatment, resection of metastases is still the only curative option. Although laparoscopic surgery for primary colorectal cancer is well documented and widely used, laparoscopic surgery for liver metastases has developed more slowly. However, in spite of some difficulties, laparoscopic approach demonstrated strong advantages including minimal parietal damage, decreased morbidity (reduced blood loss and need for transfusion, fewer pulmonary complications), and simplification of subsequent iterative hepatectomy. Up to now, more than 9 000 laparoscopic procedures have been reported worldwide and long-term results in colorectal liver metastases seem comparable to the open approach. Only one recent randomized controlled trial has compared the laparoscopic and the open approach. The purpose of the present update was to identify the barriers limiting widespread acceptance of laparoscopic approach, the benefits and the limits of laparoscopic hepatectomies in CRLM.

Resection of hepatic and pulmonary metastasis from metastatic esophageal and gastric cancer: a nationwide study

The standard of care for gastroesophageal cancer patients with hepatic or pulmonary metastases is best supportive care or palliative chemotherapy. Occasionally, patients can be selected for curative treatment instead. This study aimed to evaluate patients who underwent a resection of hepatic or pulmonary metastasis with curative intent. The Dutch national registry for histo- and cytopathology was used to identify these patients. Data were retrieved from the individual patient files. Kaplan-Meier survival analysis was performed. Between 1991 and 2016, 32,057 patients received a gastrectomy or esophagectomy for gastroesophageal cancer in the Netherlands. Of these patients, 34 selected patients received a resection of hepatic metastasis (n = 19) or pulmonary metastasis (n = 15) in 21 different hospitals. Only 4 patients received neoadjuvant therapy before metastasectomy. The majority of patients had solitary, metachronous metastases. After metastasectomy, grade 3 (Clavien-Dindo) complications occurred in 7 patients and mortality in 1 patient. After resection of hepatic metastases, the median potential follow-up time was 54 months. Median overall survival (OS) was 28 months and the 1-, 3-, and 5- year OS was 84%, 41%, and 31%, respectively. After pulmonary metastases resection, the median potential follow-up time was 80 months. The median OS was not reached and the 1-, 3-, and 5- year OS was 67%, 53%, and 53%, respectively. In selected patients with gastroesophageal cancer with hepatic or pulmonary metastases, metastasectomy was performed with limited morbidity and mortality and offered a 5-year OS of 31-53%. Further prospective studies are required.

Outcomes of salvage liver transplant for recurrent hepatocellular carcinoma: A comparison with primary liver transplant

Backgrounds/Aims

Salvage liver transplantation (SLT) is a therapeutic strategy for recurrent hepatocellular carcinoma (HCC). However, it remains controversial with compromised survival outcomes and increased perioperative morbidity compared to primary liver transplant (PLT). In the present work, we describe our institution's experience on SLT by comparing outcomes of SLT to PLT for HCCs.

Methods

Retrospective analysis was conducted for 49 transplant patients from 2006-2017. A comparative analysis was carried out between 14 SLT patients and 35 PLT patients.

Results

SLT patients demonstrated significantly shorter time to recurrence than PLT patients (median=5.5 versus 23 months, p<0.001) with a trend towards increased perioperative major morbidity (42.9% versus 37%, p=0.711), inferior 5-year overall survival (61% versus 75%, p=0.345) and inferior 5-year recurrence-free survival (57% versus 72%, p=0.263). However, overall survival from the point of primary resection over a 10-year period showed no statistical difference between the 2 groups (SLT=60% versus PLT=61%, p=0.685).

Conclusions

SLT is a viable treatment strategy for HCCs. However, it exhibited poorer short-term perioperative and oncologic outcomes than PLT. SLT requires better patient selection with liver donor grafts for optimization of resource allocation in this era of organ shortage. Considering the worldwide shortages in liver grafts, it is hypothesized that optimization of a salvage transplant strategy may improve resource allocation and reap optimal patient outcomes.

Prognostic indicators lose their value with repeated resection of colorectal liver metastases

BACKGROUND

The liver is the most common site of colorectal liver metastases (CRLM) and surgical resection improves overall survival in selected patients. Here, we investigate outcomes and relevant prognostic factors after repeated hepatic resections for CRLM.

METHODS

From a prospective database, 578 patients who underwent 788 resections of colorectal liver metastases were included into this study. In total, 169 patients underwent a second and 41 patients had a third operation due to intrahepatic metastatic recurrence. Univariate and multivariate analyses were performed to determine prognostic risk factors.

RESULTS

5-year overall survival was 36.7% (95% CI: 30.2%; 43.2%) and 10-year survival was 20.3% (95% CI: 7.6%; 33.0%) in patients undergoing single resection. In patients undergoing a second or third resection, 5- and 10-year survival rates were 56.6% (95% CI: 45.0%; 68.2%) and 21.9% (95% CI: 6.8%; 37.0%) or 53.2% (95% CI: 32.4%; 74.0%) and 25.4%, respectively. In patients undergoing single resection, established markers (number, size and pattern of CRLM [p = 0.030/0.015/<0.001], R-status [p = 0.001], surgical/medical complications [p = 0.001/0.008], CEA-level [p = 0.001] and Fong-Score [p = 0.02]) were significantly associated with survival. In patients undergoing three resections, the only predictive markers were pT-stage of the primary tumor in univariate analysis (p = 0.013) and metachronous metastasis and medical complications in multivariate analysis (p = 0.001/0.025). The Fong-Score had no predictive value in patients undergoing two (p = 0.08) or three (p = 0.7) resections.

CONCLUSION

Established prognostic indicators are not applicable in patients undergoing repeated CRLM resection. In a highly-selected group of patients, repeated hepatic resections can be performed safely with favorable long-term outcomes.

Diagnostic accuracy of CE-CT, MRI and FDG PET/CT for detecting colorectal cancer liver metastases in patients considered eligible for hepatic resection and/or local ablation

PURPOSE

To compare the diagnostic performance of contrast-enhanced computed tomography (CE-CT), magnetic resonance imaging (MRI) and combined fluorodeoxyglucose/positron emission tomography/computed tomography (FDG-PET/CT) for detection of colorectal liver metastases (CRLM) in patients eligible for local treatment.

MATERIALS AND METHODS

This health-research ethics-committee-approved prospective consecutive diagnostic accuracy study, with written informed consent, included 80 cases (76 patients, four participating twice) between 29 June 2015 and 7 February 2017. Prior chemotherapy or local treatment did not exclude participation. Combined FDG-PET/CT including CE-CT and MRI was performed within 0-3 days shortly before local treatment. CE-CT and MRI images were read independently by two readers for each modality. The combined FDG-PET/CT images were read independently by two pairs of readers. A composite reference standard was used. Sensitivities, specificities and area under the receiver operating characteristic curves (AUC_ROC) were calculated and compared.

RESULTS

In total, 260 CRLMs were confirmed. The MRI readers had significantly higher per-lesion sensitivity (85.9% and 83.8%) than both CE-CT readers (69.1% and 62.3%) and both PET/CT reader pairs (72.0% and 72.1%) (p<0.001). There were no significant differences in per-lesion specificity. MRI readers had significantly higher AUC_ROC (0.92 and 0.88) than both CE-CT readers (0.80 and 0.82) (p≤0.001). AUC_ROC for MR reader 1 was higher than that of both PET/CT reader pairs (0.83 and 0.84) (p≤0.0001).

CONCLUSION

MRI performed significantly better than both CE-CT and combined FDG-PET/CT for detection of CRLM in consecutive patients eligible for local treatment irrespective of prior chemotherapy or local treatment.

KEY POINTS

• Patients eligible for local treatment of colorectal liver-metastases require optimal imaging. • In 80 consecutive patients, MRI had superior per lesion diagnostic performance. • Findings were independent of prior treatment and type of planned local treatment. • Equally, MRI had superior diagnostic performance on per segment basis.

Longterm effects of palliative local treatment of incurable metastatic lesions in colorectal cancer patients

We assessed the value of palliative local treatment of incurable metastatic lesions in colorectal cancer patients. Consecutive patients with metastatic colorectal cancer treated between 2003 and 2014 were retrospectively reviewed. Propensity score matching was used to create comparable palliative local treatment and chemotherapy alone groups (n = 272 in each group). The primary endpoint was overall survival, which was calculated using Kaplan-Meier survival analyses. Factors possibly influencing survival were evaluated by univariate and subsequently by multivariate analyses. Palliative local treatment prolonged survival as compared with chemotherapy alone (38.73 vs. 19.8 months, p < 0.01). Univariate and subsequent multivariate analyses showed that primary stage IV at initial diagnosis; high CA199 level and LDH at the time of diagnosis were independent factors for a poor prognosis. Palliative local treatment improved survival better than chemotherapy alone in patients with 0, 1, 2, or 3 of the prognostic factors (p < 0.01). Patients administered treatment for pulmonary metastases survived longer than those treated for metastases elsewhere (56.77 vs. 35.43 months, p = 0.01). Surgical treatment provided marginally longer survival than non-surgical treatment (44.87 vs. 35.43 months, p = 0.05). These findings suggest palliative local treatment has survival benefit for selected patients with incurable metastatic colorectal cancer.

Centralization of Liver Cancer Surgery and Impact on Multidisciplinary Teams Working on Stage IV Colorectal Cancer

Surgical resection is the most effective treatment approach for colorectal liver metastases but only a minority of patients is suitable for upfront surgery. The treatment strategies of stage IV colorectal cancer have shifted towards a continuum of care in which medical and surgical treatment combinations are tailored to the clinical setting of the individual patient. The optimization of treatment through appropriate decision-making and multimodal therapy for stage IV colorectal cancer require a joint multidisciplinary meeting in a centralized liver cancer unit.