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Panni RZ, D'Angelica M. Stage IV Rectal Cancer and Timing of Surgical Approach. Clin Colon Rectal Surg 2024; 37:248-255. [PMID: 38882938 PMCID: PMC11178389 DOI: 10.1055/s-0043-1770719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Liver metastases are seen in at least 60% of patients with colorectal cancer at some point during the course of their disease. The management of both primary and liver disease is uniquely challenging in rectal cancer due to competing treatments and complex sequence of treatments depending on the clinical presentation of disease. Recently, several novel concepts are shaping new treatment paradigms, including changes in timing, sequence, and duration of therapies combined with potential deescalation of treatment components. Overall, the treatment of this clinical scenario mandates multidisciplinary evaluation and personalization of care; however, there is still considerable debate regarding the timing of liver metastasectomy in the context of the overall treatment plan. Herein, we will discuss the current literature on management of rectal cancer with synchronous liver metastasis, current treatment approaches with respect to chemotherapy, and role of hepatic artery infusion therapy.
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Affiliation(s)
- Roheena Z Panni
- Complex General Surgical Oncology, Hepatopancreatobiliary Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Michael D'Angelica
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, Cornell University, New York
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2
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Serradilla-Martín M, Villodre C, Falgueras-Verdaguer L, Zambudio-Carroll N, Castell-Gómez JT, Blas-Laina JL, Borrego-Estella V, Domingo-del-Pozo C, García-Plaza G, González-Rodríguez FJ, Montalvá-Orón EM, Moya-Herraiz Á, Paterna-López S, Suárez-Muñoz MA, Alkorta-Zuloaga M, Blanco-Fernández G, Dabán-Collado E, Gómez-Bravo MA, Miota-de-Llamas JI, Rotellar F, Sánchez-Pérez B, Sánchez-Cabús S, Pacheco-Sánchez D, Rodríguez-Sanjuan JC, Varona-Bosque MA, Carrión-Álvarez L, de la Serna-Esteban S, Dopazo C, Martín-Pérez E, Martínez-Cecilia D, Castro-Santiago MJ, Dorcaratto D, Gutiérrez-Díaz ML, Asencio-Pascual JM, Burdío-Pinilla F, Carracedo-Iglesias R, Escartín-Arias A, Ielpo B, Rodríguez-Laiz G, Valdivieso-López A, De-Vicente-López E, Alonso-Orduña V, Ramia JM. Feasibility and Short-Term Outcomes in Liver-First Approach: A Spanish Snapshot Study (the RENACI Project). Cancers (Basel) 2024; 16:1676. [PMID: 38730631 PMCID: PMC11082946 DOI: 10.3390/cancers16091676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background: The liver-first approach may be indicated for colorectal cancer patients with synchronous liver metastases to whom preoperative chemotherapy opens a potential window in which liver resection may be undertaken. This study aims to present the data of feasibility and short-term outcomes in the liver-first approach. (2) Methods: A prospective observational study was performed in Spanish hospitals that had a medium/high-volume of HPB surgeries from 1 June 2019 to 31 August 2020. (3) Results: In total, 40 hospitals participated, including a total of 2288 hepatectomies, 1350 for colorectal liver metastases, 150 of them (11.1%) using the liver-first approach, 63 (42.0%) in hospitals performing <50 hepatectomies/year. The proportion of patients as ASA III was significantly higher in centers performing ≥50 hepatectomies/year (difference: 18.9%; p = 0.0213). In 81.1% of the cases, the primary tumor was in the rectum or sigmoid colon. In total, 40% of the patients underwent major hepatectomies. The surgical approach was open surgery in 87 (58.0%) patients. Resection margins were R0 in 78.5% of the patients. In total, 40 (26.7%) patients had complications after the liver resection and 36 (27.3%) had complications after the primary resection. One-hundred and thirty-two (89.3%) patients completed the therapeutic regime. (4) Conclusions: There were no differences in the surgical outcomes between the centers performing <50 and ≥50 hepatectomies/year. Further analysis evaluating factors associated with clinical outcomes and determining the best candidates for this approach will be subsequently conducted.
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Affiliation(s)
- Mario Serradilla-Martín
- Department of Surgery, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Department of Surgery, School of Medicine, University of Granada, 18016 Granada, Spain
| | - Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
- ISABIAL, Instituto de Investigación Sanitaria y Biomédica de Alicante, 03010 Alicante, Spain
- Department of Surgery, Universidad Miguel Hernández, 03202 Alicante, Spain
| | | | | | | | | | | | | | - Gabriel García-Plaza
- Department of Surgery, Hospital Universitario Insular, 35016 Las Palmas de Gran Canaria, Spain;
| | | | - Eva M. Montalvá-Orón
- Department of Surgery, Hospital Universitario y Politécnico La Fe, IIS La Fe, Ciberehd ISCIII, 46026 Valencia, Spain;
| | - Ángel Moya-Herraiz
- Department of Surgery, Hospital Universitario de Castellón, 12004 Castelló de la Plana, Spain;
| | - Sandra Paterna-López
- Department of Surgery, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - Miguel A. Suárez-Muñoz
- Department of Surgery, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | | | | | | | - Miguel A. Gómez-Bravo
- Department of Surgery, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain;
| | | | - Fernando Rotellar
- Department of Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
| | - Belinda Sánchez-Pérez
- Department of Surgery, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain;
| | - Santiago Sánchez-Cabús
- Department of Surgery, Hospital Universitario de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | | | | | - María A. Varona-Bosque
- Department of Surgery, Hospital Universitario Nuestra Señora de la Candelaria, 38010 Santa Cruz de Tenerife, Spain;
| | | | | | - Cristina Dopazo
- Department of Surgery, Hospital Universitario Vall d’Hebron, 08035 Barcelona, Spain;
| | - Elena Martín-Pérez
- Department of Surgery, Hospital Universitario La Princesa, 28006 Madrid, Spain; (E.M.-P.); (D.M.-C.)
| | - David Martínez-Cecilia
- Department of Surgery, Hospital Universitario La Princesa, 28006 Madrid, Spain; (E.M.-P.); (D.M.-C.)
- Department of Surgery, Hospital Universitario Virgen de la Salud, 45004 Toledo, Spain
| | | | - Dimitri Dorcaratto
- Department of Surgery, Hospital Clínico Universitario, 46010 Valencia, Spain;
| | | | | | - Fernando Burdío-Pinilla
- Department of Surgery, Hospital Universitario del Mar, 08003 Barcelona, Spain; (F.B.-P.); (B.I.)
| | | | | | - Benedetto Ielpo
- Department of Surgery, Hospital Universitario del Mar, 08003 Barcelona, Spain; (F.B.-P.); (B.I.)
- Department of Surgery, Hospital Universitario de León, 24008 León, Spain
| | - Gonzalo Rodríguez-Laiz
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
| | | | | | - Vicente Alonso-Orduña
- Department of Medical Oncology, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - José M. Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
- ISABIAL, Instituto de Investigación Sanitaria y Biomédica de Alicante, 03010 Alicante, Spain
- Department of Surgery, Universidad Miguel Hernández, 03202 Alicante, Spain
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Meillat H, Garnier J, Palen A, Ewald J, de Chaisemartin C, Tyran M, Mitry E, Lelong B. Organ sparing to cure stage IV rectal cancer: A case report and review of literature. World J Gastrointest Surg 2023; 15:2619-2626. [PMID: 38111764 PMCID: PMC10725537 DOI: 10.4240/wjgs.v15.i11.2619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/03/2023] [Accepted: 08/28/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Rectal sparing is an option for some rectal cancers with complete or good response after chemoradiotherapy (CRT); however, it has never been evaluated in patients with metastases. We assessed long-term outcomes of a rectal-sparing approach in a liver-first strategy for patients with rectal cancer with resectable liver metastases. CASE SUMMARY We examined patients who underwent an organ-sparing approach for rectal cancer with synchronous liver metastases using a liver-first strategy during 2010-2015 (n = 8). Patients received primary chemotherapy and pelvic CRT. Liver surgery was performed during the interval between CRT completion and rectal tumor re-evaluation. Clinical and oncological characteristics and long-term outcomes were assessed.All patients underwent liver metastatic resection with curative intent. The R0 rate was 100%. Six and two patients underwent local excision and a watch-and-wait (WW) approach, respectively. All patients had T3N1 tumors at diagnosis and had good clinical response after CRT. The median survival time was 60 (range, 14-127) mo. Three patients were disease free for 5, 8, and 10 years after the procedure. Five patients developed metastatic recurrence in the liver (n = 5) and/or lungs (n = 2). Only one patient developed local recurrence concurrent with metastatic recurrence 24 mo after the WW approach. Two patients died during follow-up. CONCLUSION The results suggest good local control in patients undergoing organ-sparing strategies for rectal cancer with synchronous liver metastasis. Prospective trials are required to validate these data and identify good candidates for these strategies.
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Affiliation(s)
- Hélène Meillat
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Jonathan Garnier
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Anais Palen
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Jacques Ewald
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Cécile de Chaisemartin
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Marguerite Tyran
- Department of Radiotherapy, Institut Paoli Calmettes, Marseille 13009, France
| | - Emmanuel Mitry
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Bernard Lelong
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
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An optimised liver-first strategy for synchronous metastatic rectal cancer leads to higher protocol completion and lower surgical morbidity. World J Surg Oncol 2023; 21:75. [PMID: 36864464 PMCID: PMC9983162 DOI: 10.1186/s12957-023-02946-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/13/2023] [Indexed: 03/04/2023] Open
Abstract
INTRODUCTION The optimal management of rectal cancer with synchronous liver metastases remains debatable. Thus, we propose an optimised liver-first (OLF) strategy that combines concomitant pelvic irradiation with hepatic management. This study aimed to evaluate the feasibility and oncological quality of the OLF strategy. MATERIALS AND METHODS Patients underwent systemic neoadjuvant chemotherapy followed by preoperative radiotherapy. Liver resection was performed in one step (between radiotherapy and rectal surgery) or in two steps (before and after radiotherapy). The data were collected prospectively and analysed retrospectively as intent to treat. RESULTS Between 2008 and 2018, 24 patients underwent the OLF strategy. The rate of treatment completion was 87.5%. Three patients (12.5%) did not proceed to the planned second-stage liver and rectal surgery because of progressive disease. The postoperative mortality rate was 0%, and the overall morbidity rates after liver and rectal surgeries were 21% and 28.6%, respectively. Only two patients developed severe complications. Liver and rectal complete resection was performed in 100% and 84.6%, respectively. A rectal-sparing strategy was performed in 6 patients who underwent local excision (n = 4) or a watch and wait strategy (n = 2). Among patients who completed treatment, the median overall and disease-free survivals were 60 months (range 12-139 months) and 40 months (range 10-139 months), respectively. Eleven patients (47.6%) developed recurrence, among whom five underwent further treatment with curative intent. CONCLUSION The OLF approach is feasible, relevant, and safe. Organ preservation was feasible for a quarter of patients and may be associated with reduced morbidity.
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Qiu J, Wu C, Gao Q, Li S, Li Y. Effect of fecal microbiota transplantation on the TGF-β1/Smad signaling pathway in rats with TNBS-induced colitis. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:825. [PMID: 36034975 PMCID: PMC9403912 DOI: 10.21037/atm-22-3227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022]
Abstract
Background Traditional treatments for inflammatory bowel disease (IBD) have adverse side effects, and patients who receive such treatments have high recurrence rates. Fecal microbiota transplantation (FMT) has become an increasingly popular therapeutic option for patients with IBD. However, the mechanism by which FMT alleviates this disease remains unclear. Methods In this study, a rat model of 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced colitis was established and used to explore whether the transforming growth factor-beta 1 (TGF-β1)/small mothers against decapentaplegic (Smad) signaling pathway plays a critical role in the FMT alleviation of IBD. Results After the FMT intervention, the disease activity index and histologic scores were significantly decreased. In addition, the TGF-β1 expression level in the FMT group was significantly decreased by approximately 0.72-fold relative to the level in the TNBS colitis group, whereas the Smad3, Smad4, and Smad7 expression levels had increased by approximately 1.21, 1.40, and 1.18 folds, respectively. Similarly, SB431542 inhibited the expression of TGF-β1 and promoted the expression of Smad3, Smad4, and Smad7. Further, the serum levels of the inflammatory cytokines tumor necrosis factor-alpha (TNF-α), interleukin-1β (IL-1β) and interleukin-6 (IL-6) were significantly decreased, whereas that of the interferon-gamma (IFN-γ) was not significantly changed after the FMT intervention. Conclusions These results suggest that FMT inhibits the TGF-β1/Smad signaling pathway to attenuate inflammation.
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Affiliation(s)
- Jinlang Qiu
- Department of Clinical Laboratory, Fuzhou Traditional Chinese Medicine Hospital, Fuzhou, China
| | - Caixian Wu
- Department of Anus-Intestines, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Qianyu Gao
- Department of Clinical Laboratory, Fuzhou Traditional Chinese Medicine Hospital, Fuzhou, China
| | - Sheng Li
- Department of Oncology, Fuzhou Traditional Chinese Medicine Hospital, Fuzhou, China
| | - Yuhua Li
- Department of Clinical Laboratory, Fuzhou Traditional Chinese Medicine Hospital, Fuzhou, China
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Du Pasquier C, Roulin D, Bize P, Sempoux C, Rebecchini C, Montemurro M, Schäfer M, Halkic N, Demartines N. Tumor response and outcome after reverse treatment for patients with synchronous colorectal liver metastasis: a cohort study. BMC Surg 2020; 20:78. [PMID: 32306936 PMCID: PMC7169034 DOI: 10.1186/s12893-020-00738-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The reverse treatment of patients with synchronous colorectal liver metastases (CRLM) is a sequential approach with systemic chemotherapy first, followed by liver resection, and finally, primary tumor resection. The aim of this study was to assess the feasibility, the radiological and pathological tumor response to neoadjuvant therapy, recurrence rates and long-term survival after reverse treatment in a cohort study. METHODS Data from patients with CRLM who underwent a reverse treatment from August 2008 to October 2016 were extracted from our prospective hepato-biliary database and retrospectively analyzed for response rates and survival outcomes. Radiological tumor response was assessed by RECIST (Response Evaluation Criteria In Solid Tumor) criteria and pathological response according to TRG (Tumor Regression Grade). Disease-free and overall survival were estimated with Kaplan-Meier survival curves. RESULTS There were 44 patients with 19 rectal and 25 colonic tumors. The reverse treatment was fully completed until primary tumor resection in 41 patients (93%). Radiological assessment after chemotherapy showed 61% of complete/partial response. Pathological tumor response was major or partial in 52% of patients (TRG 1-3). Median disease-free survival after primary tumor resection was 10 months (95% CI 5-15 months). Disease-free survival at 3 and 5 years was 25% and 25%, respectively. Median overall survival was 50 months (95% CI 42-58 months). Overall survival at 3 and 5 years was 59% and 39%, respectively. CONCLUSION The reverse treatment approach was feasible with a high rate of patients with complete treatment sequence and offers promising long-term survival for selected patients with advanced simultaneous colorectal liver metastases.
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Affiliation(s)
- Céline Du Pasquier
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Department of Pathology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Department of Pathology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Pierre Bize
- Department of Radiology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Christine Sempoux
- Department of Pathology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Caterina Rebecchini
- Department of Pathology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Montemurro
- Department of Medical Oncology, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Coco D, Leanza S. Analysis of Treatment Option for Synchronous Liver Metastases and Colon Rectal Cancer. Open Access Maced J Med Sci 2019; 7:4176-4178. [PMID: 32165972 PMCID: PMC7061367 DOI: 10.3889/oamjms.2019.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/08/2019] [Accepted: 06/09/2019] [Indexed: 11/05/2022] Open
Abstract
Colorectal or bowel cancer is one of the major causes of cancer worldwide. Research has shown that 15 to 20% colorectal cancer patients are also diagnosed with synchronous liver metastases (LM) at presentation and about one third eventually develop liver lesions. Management of cases with colorectal cancer comorbid with liver metastases is more complex. This highlights the need for suggesting the need for effective treatment while optimizing timing during surgical and medical treatment of primary plus metastatic disease. Such patients cases are likely to present with severe cancer biology and thereby less likely to be long-term survivors.
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Kim CA, Ahmed S, Ahmed S, Brunet B, Chalchal H, Deobald R, Doll C, Dupre MP, Gordon V, Lee-Ying RM, Lim H, Liu D, Loree JM, McGhie JP, Mulder K, Park J, Yip B, Wong RP, Zaidi A. Report from the 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Winnipeg, Manitoba; 29-30 September 2017. ACTA ACUST UNITED AC 2018; 25:275-284. [PMID: 30111968 DOI: 10.3747/co.25.4109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Winnipeg, Manitoba, 29-30 September 2017. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.
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Affiliation(s)
- C A Kim
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - S Ahmed
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - S Ahmed
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - B Brunet
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - H Chalchal
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - R Deobald
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - C Doll
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - M P Dupre
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - V Gordon
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - R M Lee-Ying
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - H Lim
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - D Liu
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - J M Loree
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - J P McGhie
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - K Mulder
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - J Park
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - B Yip
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - R P Wong
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - A Zaidi
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
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10
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de Jong MC, Beckers RCJ, van Woerden V, Sijmons JML, Bemelmans MHA, van Dam RM, Dejong CHC. The liver-first approach for synchronous colorectal liver metastases: more than a decade of experience in a single centre. HPB (Oxford) 2018; 20:631-640. [PMID: 29456199 DOI: 10.1016/j.hpb.2018.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 10/19/2017] [Accepted: 01/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The feasibility of the liver-first approach for synchronous colorectal liver metastases (CRLM) has been established. We sought to assess the short-term and long-term outcomes for these patients. METHODS Outcomes of patients who underwent a liver-first approach for CRLM between 2005 and 2015 were retrospectively evaluated from a prospective database. RESULTS Of the 92 patients planned to undergo the liver-first strategy, the paradigm could be completed in 76.1%. Patients with concurrent extrahepatic disease failed significantly more often in completing the protocol (67% versus 21%; p = 0.03). Postoperative morbidity and mortality were 31.5% and 3.3% following liver resection and 30.9% and 0% after colorectal surgery. Of the 70 patients in whom the paradigm was completed, 36 patients (51.4%) developed recurrent disease after a median interval of 20.9 months. The median overall survival on an intention-to-treat basis was 33.1 months (3- and 5-year overall survival: 48.5% and 33.1%). Patients who were not able to complete their therapeutic paradigm had a significantly worse overall outcome (p = 0.03). CONCLUSION The liver-first approach is feasible with acceptable perioperative morbidity and mortality rates. Despite the considerable overall-survival-benefit, recurrence rates remain high. Future research should focus on providing selection tools to enable the optimal treatment sequence for each patient with synchronous CRLM.
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Affiliation(s)
- Mechteld C de Jong
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.
| | - Rianne C J Beckers
- Department of Radiology - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Victor van Woerden
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Julie M L Sijmons
- Faculty of Health, Medicine & Life Sciences - Maastricht University, The Netherlands
| | - Marc H A Bemelmans
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Ronald M van Dam
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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11
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Gill S, Liu DM, Green HM, Sharma RA. Beyond the Knife: The Evolving Nonsurgical Management of Oligometastatic Colorectal Cancer. Am Soc Clin Oncol Educ Book 2018; 38:209-219. [PMID: 30231355 DOI: 10.1200/edbk_200941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In patients with liver-limited oligometastatic disease, the goal of treatment can be curative intent. Historically, this was accomplished in patients presenting with upfront resectable disease. The availability of increasingly efficacious chemotherapy and biologic combinations with encouraging response rates led to the potential to convert unresectable disease to resectability. Beyond the backbone of surgery, we now have a portfolio of locoregional strategies to consider.From an interventional radiology perspective, the use of portal vein embolization can facilitate hypertrophy of the liver in anticipation of resection, thus converting unresectable disease to one amenable to a surgical approach with curative intent. Technological advances in liver-directed ablative therapies have afforded the possibility of eliminate radiographically evident disease with the hope for long-term disease control. Advanced radiotherapy techniques are further increasing the therapeutic options for patients with metastatic colorectal cancer. Improvements in external-beam radiotherapy over the past 2 decades include image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy, and proton-beam therapy. Finally, selective internal radiation therapy (SIRT) with microspheres labeled with the β-emitter 90Y enable targeted delivery of radiation to hepatic tumors. A coordinated multidisciplinary approach is required to integrate these nonsurgical adjuncts in an evidence-based manner to optimize outcomes for patients with potentially resectable metastatic disease. In this article, we summarize recent developments in systemic therapy, radiotherapy, and interventional liver-directed therapies that have changed the treatment landscape for patients with oligometastatic colorectal cancer.
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Affiliation(s)
- Sharlene Gill
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - David M Liu
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - Harshani M Green
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - Ricky A Sharma
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
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12
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Xue L, Williamson A, Gaines S, Andolfi C, Paul-Olson T, Neerukonda A, Steinhagen E, Smith R, Cannon LM, Polite B, Umanskiy K, Hyman N. An Update on Colorectal Cancer. Curr Probl Surg 2018; 55:76-116. [PMID: 29631699 DOI: 10.1067/j.cpsurg.2018.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lai Xue
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | - Sara Gaines
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Ciro Andolfi
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Terrah Paul-Olson
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Anu Neerukonda
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Emily Steinhagen
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Radhika Smith
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Lisa M Cannon
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Blasé Polite
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | | | - Neil Hyman
- Department of Surgery, University of Chicago Medicine, Chicago, IL.
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13
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Labori KJ, Guren MG, Brudvik KW, Røsok BI, Waage A, Nesbakken A, Larsen S, Dueland S, Edwin B, Bjørnbeth BA. Resection of synchronous liver metastases between radiotherapy and definitive surgery for locally advanced rectal cancer: short-term surgical outcomes, overall survival and recurrence-free survival. Colorectal Dis 2017; 19:731-738. [PMID: 28181384 DOI: 10.1111/codi.13622] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 11/28/2016] [Indexed: 02/08/2023]
Abstract
AIM There is debate as to the correct treatment algorithm sequence for patients with locally advanced rectal cancer with liver metastases. The aim of the study was to assess safety, resectability and survival after a modified 'liver-first' approach. METHOD This was a retrospective study of patients undergoing preoperative radiotherapy for the primary rectal tumour, followed by liver resection and, finally, resection of the primary tumour. Short-term surgical outcome, overall survival and recurrence-free survival are reported. RESULTS Between 2009 and 2013, 45 patients underwent liver resection after preoperative radiotherapy. Thirty-four patients (76%) received neoadjuvant chemotherapy, 24 (53%) concomitant chemotherapy during radiotherapy and 17 (43%) adjuvant chemotherapy. The median time interval from the last fraction of radiotherapy to liver resection and rectal surgery was 21 (range 7-116) and 60 (range 31-156) days, respectively. Rectal resection was performed in 42 patients but was not performed in one patient with complete response and two with progressive metastatic disease. After rectal surgery three patients did not proceed to a planned second stage liver (n = 2) or lung (n = 1) resection due to progressive disease. Clavien-Dindo ≥Grade III complications developed in 6.7% after liver resection and 19% after rectal resection. The median overall survival and recurrence-free survival in the patients who completed the treatment sequence (n = 40) were 49.7 and 13.0 months, respectively. Twenty of the 30 patients who developed recurrence underwent further treatment with curative intent. CONCLUSION The modified liver-first approach is safe and efficient in patients with locally advanced rectal cancer and allows initial control of both the primary tumour and the liver metastases.
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Affiliation(s)
- K J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - M G Guren
- Department of Oncology, Oslo University Hospital, Oslo, Norway.,K. G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway
| | - K W Brudvik
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - B I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - A Waage
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - A Nesbakken
- K. G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway.,Department of Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - S Larsen
- Department of Gastroenterological Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - S Dueland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - B Edwin
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - B A Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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14
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Treatment strategies for rectal cancer with synchronous liver metastases: surgical and oncological outcomes with propensity-score analysis. Clin Transl Oncol 2017; 20:221-229. [PMID: 28707036 DOI: 10.1007/s12094-017-1712-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal sequence of surgery for rectal cancer (RC) with synchronous liver metastases (SLM) is controversial. OBJECTIVES The primary objective was to explore differences between the rectum first (RF) and the liver first strategy (LF) to achieve the complete resection (CR) of both tumors. METHODS Patients diagnosed of RC with resectable or potentially resectable SLM were included. Data collected prospectively were analyzed with an intention-to-treat perspective, adjusting for between-sample differences (propensity score). The complete resection rate (CRR) was the main outcome variable. RESULTS During a 5-year period, 23 patients underwent the LF strategy and 24 patients the RF strategy. Median overall survival (OS) was 32 months in the LF group and 41 months in the RF group (p = 0.499), and was 51 and 17 months, respectively, for patients achieving or not achieving CR of both tumors (p < 0.001). CRR's were 65% in liver first group and 63% in rectum first group, (p = 0.846). No between-strategy differences in morbidity or duration of treatment were observed. CONCLUSIONS This study supports the notion that the achievement of CR of RC and SLM should be the goal of oncological treatment. Both RF and LF strategies are feasible and safe, but no between-strategy differences have been found in the CRR.
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15
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Siriwardena AK, Chan AKC, Ignatowicz AM, Mason JM. Colorectal cancer with Synchronous liver-limited Metastases: the protocol of an Inception Cohort study (CoSMIC). BMJ Open 2017; 7:e015018. [PMID: 28601828 PMCID: PMC5734400 DOI: 10.1136/bmjopen-2016-015018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Colorectal cancer is the fourth most common cancer in the UK and an important cause of cancer-related death. In 20% of patients, there is metastasis to the liver or beyond at the time of diagnosis. The management of synchronous disease is complex. Conventional surgery removes the colorectal primary first, followed by chemotherapy, with resection of liver metastases as a final step. Advances in the availability and safety of liver surgery, anaesthesia and critical care have made two alternative options feasible. The first is synchronous resection of the primary and liver metastases. The second is resection of the metastatic disease as the first step, termed the reverse or liver-first approach. Currently, evidence is inadequate to inform the selection of care pathway for patients with colorectal cancer and synchronous liver-limited metastases. Specifically, optimal pathways are not defined and there is a dearth of prospectively recorded cohort-defining factors influencing treatment selection or outcome. METHODS AND ANALYSIS Colorectal cancer with Synchronous liver-limited Metastases: an Inception Cohort (CoSMIC) is an inception cohort study of patients with a new diagnosis of colorectal cancer with synchronous liver-limited metastases. The sequence of treatment received, and factors influencing treatment decisions, will be evaluated against European Society of Medical Oncology guidelines. Clinical data will be collected, and quality of life, morbidity, mortality and long-term outcome compared for different treatment sequences adjusted for prognostic factors. Disease-free survival or progression will be measured at 1, 2 and 5 years. A nested qualitative study will ascertain patient experiences and clinician perspectives on delivery of care. ETHICS AND DISSEMINATION The full study protocol was independently peer reviewed by Professor Kees de Jong (University of Maastricht, Holland). CoSMIC has ethical approval from the National Health Service Research Ethics Committee (14/NW/1397). Results will be disseminated to healthcare professionals and patient groups, and may be used to design a definitive trial addressing areas of equipoise in treatment pathways, as well as optimising current pathways to improve outcomes and experiences. TRIAL REGISTRATION NUMBER NCT02456285, pre-results.
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Affiliation(s)
- Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
- Faculty of Medicine, University of Manchester, Manchester, UK
| | - Anthony K C Chan
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - James M Mason
- Warwick Medical School, University of Warwick, Coventry, UK
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16
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Aigner F, Pratschke J, Schmelzle M. Oligometastatic Disease in Colorectal Cancer - How to Proceed? Visc Med 2017; 33:23-28. [PMID: 28612013 DOI: 10.1159/000454688] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Oligometastatic disease in colorectal cancer may affect the liver, lung, and peritoneum. This review mainly focuses on colorectal liver metastases (CRLM) and highlights recommendations and therapeutic strategies drawn from the current literature and consensus conferences. The following data address a paradigm shift in surgical approaches to CRLM, pushing the limits of multimodal treatment concepts. METHODS A systematic review of the relevant literature on multimodal treatment strategies for synchronous and metachronous CRLM is presented. RESULTS The choice of treatment strategy depends on the clinical scenario; however, perioperative chemotherapy and the liver-first concept in synchronous CRLM are favored with subsequent partial extended liver resection with or without various augmentation techniques for liver surgery. CONCLUSION Surgical strategies should be strongly defined with regard to an adequate liver remnant. All patients with synchronous CRLM should be evaluated by a multidisciplinary team.
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Affiliation(s)
- Felix Aigner
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
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17
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Sturesson C, Valdimarsson VT, Blomstrand E, Eriksson S, Nilsson JH, Syk I, Lindell G. Liver-first strategy for synchronous colorectal liver metastases - an intention-to-treat analysis. HPB (Oxford) 2017; 19:52-58. [PMID: 27838252 DOI: 10.1016/j.hpb.2016.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 10/02/2016] [Accepted: 10/12/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The liver-first strategy signifies resection of liver metastases before the primary colorectal cancer. The aim of the present study was to compare failure to complete intended treatment and survival in liver-first and classical strategies. METHODS All patients with colorectal cancer and synchronous liver metastases planned for sequential radical surgery in a single institution between 2011 and 2015 were included. RESULTS A total of 109 patients were presented to a multidisciplinary team conference (MDT) with un-resected colorectal cancer and synchronous liver metastases. Seventy-five patients were planned as liver-first, whereas 34 were recommended the classical strategy. Twenty-six patients (35%) failed to complete treatment in the liver-first group compared to 10 patients in the classical group (P = 0.664). Reason for failure was most commonly disease progression. A total of 91 patients had the primary tumor resected before the liver metastases of which 67 before referral and 24 after allocation at MDT. Median survival after diagnosis in this group was 60 (48-73) months compared to 46 (31-60) months in the group operated with liver-first strategy (n = 49), (P = 0.310). DISCUSSION Up to 35% of patients with colorectal cancer and synchronous liver metastases do not complete the intended treatment of liver and bowel resections, irrespective of treatment strategy.
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Affiliation(s)
- Christian Sturesson
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden.
| | - Valentinus T Valdimarsson
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Erik Blomstrand
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Sam Eriksson
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Jan H Nilsson
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Ingvar Syk
- Lund University, Skane University Hospital, Department of Clinical Sciences Malmö, Surgery, Malmö, Sweden
| | - Gert Lindell
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
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18
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Shi L, Chen L, Wu C, Zhu Y, Xu B, Zheng X, Sun M, Wen W, Dai X, Yang M, Lv Q, Lu B, Jiang J. PD-1 Blockade Boosts Radiofrequency Ablation-Elicited Adaptive Immune Responses against Tumor. Clin Cancer Res 2016; 22:1173-1184. [PMID: 26933175 DOI: 10.1158/1078-0432.ccr-15-1352] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Radiofrequency ablation (RFA) has been shown to elicit tumor-specific T-cell immune responses, but is not sufficient to prevent cancer progression. Here, we investigated immune-suppressive mechanisms limiting the efficacy of RFA. EXPERIMENTAL DESIGN We performed a retrospective case-controlled study on patients with synchronous colorectal cancer liver metastases who had received primary tumor resection with or without preoperative RFA for liver metastases. Tumor-infiltrating T cells and tumoral PD-L1 expression in human colorectal cancer tissues were analyzed by immunohistochemistry. T-cell immune responses and PD-1/PD-L1 expression were also characterized in an RFA mouse model. In addition, the combined effect of RAF and PD-1 blockade was evaluated in the mouse RFA model. RESULTS We found that RFA treatment of liver metastases increased not only T-cell infiltration, but also PD-L1 expression in primary human colorectal tumors. Using mouse tumor models, we demonstrated that RFA treatment of one tumor initially enhanced a strong T-cell-mediated immune response in tumor. Nevertheless, tumor quickly overcame the immune responses by inhibiting the function of CD8(+) and CD4(+) T cells, driving a shift to higher regulatory T-cell to Teff ratio, and upregulating PD-L1/PD-1 expression. Furthermore, we established that the combined therapy of RFA and anti-PD-1 antibodies significantly enhanced T-cell immune responses, resulting in stronger antitumor immunity and prolonged survival. CONCLUSIONS The PD-L1-PD-1 axis plays a critical role in dampening RFA-induced antitumor immune responses, and this study provides a strong rationale for combining RFA and the PD-L1/PD-1 blockade in the clinical setting.
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Affiliation(s)
- Liangrong Shi
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Department of Oncology, the Third Affiliated Hospital, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Lujun Chen
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Changping Wu
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Department of Oncology, the Third Affiliated Hospital, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Yibei Zhu
- Institute of Biotechnology, Key Laboratory of Clinical Immunology of Jiangsu Province, Soochow University, Jiangsu Suzhou, China
| | - Bin Xu
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Xiao Zheng
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Mingfen Sun
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Wen Wen
- Institute of Biotechnology, Key Laboratory of Clinical Immunology of Jiangsu Province, Soochow University, Jiangsu Suzhou, China
| | - Xichao Dai
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Department of Oncology, the Third Affiliated Hospital, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
| | - Min Yang
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Department of Oncology, the Third Affiliated Hospital, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China.,Institute of Biotechnology, Key Laboratory of Clinical Immunology of Jiangsu Province, Soochow University, Jiangsu Suzhou, China
| | - Quansheng Lv
- Institute of Biotechnology, Key Laboratory of Clinical Immunology of Jiangsu Province, Soochow University, Jiangsu Suzhou, China
| | - Binfeng Lu
- Department of Immunology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Jingting Jiang
- Department of Tumor Biological Treatment, Soochow University, Changzhou 213003, Jiangsu, China.,Jiangsu Engineering Research Center for tumor Immunotherapy, Changzhou 213003, Jiangsu, China
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19
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Dervenis C, Xynos E, Sotiropoulos G, Gouvas N, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Chrysou E, Emmanouilidis C, Georgiou P, Karachaliou N, Katopodi O, Kountourakis P, Kyriazanos I, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Tekkis P, Triantopoulou C, Tzardi M, Vassiliou V, Vini L, Xynogalos S, Ziras N, Souglakos J. Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:390-416. [PMID: 27708505 PMCID: PMC5049546 DOI: 10.20524/aog.2016.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/10/2016] [Indexed: 12/12/2022] Open
Abstract
There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.
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Affiliation(s)
- Christos Dervenis
- General Surgery, "Konstantopouleio" Hospital of Athens, Greece (Christos Dervenis)
| | - Evaghelos Xynos
- General Surgery, "InterClinic" Hospital of Heraklion, Greece (Evangelos Xynos)
| | | | - Nikolaos Gouvas
- General Surgery, "METROPOLITAN" Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Ioannis Boukovinas
- Medical Oncology, "Bioclinic" of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, "Venizeleion" Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Christos Emmanouilidis
- Medical Oncology, "Interbalkan" Medical Center, Thessaloniki, Greece (Christos Emmanoulidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institut, Barcelona, Spain (Niki Carachaliou)
| | - Ourania Katopodi
- Medical Oncology, "Iaso" General Hospital, Athens, Greece (Ourania Katopoidi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - Ioannis Kyriazanos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, "Ippokrateion" Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, "Theageneion" Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, "Agioi Anargyroi" Hospital of Athens, Greece (Joseph Sgouros)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | | | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Louiza Vini
- Radiation Oncology, "Iatriko" Center of Athens, Greece (Lousa Vini)
| | - Spyridon Xynogalos
- Medical Oncology, "George Gennimatas" General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Nikolaos Ziras
- Medical Oncology, "Metaxas" Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Petrou A, Moris D, Kountourakis P, Fard-Aghaie M, Neofytou K, Felekouras E, Papalampros A. The ALPPS procedure as a novel "liver-first" approach in treating liver metastases of colon cancer: the first experience in Greek Cypriot area. World J Surg Oncol 2016; 14:67. [PMID: 26956733 PMCID: PMC4782321 DOI: 10.1186/s12957-016-0827-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 02/29/2016] [Indexed: 12/18/2022] Open
Abstract
Background Despite recent advances in multimodality and multidisciplinary treatment of colorectal liver metastases, many patients suffer from extensive bilobar disease, which prevents the performance of a single procedure due to an insufficient future liver remnant (FLR). We present a novel indication for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a “liver-first” approach when inadequate FLR was faced preoperatively, in a patient with extensive bilobar liver metastatic disease of colon cancer origin. Case presentation A 51-year-old lady was referred to our center due to a stage IV colon cancer with extensive bilobar liver disease and synchronous colon obstruction. During the multidisciplinary tumor board, it was recommended to proceed first in a palliative loop colostomy (at the level of transverse colon) operation and afterwards to offer her palliative chemotherapy. After seven cycles of chemotherapy, the patient was re-evaluated by CT scans that revealed an excellent response (>30 %), but the metastatic liver disease was still considered inoperable. Moreover, with the completion of 12 cycles, the indicated restaging process showed further response. Subsequent to a thorough review by the multidisciplinary team, it was decided to proceed to the ALPPS procedure as a feasible means to perform extensive or bilobar liver resections, combined with a decreased risk of tumor progression in the interim. Conclusions All in all, ALPPS can offer a feasible but surgically demanding liver-first approach with satisfactory short-term results in selected patients. Larger studies are mandatory to evaluate short- and long-term results of the procedure on survival, morbidity, and mortality.
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Affiliation(s)
- Athanasios Petrou
- Nicosia Surgical Department, Division of Hepatobiliary Pancreatic Surgery, Nicosia General Hospital, Nicosia, Cyprus
| | - Demetrios Moris
- 1st Department of Surgery, Medical School, Laikon General Hospital, University of Athens, Athens, Greece. .,Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. .,, Anastasiou Gennadiou 56, 11474, Athens, Greece.
| | | | - Mohammad Fard-Aghaie
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Kyriakos Neofytou
- Nicosia Surgical Department, Division of Hepatobiliary Pancreatic Surgery, Nicosia General Hospital, Nicosia, Cyprus
| | - Evangelos Felekouras
- 1st Department of Surgery, Medical School, Laikon General Hospital, University of Athens, Athens, Greece
| | - Alexandros Papalampros
- 1st Department of Surgery, Medical School, Laikon General Hospital, University of Athens, Athens, Greece.,Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
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Donati M, Stavrou GA, Stang A, Basile F, Oldhafer KJ. 'Liver-first' approach for metastatic colorectal cancer. Future Oncol 2016; 11:1233-43. [PMID: 25832880 DOI: 10.2217/fon.14.316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The liver-first approach was proposed for the first time in 2006 to obtain resectability of stage IV colorectal cancer patients and complete the therapeutic plan. From then some groups have used this new revolutionary approach reporting promising results. Other alternative strategies have been proposed for metastatic patients. The authors reviewed the literature weighing the pros and cons of each strategy proposed to manage these advanced tumor stages. The therapeutic options are analyzed in the light of oncologic problems and evidence. Also problems, questions and perspectives are given. Even if the 'liver-first' approach seems to be a promising strategy, the ideal diagnostic-therapeutic flowchart for metastatic colorectal cancer is still difficult to standardize. The great heterogeneity of this population of patients is one of the main problems. A 'tailored approach' philosophy is necessary to calibrate, in a multidisciplinary setting, a case-by-case choice of therapeutic options.
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Affiliation(s)
- Marcello Donati
- Department of Surgery & Medical-Surgical Specialties, General & Oncologic Surgery Unit, Vittorio-Emanuele University Hospital, University of Catania, 95122 Catania, Italy
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Wang K, Liu W, Yan XL, Xing BC. Role of a liver-first approach for synchronous colorectal liver metastases. World J Gastroenterol 2016; 22:2126-2132. [PMID: 26877617 PMCID: PMC4726685 DOI: 10.3748/wjg.v22.i6.2126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/11/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility and survival outcomes of a liver-first approach.
METHODS: Between January 2009 and April 2013, 18 synchronous colorectal liver metastases (sCRLMs) patients with a planned liver-first approach in the Hepatopancreatobiliary Surgery Department I of the Beijing Cancer Hospital were enrolled in this study. Clinical data, surgical outcomes, morbidity and mortality rates were collected. The feasibility and long-term outcomes of the approach were retrospectively analyzed.
RESULTS: Sixteen patients (88.9%) completed the treatment protocol for primary and liver tumors. The main reason for treatment failure was liver disease recurrence. The 1 and 3 year overall survival rates were 94.4% and 44.8%, respectively. The median survival time was 30 mo. The postoperative morbidity and mortality were 22.2% and 0%, respectively, following a hepatic resection, and were 18.8% and 0%, respectively, after a colorectal surgery.
CONCLUSION: The liver-first approach appeared to be feasible and safe. It can be performed with a comparable mortality and morbidity to the traditional treatment paradigm. This approach might offer a curative opportunity for sCRLM patients with a high liver disease burden.
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Welsh FKS, Chandrakumaran K, John TG, Cresswell AB, Rees M. Propensity score-matched outcomes analysis of the liver-first approach for synchronous colorectal liver metastases. Br J Surg 2016; 103:600-6. [PMID: 26864820 DOI: 10.1002/bjs.10099] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/06/2015] [Accepted: 12/02/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Liver resection before primary cancer resection is a novel strategy advocated for selected patients with synchronous colorectal liver metastases (sCRLM). This study measured outcomes in patients with sCRLM following a liver-first or classical approach, and used a validated propensity score. METHODS Clinical, pathological and follow-up data were collected prospectively from consecutive patients undergoing hepatic resection for sCRLM at a single centre (2004-2014). Cumulative disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) were calculated by means of Kaplan-Meier analysis. Survival differences were analysed in the whole cohort and in subgroups matched according to Basingstoke Predictive Index (BPI). RESULTS Of 582 patients, 98 had a liver-first and 467 a classical approach to treatment; 17 patients undergoing simultaneous bowel and liver resection were excluded. The median (i.q.r.) BPI was significantly higher in the liver-first compared with the classical group: 8·5 (5-10) versus 8 (4-9) (P = 0·030). Median follow-up was 34 months. The 5-year DFS rate was lower in the liver-first group than in the classical group (23 versus 45·6 per cent; P = 0·001), but there was no difference in 5-year CSS (51 versus 53·8 per cent; P = 0·379) or OS (44 versus 49·6 per cent; P = 0·305). After matching for preoperative BPI, there was no difference in 5-year DFS (37 versus 41·2 per cent for liver-first versus classical approach; P = 0·083), CSS (51 versus 53·2 per cent; P = 0·616) or OS (47 versus 49·1 per cent; P = 0·846) rates. CONCLUSION Patients with sCRLM selected for a liver-first approach had more oncologically advanced disease and a poorer prognosis. They had inferior cumulative DFS than those undergoing a classical approach, a difference negated by matching preoperative BPI.
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Affiliation(s)
- F K S Welsh
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - K Chandrakumaran
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - T G John
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - A B Cresswell
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - M Rees
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke RG24 9NA, UK
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Colorectal cancer with synchronous hepatic metastases: Systematic review of reports comparing synchronous surgery with sequential bowel-first or liver-first approaches. Eur J Surg Oncol 2016; 42:159-65. [DOI: 10.1016/j.ejso.2015.11.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 11/08/2015] [Indexed: 12/16/2022] Open
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25
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Rectal cancer with synchronous liver metastases: Do we have a clear direction? Eur J Surg Oncol 2015; 41:1570-7. [DOI: 10.1016/j.ejso.2015.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/07/2015] [Indexed: 12/12/2022] Open
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Sabbagh C, Cosse C, Ravololoniaina T, Chauffert B, Joly JP, Mauvais F, Regimbeau JM. Oncological strategies for middle and low rectal cancer with synchronous liver metastases. Int J Surg 2015; 23:186-93. [DOI: 10.1016/j.ijsu.2015.08.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/03/2015] [Accepted: 08/22/2015] [Indexed: 01/20/2023]
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Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases. Surg Today 2015; 46:721-8. [DOI: 10.1007/s00595-015-1242-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/21/2015] [Indexed: 02/07/2023]
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Waisberg J, Ivankovics IG. Liver-first approach of colorectal cancer with synchronous hepatic metastases: A reverse strategy. World J Hepatol 2015; 7:1444-1449. [PMID: 26085905 PMCID: PMC4462684 DOI: 10.4254/wjh.v7.i11.1444] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/22/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Recently, there has been a change in the strategy of how synchronous colorectal hepatic metastases are attributed to the development of more valuable protocols of chemotherapy and radiotherapy for neoadjuvant treatment of colorectal neoplasms and their hepatic metastases. There is a consensus that patients with synchronous colorectal hepatic metastases have lower survival than those with metachronous colorectal hepatic metastases. Currently, controversy remains concerning the best approach is sequence in a patient with colorectal cancer and synchronous hepatic metastases resection. To obtain a better patient selection, the authors have suggested the initial realization of systemic chemotherapy in the circumstance of patients with colorectal tumor stage IV, since these patients have a systemic disease. The rationale behind this liver-first strategy is initially the control of synchronous hepatic metastases of colorectal carcinoma, which can optimize a potentially curative hepatic resection and longstanding survival. The liver-first strategy procedure is indicated for patients with colorectal hepatic metastases who require downstaging therapy to make a curative liver resection possible. Thus, the liver-first strategy is considered an option in cases of rectal carcinoma in the early stage and with limited or advanced synchronous colorectal hepatic metastases or in case of patients with asymptomatic colorectal carcinoma, but with extensive liver metastases. Patients undergoing systemic chemotherapy and with progression of neoplastic disease should not undergo hepatic resection, because it does not change the prognosis and may even make it worse. To date, there have been no randomized controlled trials on surgical approach of colorectal synchronous hepatic metastases, despite the relatively high number of available manuscripts on this subject. All of these published studies are observational, usually retrospective, and often non-comparative. The patient selection criteria for the liver-first strategy should be individualized, and the approach of these patients should be performed by a multidisciplinary team so its benefits will be fully realized.
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Robson DE, Lewin J, Cheng AW, O'Rourke NA, Cavallucci DJ. Synchronous colorectal liver metastases in pregnancy and post-partum. ANZ J Surg 2015; 87:800-804. [DOI: 10.1111/ans.13196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Danielle E. Robson
- Hepatopancreatobiliary Unit; Department of General Surgery; Royal Brisbane Hospital; Brisbane Queensland Australia
| | - Joel Lewin
- Hepatopancreatobiliary Unit; Department of General Surgery; Royal Brisbane Hospital; Brisbane Queensland Australia
| | - Anthony W. Cheng
- Hepatopancreatobiliary Unit; Department of General Surgery; Royal Brisbane Hospital; Brisbane Queensland Australia
| | - Nicholas A. O'Rourke
- Hepatopancreatobiliary Unit; Department of General Surgery; Royal Brisbane Hospital; Brisbane Queensland Australia
| | - David J. Cavallucci
- Hepatopancreatobiliary Unit; Department of General Surgery; Royal Brisbane Hospital; Brisbane Queensland Australia
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Ihnát P, Vávra P, Zonča P. Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go? World J Gastroenterol 2015; 21:7014-7021. [PMID: 26078580 PMCID: PMC4462744 DOI: 10.3748/wjg.v21.i22.7014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 02/06/2015] [Accepted: 04/03/2015] [Indexed: 02/07/2023] Open
Abstract
AIM: To offer an up-to-date review of all available treatment strategies for patients with synchronous colorectal liver metastases (CLM).
METHODS: A comprehensive literature search was performed to identify articles related to the management of patients with synchronous CLM. A search of the electronic databases PubMed, MEDLINE, and Google Scholar was conducted in September 2014. The following search terms were used: synchronous colorectal liver metastases, surgery, stage IV colorectal cancer, liver-first approach, and up-front hepatectomy. These terms were employed in various combinations to maximize the search. Only articles written in English were included. Particular attention was devoted to studies and review articles that were published within the last six years (2009-2014). Additional searches of the cited references from primary articles were performed to further improve the review. The full texts of all relevant articles were accessed by two independent reviewers.
RESULTS: Poor long-term outcomes of patients with synchronous CLM managed by a traditional treatment strategy have led to questions about the timing and sequence of possible therapeutic interventions. Thus, alternative paradigms called reverse strategies have been proposed. Presently, there are four treatment strategies available: (1) primary first approach (or traditional approach) comprises resection of the primary colorectal tumor followed by chemotherapy; subsequent liver resection is performed 3-6 mo after colorectal resection (provided that CLM are still resectable); (2) simultaneous resection of the primary colorectal tumor and CLM during a single operation presents intriguing options for a highly select group of patients, which can be associated with significant postoperative morbidity; (3) liver-first (or chemotherapy-first) approach comprises preoperative chemotherapy (3-6 cycles) followed by liver resection, adjuvant chemotherapy, and resection of the primary colorectal tumor (it is best suited for patients with asymptomatic primary tumors and initially unresectable or marginally resectable CLM); and (4) up-front hepatectomy (or “true” liver-first approach) includes liver resection followed by adjuvant chemotherapy, colorectal resection, and adjuvant chemotherapy (strategy can be offered to patients with asymptomatic primary tumors and initially resectable CLM).
CONCLUSION: None of the aforementioned strategies appears inferior. It is necessary to establish individual treatment plans in multidisciplinary team meetings through careful appraisal of all strategies.
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Abstract
Colorectal cancer is a common malignancy and often presents with synchronous or metachronous distant spread. For patients with hepatic metastases, resection is the principal curative option. Liberalization of the indications for hepatic resection has introduced a number of challenges related to the size, distribution, and number of metastases as well as the condition of the future liver remnant. Advances in systemic therapy have solidified its role as both an important adjunct to surgery and also for many patients as a mechanism to facilitate resection. In patients whose disease is marginally resectable as a consequence of the distribution of hepatic lesions that precludes complete resection or out of concern for the future liver remnant, a number of strategies have been advocated, including prehepatectomy systemic therapy, staged surgical approaches, ablative technologies, and preoperative portal vein embolization. It is the purpose of this review to discuss ways in which to optimize the treatment of patients with potentially resectable disease, specifically those who are judged to have "borderline" resectable situations.
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Ahmed S, Bathe O, Berry S, Buie D, Davies J, Doll C, Dowden S, Gill S, Gordon V, Hebbard P, Jones E, Kennecke H, Koski S, Krahn M, Le D, Lim H, Lund C, Luo Y, Mcffadden A, Mcghie J, Mulder K, Park J, Rashidi F, Sami A, Tan KT, Wong R. Consensus statement: the 16th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; September 5-6, 2014. ACTA ACUST UNITED AC 2015; 22:e113-23. [PMID: 25908916 DOI: 10.3747/co.22.2362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 16th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, September 4-5, 2014. The Consensus Conference is an interactive, multidisciplinary event attended by health care professionals from across western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) involved in the care of gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.
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Affiliation(s)
- S Ahmed
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - O Bathe
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - S Berry
- Ontario: Medical Oncology (Berry), Sunnybrook Odette Cancer Centre, University of Toronto, Toronto
| | - D Buie
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - J Davies
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - C Doll
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - S Dowden
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - S Gill
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - V Gordon
- Manitoba: Medical Oncology (Gordon, Krahn, Wong), Cancer Care Manitoba, University of Manitoba, Winnipeg; Surgery (Hebbard, Park), University of Manitoba, Winnipeg
| | - P Hebbard
- Manitoba: Medical Oncology (Gordon, Krahn, Wong), Cancer Care Manitoba, University of Manitoba, Winnipeg; Surgery (Hebbard, Park), University of Manitoba, Winnipeg
| | - E Jones
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - H Kennecke
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - S Koski
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - M Krahn
- Manitoba: Medical Oncology (Gordon, Krahn, Wong), Cancer Care Manitoba, University of Manitoba, Winnipeg; Surgery (Hebbard, Park), University of Manitoba, Winnipeg
| | - D Le
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - H Lim
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - C Lund
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - Y Luo
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - A Mcffadden
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - J Mcghie
- British Columbia: Medical Oncology (Davies), BC Cancer Agency-Centre for the Southern Interior, Kelowna; Medical Oncology (Gill, Kennecke, Lim, Mcghie), BC Cancer Agency, University of BC, Vancouver; Radiation Oncology (Lund), BC Cancer Agency-Fraser Valley Cancer Centre, Fraser Valley; Surgical Oncology (Mcffadden), BC Cancer Agency, Vancouver
| | - K Mulder
- Alberta: Department of Surgery (Bathe, Buie), University of Calgary, Calgary; Radiation Oncology (Doll) and Medical Oncology (Dowden), Tom Baker Cancer Centre, University of Calgary, Calgary; Medical Oncology (Koski, Mulder), Cross Cancer Centre, University of Alberta, Edmonton
| | - J Park
- Manitoba: Medical Oncology (Gordon, Krahn, Wong), Cancer Care Manitoba, University of Manitoba, Winnipeg; Surgery (Hebbard, Park), University of Manitoba, Winnipeg
| | - F Rashidi
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - A Sami
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - K T Tan
- Saskatchewan: Medical Oncology (Ahmed, Sami) and Radiation Oncology (Le), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Pathology (Jones), University of Saskatchewan, Regina; Surgery (Luo), Diagnostic Radiology (Rashidi), and Interventional Radiology (Tan), University of Saskatchewan, Saskatoon
| | - R Wong
- Manitoba: Medical Oncology (Gordon, Krahn, Wong), Cancer Care Manitoba, University of Manitoba, Winnipeg; Surgery (Hebbard, Park), University of Manitoba, Winnipeg
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Kassahun WT. Unresolved issues and controversies surrounding the management of colorectal cancer liver metastasis. World J Surg Oncol 2015; 13:61. [PMID: 25890279 PMCID: PMC4340492 DOI: 10.1186/s12957-014-0420-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 12/23/2014] [Indexed: 02/06/2023] Open
Abstract
Ideally, tumors that might cause morbidity and mortality should be treated, preferably early, with proven, convincing, and effective therapy to prevent tumor progression or recurrence, while maintaining a favorable risk-benefit profile for the individual patient. For patients with colorectal cancer (CRC), this diagnostic, prognostic, and therapeutic precision is currently impossible. Despite significant improvements in diagnostic procedures, a sizable number of patients with CRC have liver metastases either at presentation or will subsequently develop it. And in many parts of the world, most cancer-related deaths are still due to metastases that are resistant to conventional therapy. Metastases to the liver occur in more than 50% of patients with CRC and represent the major determinant of outcome following curative treatment of the primary tumor. Liver resection offers the best chance of cure for metastases confined to the liver. However, due to a paucity of randomized controlled trials, its timing is controversial and a hotly debated topic. This article reviews some of the main controversies surrounding the surgical management of colorectal cancer liver metastases (CRLM).
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Affiliation(s)
- Woubet T Kassahun
- Department of Surgery II, Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, OKL, University of Leipzig, Liebig Str. 20, 04103, Leipzig, Germany.
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Fazeli MS, Keramati MR. Rectal cancer: a review. Med J Islam Repub Iran 2015; 29:171. [PMID: 26034724 PMCID: PMC4431429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/24/2014] [Indexed: 11/22/2022] Open
Abstract
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.
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Affiliation(s)
- Mohammad Sadegh Fazeli
- 1 Associate Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Keramati
- 2 Assistant Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
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Tanaka K, Murakami T, Matsuo K, Hiroshima Y, Endo I, Ichikawa Y, Taguri M, Koda K. Preliminary results of 'liver-first' reverse management for advanced and aggressive synchronous colorectal liver metastases: a propensity-matched analysis. Dig Surg 2015; 32:16-22. [PMID: 25613745 DOI: 10.1159/000370253] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/30/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although a 'liver-first' approach recently has been advocated in treating synchronous colorectal metastases, little is known about how results compare with those of the classical approach among patients with similar grades of liver metastases. METHODS Propensity-score matching was used to select study subjects. Oncologic outcomes were compared between 10 consecutive patients with unresectable advanced and aggressive synchronous colorectal liver metastases treated with the reverse strategy and 30 comparable classically treated patients. RESULTS Numbers of recurrence sites and recurrent tumors irrespective of recurrence sites were greater in the reverse group then the classic group (p = 0.003 and p = 0.015, respectively). Rates of freedom from recurrence in the remaining liver and of freedom from disease also were poorer in the reverse group than in the classical group (p = 0.009 and p = 0.043, respectively). Among patients treated with 2-stage hepatectomy, frequency of microvascular invasion surrounding macroscopic metastases at second resection was higher in the reverse group than in the classical group (p = 0.011). CONCLUSIONS Reverse approaches may be feasible in treating synchronous liver metastases, but that strategy should be limited to patients with less liver tumor burden.
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Affiliation(s)
- Kuniya Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
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Buchs NC, Ris F, Majno PE, Andres A, Cacheux W, Gervaz P, Roth AD, Terraz S, Rubbia-Brandt L, Morel P, Mentha G, Toso C. Rectal outcomes after a liver-first treatment of patients with stage IV rectal cancer. Ann Surg Oncol 2014; 22:931-7. [PMID: 25201505 DOI: 10.1245/s10434-014-4069-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The treatment of patients with metastatic rectal cancer remains controversial. We developed a reverse strategy, the liver-first approach, to optimize the chance of a curative resection. The aim of this study was to assess rectal outcomes after reverse treatment of patients with metastatic rectal cancer. METHODS From May 2000 to November 2013, a total of 34 consecutive selected patients with histology-proven adenocarcinoma of the rectum and liver metastases were prospectively entered into a dedicated computerized database. All patients were treated via our reverse strategy. Rectal and overall survival outcomes were analyzed. RESULTS Most patients presented with advanced disease (median Fong clinical risk score of 3; range 2-5). One patient failed to complete the whole treatment (3%). Rectal surgery was performed after a median of 3.9 months (range 0.4-17.8 months). A total of 73.3% patients received preoperative radiotherapy. Perioperative mortality and morbidity rates were 0 and 27.3% after rectal surgery. Severe complications were reported in two patients (6.1%): one anastomotic leak and one systemic inflammatory response syndrome. The median hospital stay was 11 days (range 5-23 days). Complete local pathological response was observed in three patients (9.1%). The median number of lymph nodes collected was 14. The R0 rate was 93.9%. There was no positive circumferential margin. After a mean follow-up of 36 months after rectal surgery, 5-year overall survival was 52.5%. Five patients experienced pelvic recurrence. CONCLUSIONS In our cohort of selected patients with stage IV rectal cancer, the reverse strategy was not only safe and effective, but also oncologically promising, with a low morbidity rate and high long-term survival.
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Affiliation(s)
- Nicolas C Buchs
- Department of Surgery, Clinic for Visceral and Transplantation Surgery, University Hospital of Geneva, Geneva, Switzerland,
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Castellanos JA, Merchant NB. Strategies for Management of Synchronous Colorectal Metastases. CURRENT SURGERY REPORTS 2014; 2:62. [PMID: 25431745 DOI: 10.1007/s40137-014-0062-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of synchronous presentation of colorectal cancer and liver metastases has long been a topic of debate and discussion for surgeons due to the unique dilemma of balancing operative timing along with treatment strategy. Operative strategies for resection include staged resection with colon first approach, "reverse" staged resection with liver metastases resected first, and one-stage, or simultaneous, resection of both the primary tumor and liver metastases approach. These operative strategies can be further augmented with perioperative chemotherapy and other novel approaches that may improve resectability and patient survival. The decision on operative timing and approach, however, remains largely dependent on the surgeon's determination of disease resectability, patient fitness, and the need for neoadjuvant chemotherapy.
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Affiliation(s)
- Jason A Castellanos
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nipun B Merchant
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Siriwardena AK, Mason JM, Mullamitha S, Hancock HC, Jegatheeswaran S. Management of colorectal cancer presenting with synchronous liver metastases. Nat Rev Clin Oncol 2014; 11:446-59. [DOI: 10.1038/nrclinonc.2014.90] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sahay SJ, Glynne-Jones R, Davidson BR. Current Evidence for Chemotherapy, Chemoradiation, and the Liver-First Approach for the Management of Patients With Rectal Cancer and Synchronous Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2014. [DOI: 10.1007/s11888-014-0225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lykoudis PM, O'Reilly D, Nastos K, Fusai G. Systematic review of surgical management of synchronous colorectal liver metastases. Br J Surg 2014; 101:605-12. [PMID: 24652674 DOI: 10.1002/bjs.9449] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND The optimal management of colorectal cancer with synchronous liver metastases has not yet been elucidated. The aim of the present study was systematically to review current evidence concerning the timing and sequence of surgical interventions: colon first, liver first or simultaneous. METHODS A systematic literature review was performed of clinical studies comparing the timing and sequence of surgical interventions in patients with synchronous liver metastases. Retrospective studies were included but case reports and small case series were excluded. Preoperative and intraoperative data, length of hospital stay, perioperative mortality and morbidity, and 1-, 3- and 5-year survival rates were compared. The studies were evaluated according to a modification of the methodological index for non-randomized studies (MINORS) criteria. RESULTS Eighteen papers were included and 21 entries analysed. Five entries favoured the simultaneous approach regarding duration of procedure, whereas three showed no difference; five entries favoured simultaneous treatment in terms of blood loss, whereas in four there was no difference; and all studies comparing length of hospital stay favoured the simultaneous approach. Five studies favoured the simultaneous approach in terms of morbidity and eight found no difference, and no study demonstrated a difference in perioperative mortality. One study suggested a better 5-year survival rate after staged procedures, and another suggested worse 1-year but better 3- and 5-year survival rates following the simultaneous approach. The median MINORS score was 10, with incomplete follow-up and outcome reporting accounting primarily for low scores. CONCLUSION None of the three surgical strategies for synchronous colorectal liver metastases appeared inferior to the others.
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Affiliation(s)
- P M Lykoudis
- Hepatopancreatobiliary Surgery and Liver Transplantation, 8 South, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
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Lam VWT, Laurence JM, Pang T, Johnston E, Hollands MJ, Pleass HCC, Richardson AJ. A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases. HPB (Oxford) 2014; 16:101-8. [PMID: 23509899 PMCID: PMC3921004 DOI: 10.1111/hpb.12083] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 01/26/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since the liver metastases rather than the colorectal cancer itself is the main determinant of patient's survival, the 'Liver-First Approach (LFA)' with upfront chemotherapy followed by a hepatic resection of colorectal liver metastases (CLM) and finally a colorectal cancer resection was proposed. The aim of this review was to analyse the evidence for LFA in patients with colorectal cancer and synchronous CLM. METHODS A literature search of databases (MEDLINE and EMBASE) to identify published studies of LFA in patients with colorectal cancer and synchronous CLM was undertaken focussing on the peri-operative regimens of LFA and survival outcomes. RESULTS Three observational studies and one retrospective cohort study were included for review. A total of 121 patients with colorectal cancer and synchronous CLM were selected for LFA. Pre-operative chemotherapy was used in 99% of patients. One hundred and twelve of the initial 121 patients (93%) underwent a hepatic resection of CLM. In total, 60% had a major liver resection and the R0 resection rate was 93%. Post-operative morbidity and mortality after the hepatic resection were 20% and 1%, respectively. Ultimately, 89 of the initial 121 (74%) patients underwent a colorectal cancer resection. Post-operative morbidity and mortality after a colorectal resection were 50% and 6%, respectively. The median overall survival was 40 months (range 19-50) with a recurrence rate of 52%. CONCLUSIONS Current evidence suggests that LFA is safe and feasible in selected patients with colorectal cancer and synchronous CLM. Future studies are required to further define patient selection criteria for LFA and the exact role of LFA in the management of synchronous CLM.
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Affiliation(s)
- Vincent WT Lam
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Jerome M Laurence
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
| | - Tony Pang
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Emma Johnston
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Michael J Hollands
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Henry CC Pleass
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Arthur J Richardson
- Department of Surgery Westmead Hospital, University of SydneySydney, NSW, Australia
- Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
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Denstman F. An approach to the newly diagnosed colorectal cancer patient with synchronous stage 4 disease. Surg Oncol Clin N Am 2013; 23:151-60. [PMID: 24267171 DOI: 10.1016/j.soc.2013.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
At initial presentation, 20% to 30% of patients with colon and rectal cancer have detectable metastatic disease. Precise guidelines are lacking for the treatment of this special subset. Most of these patients have only hepatic metastases. Treatment recommendations for these stage 4 patients must take into account characteristics of the primary tumor, the potential resectability of the metastatic disease, and the proper role of chemotherapy and radiation therapy. Because of the tremendous variability of these characteristics, recommendations must be individualized. This article is a basic approach to the treatment of these patients.
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Affiliation(s)
- Frederick Denstman
- Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA.
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"Liver-first" approach for synchronous colorectal liver metastases: is this a justifiable approach? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:263-70. [PMID: 23325126 DOI: 10.1007/s00534-012-0583-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To review the outcomes of patients with synchronous colorectal liver metastases (CRLM) treated by the "liver-first" approach. METHODS Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords "colorectal cancer", "liver-first", "reverse strategy", "liver metastases", "liver resection" and "hepatectomy". RESULTS There have been four retrospective studies that have reported the outcomes of patients with synchronous CRLM following the reverse strategy. The number of patients included ranged from 16 to 27. One study included patients with advanced rectal cancer and synchronous liver metastases only. None of the studies defined resectability for the CRLM. Overall, the morbidity and mortality rates were low. The recurrence rate ranged from 25 to 70 %. One study did not report survival data, and the overall 5 year survival ranged from 31 to 41 %. CONCLUSION The "liver-first" approach may be beneficial to a selected group of patients with synchronous CRLM. Patient selection is likely to be determined by their response to down-staging chemotherapy with or without biological agents.
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de Rosa A, Gomez D, Hossaini S, Duke K, Fenwick SW, Brooks A, Poston GJ, Malik HZ, Cameron IC. Stage IV colorectal cancer: outcomes following the liver-first approach. J Surg Oncol 2013; 108:444-9. [PMID: 24009161 DOI: 10.1002/jso.23429] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 08/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date, there is limited data on the liver-first approach in the management of colorectal liver metastases (CRLM). The aim of the study was to assess the outcomes of the liver-first approach for patients with synchronous CRLM in two tertiary referral centers. METHODS Patients with stage IV colorectal cancer selected for the liver-first approach from January 2009 to December 2012 in two tertiary referral centers were included. Data collated included demographics, chemotherapy, operative findings, histo-pathological features, and survival. RESULTS Thirty-seven patients with synchronous CRLM were considered for the liver-first approach. Twenty-five patients had rectal cancer. All patients underwent induction chemotherapy. Thirty patients underwent hepatic resections with no post-operative deaths. Following liver resection, five patients failed to proceed to colorectal resection and one patient had complete response to chemo-radiotherapy. Of the 25 patients that completed the liver-first approach, 13 patients had recurrent disease, of which 12 patients died. The overall 1- and 3-year survival rates were 65.9% and 30.4%, respectively. CONCLUSION The liver-first approach is a feasible strategy for patients with synchronous CRLM and may improve survival in selected patients. The selection of patients should be incorporated in a multidisciplinary approach to achieve the best possible outcomes.
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Affiliation(s)
- Antonella de Rosa
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Ceelen W, Pattyn P, Mareel M. Surgery, wound healing, and metastasis: recent insights and clinical implications. Crit Rev Oncol Hematol 2013; 89:16-26. [PMID: 23958676 DOI: 10.1016/j.critrevonc.2013.07.008] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/15/2013] [Accepted: 07/18/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Surgery-induced acceleration of tumour growth has been observed since several centuries. METHODS We reviewed recent insights from in vitro data, animal experimentation, and clinical studies on how surgery-induced wound healing or resection of a primary cancer influences the tumour-host ecosystem in patients harbouring minimal residual or metastatic disease. RESULTS Most of the growth factors, chemokines, and cytokines orchestrating surgical wound healing promote tumour growth, invasion, or angiogenesis. In addition, resection of a primary tumour may accelerate synchronous metastatic growth. In the clinical setting, indirect evidence supports the relevance of the above findings. Randomized clinical trials are underway comparing resection versus observation in metastatic breast and colon cancer with asymptomatic primary tumours. CONCLUSIONS In depth knowledge of how surgical intervention alters the tumour-host-metastasis communicating ecosystems could have important implications for clinical decision making in patients with synchronous metastatic disease and for the design and timing of multimodality treatment strategies.
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Affiliation(s)
- Wim Ceelen
- Department of of Surgery, Ghent University Hospital, B-9000 Ghent, Belgium.
| | - Piet Pattyn
- Department of of Surgery, Ghent University Hospital, B-9000 Ghent, Belgium
| | - Marc Mareel
- Department of Radiotherapy and Experimental Cancer Research, Ghent University Hospital, B-9000 Ghent, Belgium
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van den Broek MAJ, Vreuls CPH, Winstanley A, Jansen RLH, van Bijnen AA, Dello SAWG, Bemelmans MH, Dejong CHC, Driessen A, Olde Damink SWM. Hyaluronic acid as a marker of hepatic sinusoidal obstruction syndrome secondary to oxaliplatin-based chemotherapy in patients with colorectal liver metastases. Ann Surg Oncol 2013; 20:1462-9. [PMID: 23463086 DOI: 10.1245/s10434-013-2915-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND A considerable number of patients develop sinusoidal obstruction syndrome (SOS) after oxaliplatin-based chemotherapy for colorectal liver metastases (CLMs). SOS is associated with adverse outcomes after major hepatectomy. Hyaluronic acid (HA) is a marker of hepatic sinusoidal endothelial cell function and may serve as an accurate marker of SOS. This study aimed to assess the value of systemic HA levels and fractional extraction (FE) of HA by the splanchnic area and liver as markers of SOS after oxaliplatin-based chemotherapy for CLMs. METHODS Forty patients were studied. The presence of SOS was assessed histopathologically. Blood samples from the radial artery and portal and hepatic veins were collected. HA levels were determined by ELISA and the FE of HA was estimated. RESULTS SOS was present in 23 patients, 11 of whom demonstrated moderate or severe SOS. Preoperative HA levels were significantly higher in patients with moderate or severe SOS (group B, n = 11) compared to patients with no or mild SOS (group A, n = 29) (51.6 ± 10.2 ng/mL vs. 32.1 ± 3.5 ng/mL, p = 0.030). A cutoff HA level of 44.1 ng/mL yielded a sensitivity of 67 % and specificity of 83 % for detection of SOS. The positive predictive value was 50 % and the negative predictive value 91 %. Both groups exhibited a similar FE of HA by the splanchnic area (-7.9 ± 8.5 % in Group A vs. 7.3 ± 3.6 % in Group B, p = 0.422) and liver (-10.7 ± 6.2 % in Group A vs. 4.6 ± 2.3 % in Group B, p = 0.265). CONCLUSIONS Systemic HA levels can be used to detect patients at risk of SOS after oxaliplatin-based chemotherapy for CLMs. Additional investigations into the presence of SOS are indicated in patients with elevated HA levels.
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Ayez N, Burger JWA, van der Pool AE, Eggermont AMM, Grunhagen DJ, de Wilt JHW, Verhoef C. Long-term results of the "liver first" approach in patients with locally advanced rectal cancer and synchronous liver metastases. Dis Colon Rectum 2013; 56:281-7. [PMID: 23392140 DOI: 10.1097/dcr.0b013e318279b743] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are no reports available on the long-term outcome of patients with the "liver first" approach. OBJECTIVES The aim of this study was to present the long-term results of the "liver first" approach in our center. DESIGN This study is a retrospective analysis. SETTING This study was conducted at a tertiary referral center. PATIENTS Patients from May 2003 to March 2009 were included. INTERVENTIONS Patients with locally advanced rectal cancer and synchronous liver metastases were first treated for their liver metastases. If the treatment was successful, patients underwent neoadjuvant chemoradiotherapy and surgery for the rectal cancer. If metastases could not be resected, resection of the rectal primary was not routinely performed. MAIN OUTCOME MEASURES The primary outcome measured was long-term results of the "liver first" approach. RESULTS Of the 42 patients included (median age, 61 years), all but one (98%) started with neoadjuvant chemotherapy. In total, 31 (74%) patients completed the "liver first" approach. In 11 patients, curative therapy was not possible because of unresectable metastases; in 10 of these patients (91%), the primary tumor was not resected. LIMITATIONS This study was limited because it was a retrospective analysis without a control group. CONCLUSIONS By applying the "liver first" approach, the majority of this group of patients (74%) could undergo curative treatment of both metastatic and primary disease in combination with optimal neoadjuvant therapy. This strategy may avoid unnecessary rectal surgery in patients with incurable metastatic disease. In this selected patient group, long-term survival may be achieved with a 5-year survival rate of 67%.
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Affiliation(s)
- Ninos Ayez
- Division of Surgical Oncology, Erasmus MC, Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Hasegawa K, Takahashi M, Ohba M, Kaneko J, Aoki T, Sakamoto Y, Sugawara Y, Kokudo N. Perioperative chemotherapy and liver resection for hepatic metastases of colorectal cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:503-8. [PMID: 22426591 DOI: 10.1007/s00534-012-0509-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Surgical resection has played a major role in the treatment for colorectal liver metastases. The safety and efficacy of surgery for liver metastasis are obvious, although there are some differences between the western countries and Japan concerning the surgical indication, procedures, timing of chemotherapies in a perioperative period, and treatment of a primary disease. In future, long-term outcomes after surgical resection for colorectal liver metastases would be expected to be prolonged by combination of surgery and chemotherapies.
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Affiliation(s)
- Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Is there a role for simultaneous hepatic and colorectal resections? A contemporary view from NSQIP. J Gastrointest Surg 2012; 16:2074-85. [PMID: 22972010 DOI: 10.1007/s11605-012-1990-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 07/25/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. We aimed to compare perioperative outcomes of simultaneous colorectal/liver resection (SCLR) with isolated resections utilizing a national clinical database. METHODS NSQIP data from 2005 to 2009 were examined to construct risk-adjusted generalized linear models and to calculate group-specific predicted estimates. These were used to compare 30-day perioperative outcomes among patients undergoing SCLR with colorectal (CR) and liver resections (LR) only in patients with metastatic colorectal cancer. RESULTS A total of 3,983 patients were identified, who underwent SCLR (192), LR (1,857), or CR (1,934). Rectal resection was performed in 45 (23.4 %) SCLR patients and 269 (13.9 %) CR patients (p < 0.001). Major hepatectomy was performed in 69 (35.9 %) SCLR patients and 774 (41.7 %) LR patients (p = 0.12). Median adjusted operation time (SCLR: 273 min, 95 % CI: 253-295; CR: 172, CI: 168-177; LR: 222, CI: 217-228; p < 0.001) and median adjusted length of hospital stay (SCLR: 9.5 days, CI: 8.8-10.4; CR: 8.1, CI: 7.9-8.3; LR: 6.4, CI: 6.3-6.6; p < 0.001) were longer for SCLR compared to CR and LR. Adjusted predicted risks for at least one postoperative complication were higher in SCLR (36.3 %) than in CR (26.6 %) and LR (19.8 %) (p < 0.003), mostly due to infectious/cardiopulmonary issues. DISCUSSION In SCLR patients, the risk of 30-day adverse outcomes is higher, and median operation time as well as length of hospital stay is longer compared to CR and LR patients. However, the expected combined morbidities of staged procedures though likely favor SCLR in carefully selected patients undergoing even complex hepatic and colorectal resections and should be considered.
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Adam R, De Gramont A, Figueras J, Guthrie A, Kokudo N, Kunstlinger F, Loyer E, Poston G, Rougier P, Rubbia-Brandt L, Sobrero A, Tabernero J, Teh C, Van Cutsem E. The oncosurgery approach to managing liver metastases from colorectal cancer: a multidisciplinary international consensus. Oncologist 2012; 17:1225-39. [PMID: 22962059 DOI: 10.1634/theoncologist.2012-0121] [Citation(s) in RCA: 376] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
An international panel of multidisciplinary experts convened to develop recommendations for the management of patients with liver metastases from colorectal cancer (CRC). The aim was to address the main issues facing the CRC hepatobiliary multidisciplinary team (MDT) when managing such patients and to standardize the treatment patients receive in different centers. Based on current evidence, the group agreed on a number of issues including the following: (a) the primary aim of treatment is achieving a long disease-free survival (DFS) interval following resection; (b) assessment of resectability should be performed with high-quality cross-sectional imaging, staging the liver with magnetic resonance imaging and/or abdominal computed tomography (CT), depending on local expertise, staging extrahepatic disease with thoracic and pelvic CT, and, in selected cases, fluorodeoxyglucose positron emission tomography with ultrasound (preferably contrast-enhanced ultrasound) for intraoperative staging; (c) optimal first-line chemotherapy-doublet or triplet chemotherapy regimens combined with targeted therapy-is advisable in potentially resectable patients; (d) in this situation, at least four courses of first-line chemotherapy should be given, with assessment of tumor response every 2 months; (e) response assessed by the Response Evaluation Criteria in Solid Tumors (conventional chemotherapy) or nonsize-based morphological changes (antiangiogenic agents) is clearly correlated with outcome; no imaging technique is currently able to accurately diagnose complete pathological response but high-quality imaging is crucial for patient management; (f) the duration of chemotherapy should be as short as possible and resection achieved as soon as technically possible in the absence of tumor progression; (g) the number of metastases or patient age should not be an absolute contraindication to surgery combined with chemotherapy; (h) for synchronous metastases, it is not advisable to undertake major hepatic surgery during surgery for removal of the primary CRC; the reverse surgical approach (liver first) produces as good an outcome as the conventional approach in selected cases; (i) for patients with resectable liver metastases from CRC, perioperative chemotherapy may be associated with a modestly better DFS outcome; and (j) whether initially resectable or unresectable, cure or at least a long survival duration is possible after complete resection of the metastases, and MDT treatment is essential for improving clinical and survival outcomes. The group proposed a new system to classify initial unresectability based on technical and oncological contraindications.
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Affiliation(s)
- René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, UMR-S 776, Villejuf, France.
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