Prognostic factors and survival after resection of colorectal liver metastasis in the era of preoperative chemotherapy: an 11-year single-centre study

The Effect of Hepatic Surgical Margins of Colorectal Liver Metastases on Prognosis: A Systematic Review and Meta-Analysis

Introduction: Colorectal cancer is the third most common malignancy, with around half of patients developing liver metastases. Hepatectomy is the preferred treatment, but its success depends on several factors, including surgical margins. Various surgical margins have been suggested to achieve optimal results. This systematic review and meta-analysis aim to explore the impact of negative surgical margins ranging from 1 to 10 mm, and >10 mm on survival, with the objective of identifying optimal surgical margins. Methods: A systematic literature search was conducted on the MEDLINE, Scopus, and Cochrane databases. The six included studies that examined the effect of surgical margins at the aforementioned distances on patient survival. Studies were assessed for risk of bias using the Quality in Prognosis Studies tool. Statistical analysis was performed using SPSS software. Results: The results of the meta-analysis revealed the superiority of wider surgical margins (>10) on overall survival compared to smaller margins (1-10 mm), as the HR was calculated to be 1.38 [1.10; 1.73]. Specifically, negative margins between 1 and 10 mm are linked to a 38% increased risk of mortality compared to margins larger than 10 mm. The low heterogeneity indicates consistent findings across studies, and the statistically significant hazard ratio underscores the importance of aiming for larger surgical margins to enhance patient outcomes. In the subgroup that included only studies in which patients received neoadjuvant therapy, the HR was 1.48 [1.06; 2.07], further emphasizing the importance of ensuring negative surgical margins in today's era. Conclusions: In summary, this systematic review and meta-analysis highlights the impact of surgical margin width on the survival of patients with colorectal liver metastases, as well as the importance of margin optimization in surgical management strategies.

Patterns and Predictors of Recurrence After Curative Resection of Colorectal Liver Metastasis (CRLM)

BACKGROUND

Our study aims to determine the predictors and patterns of relapses after curative colorectal liver metastasis (CRLM) resection.

METHODS

A single-centre, retrospective study of CRLM patients operated between 2010 and 2022 was performed. The site of first recurrence was either hepatic (marginal (≤ 1 cm) or extramarginal), extrahepatic, or both. Factors that predicted relapse patterns and overall survival were determined by multivariable Cox regression analysis with backward elimination of variables.

RESULTS

The study consisted of 258 patients, with a similar proportion of synchronous (144; 56%) and metachronous(114; 43%) metastasis. At a 43-month median follow-up, 156 patients (60.4%) developed recurrences with 33 (21.1%) in the liver, 62(24.03%) extra-hepatic recurrences, and 58 (22.48%) having both. Isolated marginal liver relapses were seen in seven (9.89%) liver recurrence patients. The median overall and relapse-free survivals were 38 months (30-54) and 13 months (11-16), respectively. The 3-year liver-relapse-free survival was 54.4% (44.9-60.6). Size of liver metastases > 5 cm (HR 2.06 (1.34-3.17), involved surgical margins (HR 2.16 (1.27-3.68)), and adjuvant chemotherapy (HR 1.89 (1.07-3.35)) were predictors of hepatic recurrences. Node positivity of primary (HR 1.61 (1.02-2.56)), presence of baseline extra-hepatic metastases (HR 0.30 (0.18-0.51)), size of liver metastases > 5 cm (HR 2.02 (1.37-2.99)), poorly differentiated histology (HR 2.25 (1.28-3.49)), presence of LVI (HR 2.25 (1.28-3.94)), and adjuvant chemotherapy (HR 2.15 (1.28-3.61)) were predictors of extra-hepatic recurrences.

CONCLUSION

The study found majority relapses occurred at extrahepatic sites whilst isolated marginal recurrences were few. The consistent predictors of recurrence were size and inability to deliver adjuvant therapy. A tailored adjuvant therapy might improve outcomes after liver metastasectomy in colorectal cancers.

Meta-analysis of the prognostic value of serum carcinoembryonic antigen in patients with colorectal cancer liver metastases after hepatectomy

OBJECTIVES

Carcinoembryonic antigen (CEA) is a broad-spectrum tumor marker for differential diagnosis, monitoring, and response assessment of a variety of malignancies. This meta-analysis was aimed at evaluating whether serum CEA could predict the prognosis in patients with colorectal cancer liver metastasis (CRCLM) before and after liver resection (LR).

METHODS

PubMed, Embase, Cochrane, and Web of Science were systematically searched to retrieve literature, with a search cutoff date of 27 February 2023. Articles were strictly screened for inclusion according to pre-specified inclusion and exclusion criteria. Data were pooled and analyzed using Stata 16.0.

RESULTS

This meta-analysis included 36 studies involving a total of 11 143 CRCLM patients. The results showed that a high pre-LR serum CEA level was correlated with poor overall survival (OS: HR = 1.61, 95% CI = 1.49-1.75, P  < 0.001) and recurrence-free survival (RFS: HR = 1.27, 95% CI = 1.11-1.45, P  < 0.001) in CRCLM patients. A high post-LR serum CEA level predicted poor overall survival (OS: HR = 2.66, 95% CI = 2.10-3.38, P  < 0.001).

CONCLUSION

High preoperative and postoperative serum CEA levels in patients with CRCLM were significantly associated with poor prognosis, independent of treatment modality, mode of analysis, case origin, and cutoff value classification.

Liver Transplantation for Nonresectable Colorectal Liver Metastases (CRLM)

Transplantation represents the most radical locoregional therapy through removal of the liver, associated vasculature and locoregional lymph nodes, and replacing it with an allograft. Recent evidence has demonstrated that transplantation for unresectable CRLM is feasible with acceptable post-transplant outcomes in a highly selected cohort of patients. Controversy exists regarding whether transplantation is an appropriate treatment for such patients, due to concerns regarding disease recurrence in the transplanted graft in an immunosuppressed recipient along with utilising a donor liver which are in short supply. Expanding the indications for liver transplantation may also limit access for other patients with end-stage liver disease having ethical implications due to the effect of increasing the waiting list. In this review, we summarise the current evidence for liver transplantation in patients with nonresectable CRLM and highlight unresolved controversies and future directions for this type of treatment.

Prognostic role of serum carcinoembryonic antigen in patients receiving liver resection for colorectal cancer liver metastasis: A meta-analysis

BACKGROUND

Carcinoembryonic antigen (CEA) is a broad-spectrum tumor marker for differential diagnosis, monitoring, and response assessment of a variety of malignancies.

AIM

To evaluate whether serum CEA could predict the prognosis in patients with colorectal cancer liver metastasis (CRCLM) before and after liver resection (LR).

METHODS

PubMed, Embase, Cochrane, and Web of Science were systematically searched to retrieve literature, with a search cut-off date of February 27, 2023. Articles were strictly screened for inclusion according to pre-specified inclusion and exclusion criteria. Data were pooled and analyzed using Stata 16.0.

RESULTS

This meta-analysis included 36 studies involving a total of 11143 CRCLM patients. The results showed that a high pre-LR serum CEA level was correlated with poor overall survival (OS) [hazard ratio (HR) = 1.61, 95% confidence interval (CI): 1.49-1.75, P < 0.001] and recurrence-free survival (HR = 1.27, 95%CI: 1.11-1.45, P < 0.001) in CRCLM patients. A high post-LR serum CEA level predicted poor OS (HR = 2.66, 95%CI: 2.10-3.38, P < 0.001). A comparison by treatment modality, analysis modality, patient source, and cutoff-value showed that overall, high preoperative and postoperative serum CEA levels remained correlated with a poor prognosis.

CONCLUSION

This study concluded that high pre-LR and post-LR serum CEA levels were significantly correlated with a poor prognosis in CRCLM patients.

Survival Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-2)

Introduction: Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-CRLM) was a propensity score matched (PSM) study that reported short-term outcomes of patients with CRLM who met the Milan criteria and underwent either open (OLR), laparoscopic (LLR) or robotic liver resection (RLR). This study, designated as SIMMILR-2, reports the long-term outcomes from that initial study, now referred to as SIMMILR-1. Methods: Data regarding neoadjuvant chemotherapeutic (NC) and neoadjuvant biological (NB) treatments received were collected, and Kaplan−Meier curves reporting the 5-year overall (OS) and recurrence-free survival (RFS) for OLR, LLR and RLR were created for patients who presented with synchronous lesions only, as there was insufficient follow-up for patients with metachronous lesions. Results: A total of 73% of patients received NC and 38% received NB in the OLR group compared to 70% and 28% in the LLR group, respectively (p = 0.5 and p = 0.08). A total of 82% of patients received NC and 40% received NB in the OLR group compared to 86% and 32% in the RLR group, respectively (p > 0.05). A total of 71% of patients received NC and 53% received NB in the LLR group compared to 71% and 47% in the RLR group, respectively (p > 0.05). OS at 5 years was 34.8% after OLR compared to 37.1% after LLR (p = 0.4), 34.3% after OLR compared to 46.9% after RLR (p = 0.4) and 30.3% after LLR compared to 46.9% after RLR (p = 0.9). RFS at 5 years was 12.1% after OLR compared to 20.7% after LLR (p = 0.6), 33.3% after OLR compared to 26.3% after RLR (p = 0.6) and 22.7% after LLR compared to 34.6% after RLR (p = 0.6). Conclusions: When comparing OLR, LLR and RLR, the OS and RFS were all similar after utilization of the Milan criteria and PSM. Biological agents tended to be utilized more in the OLR group when compared to the LLR group, suggesting that highly aggressive tumors are still managed through an open approach.

Impact of Preoperative CEA Uptrend on Survival Outcomes in Patients with Colorectal Liver Metastasis After Hepatectomy

BACKGROUND

Preoperative carcinoembryonic antigen (CEA) has been reported as a prognostic factor in patients with colorectal liver metastasis (CRLM) after hepatectomy. However, the impact of a preoperative "CEA uptrend" on prognosis after hepatectomy in these patients remains unknown. This study assessed the impact of CEA uptrend on prognosis in patients undergoing hepatectomy for CRLM.

METHODS

Consecutive patients with CRLM who underwent hepatectomy between 2009 and 2018 were retrospectively analyzed. Patients with CRLM for whom CEA was measured both around 1 month before (CEA-1m) and within 3 days (CEA-3d) before hepatectomy were enrolled. A CEA-3d higher than both the upper limit of normal (5 ng/ml) and CEA-1m was defined as a CEA uptrend.

RESULTS

Study participants comprised 212 patients with CRLM. Of these, 88 patients (41.5%) showed a CEA uptrend. CEA uptrend indicated better discriminatory ability (corrected Akaike information criteria, 733.72) and homogeneity (likelihood ratio chi-square value, 18.80) than CEA-3d or CEA-1m. Patients with CEA uptrend showed poorer overall survival than those without CEA uptrend (p < 0.001). After adjusting for known prognostic factors, the prognostic significance of CEA uptrend retained (hazard ratio 2.63, 95% confidence interval 1.63-4.26, p < 0.001). In subgroup analyses, the prognostic significance of CEA uptrend was retained irrespective of the status of RAS mutation or response to preoperative chemotherapy.

CONCLUSIONS

CEA uptrend offers better prediction of survival outcomes than conventional CEA measurements in patients undergoing hepatectomy for CRLM.

Association of CT-Based Delta Radiomics Biomarker With Progression-Free Survival in Patients With Colorectal Liver Metastases Undergo Chemotherapy

Predicting the prognosis of patients in advance is conducive to providing personalized treatment for patients. Our aim was to predict the therapeutic efficacy and progression free survival (PFS) of patients with liver metastasis of colorectal cancer according to the changes of computed tomography (CT) radiomics before and after chemotherapy.

Methods

This retrospective study included 139 patients (397 lesions) with colorectal liver metastases who underwent neoadjuvant chemotherapy from April 2015 to April 2020. We divided the lesions into training cohort and testing cohort with a ratio of 7:3. Two - dimensional region of interest (ROI) was obtained by manually delineating the largest layers of each metastasis lesion. The expanded ROI (3 mm and 5 mm) were also included in the study to characterize microenvironment around tumor. For each of the ROI, 1,316 radiomics features were extracted from delineated plain scan, arterial, and venous phase CT images before and after neoadjuvant chemotherapy. Delta radiomics features were constructed by subtracting the radiomics features after treatment from the radiomics features before treatment. Univariate Cox regression and the Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression were applied in the training cohort to select the valuable features. Based on clinical characteristics and radiomics features, 7 Cox proportional-hazards model were constructed to predict the PFS of patients. C-index value and Kaplan Meier (KM) analysis were used to evaluate the efficacy of predicting PFS of these models. Moreover, the prediction performance of one-year PFS was also evaluated by area under the curve (AUC).

Results

Compared with the PreRad (Radiomics form pre-treatment CT images; C-index [95% confidence interval (CI)] in testing cohort: 0.614(0.552-0.675) and PostRad models (Radiomics form post-treatment CT images; 0.642(0.578-0.707), the delta model has better PFS prediction performance (Delta radiomics; 0.688(0.627-0.749). By incorporating clinical characteristics, CombDeltaRad obtains the best performance in both training cohort [C-index (95% CI): 0.802(0.772-0.832)] and the testing cohort (0.744(0.686-0.803). For 1-year PFS prediction, CombDeltaRad model obtained the best performance with AUC (95% CI) of 0.871(0.828-0.914) and 0.745 (0.651-0.838) in training cohort and testing cohort, respectively.

Conclusion

CT radiomics features have the potential to predict PFS in patients with colorectal cancer and liver metastasis who undergo neoadjuvant chemotherapy. By combining pre-treatment radiomics features, post-treatment radiomics features, and clinical characteristics better prediction results can be achieved.

Machine Learning Approach to Stratifying Prognosis Relative to Tumor Burden after Resection of Colorectal Liver Metastases: An International Cohort Analysis

BACKGROUND

Assessing overall tumor burden on the basis of tumor number and size may assist in prognostic stratification of patients after resection of colorectal liver metastases (CRLM). We sought to define the prognostic accuracy of tumor burden by using machine learning (ML) algorithms compared with other commonly used prognostic scoring systems.

STUDY DESIGN

Patients who underwent hepatectomy for CRLM between 2001 and 2018 were identified from a multi-institutional database and split into training and validation cohorts. ML was used to define tumor burden (ML-TB) based on CRLM tumor number and size thresholds associated with 5-year overall survival. Prognostic ability of ML-TB was compared with the Fong and Genetic and Morphological Evaluation scores using Cohen's d.

RESULTS

Among 1,344 patients who underwent resection of CRLM, median tumor number (2, interquartile range 1 to 3) and size (3 cm, interquartile range 2.0 to 5.0) were comparable in the training (n = 672) vs validation (n = 672) cohorts; patient age (training 60.8 vs validation 61.0) and preoperative CEA (training 10.2 ng/mL vs validation 8.3 ng/mL) was also similar (p > 0.05). ML empirically derived optimal cutoff thresholds for number of lesions (3) and size of the largest lesion (1.3 cm) in the training cohort, which were then used to categorize patients in the validation cohort into 3 prognostic groups. Patients with low, average, or high ML-TB had markedly different 5-year overall survival (51.6%, 40.9%, and 23.1%, respectively; p < 0.001). ML-TB was more effective at stratifying patients relative to 5-year overall survival (low vs high ML-TB, d = 2.73) vs the Fong clinical (d = 1.61) or Genetic and Morphological Evaluation (d = 0.84) scores.

CONCLUSIONS

Using a large international cohort, ML was able to stratify patients into 3 distinct prognostic categories based on overall tumor burden. ML-TB was noted to be superior to other CRLM prognostic scoring systems.

Predicting metachronous liver metastasis in patients with colorectal cancer: development and assessment of a new nomogram

Background

We aimed to develop and validate a nomogram model, which could predict metachronous liver metastasis in colorectal cancer within two years after diagnosis.

Methods

A retrospective study was performed on colorectal cancer patients who were admitted to Beijing Shijitan Hospital from January 1, 2016 to June 30, 2019. The least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for susceptibility to metachronous liver metastasis in colorectal cancer. Multivariable logistic regression analysis was applied to establish a predictive model through incorporating features selected in the LASSO regression model. C-index, receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were employed to assess discrimination, distinctiveness, consistency with actual occurrence risk, and clinical utility of candidate predictive model. Internal validation was assessed with bootstrapping method.

Results

Predictors contained in candidate prediction nomogram included age, CEA, vascular invasion, T stage, N stage, family history of cancer, and KRAS mutation. This model displayed good discrimination with a C-index of 0.787 (95% confidence interval: 0.728–0.846) and good calibration, whereas area under the ROC curve (AUC) of 0.786. Internal validation obtained C-index of 0.786, and AUC of validation cohort is 0.784. Based on DCA, with threshold probability range from 1 to 60%; this predictive model might identify colorectal cancer metachronous liver metastasis to achieve a net clinical benefit.

Conclusion

We have developed and validated a prognostic nomogram with good discriminative and high accuracy to predict metachronous liver metastasis in CRC patients.

Analysis of surgical approach and tumor distance to margin after liver resection for colorectal liver metastasis

This study was undertaken to compare tumor distance to margin after robotic vs. open hepatectomy for colorectal liver metastases (CLM) and to determine the relationship between perioperative variables, surgical approach and tumor distance to margin with overall survival. With IRB approval, we followed 56 patients who underwent a robotic or open hepatectomy for treatment of CLM. The relationships between the tumor distance to margin, operative approach, perioperative variables and survival was determined. The robotic approach yielded greater margins than the open approach (p = 0.04). The robotic vs. open approach had an operative duration of 375 vs. 269 min (p = 0.05), ICU length of stay (LOS) of 0 vs. 1 day (p = 0.01), and hospital LOS of 4 vs. 7 days (p = 0.04). Patients with a tumor distance to margin of ≤ 1 mm and 1.1-9.9 mm had an estimated median survival of 49 months and 24 months, respectively. Estimated median survival for patients with tumor distance to margin of ≥ 10 mm has not been reached but is > 84 months. The use of the robotic approach is associated with greater tumor distance to margin and shorter hospital LOS, but with longer operations. The robotic approach does not compromise oncological margins during resection for CLM.

PRIMARY TUMOR LYMPHOVASCULAR INVASION NEGATIVELY AFFECTS SURVIVAL AFTER COLORECTAL LIVER METASTASIS RESECTION?

BACKGROUND

About 50% of the patients with colorectal adenocarcinoma will present with liver metastasis and 20% are synchronic. Liver resection is associated with improvement in survival in comparison to chemotherapy alone.

AIM

To analyze the overall survival in patients submitted to liver resection of colorectal cancer metastasis and prognostic factors related to the primary and secondary tumors.

METHODS

A retrospective analysis of a prospectively maintained database regarding demographic, primary tumor and liver metastasis characteristics.

RESULTS

There were 84 liver resections due to colorectal cancer metastasis in the period. The 5-year disease-free and overall survivals were 27.5% and 48.8% respectively. The statistically significant factors for survival were tumor grade (p=0.050), lymphovascular invasion (p=0.021), synchronous metastasis (p=0.020), as well as number (p=0.004), bilobar distribution (p=0.019) and diameter of the liver metastasis over 50 mm (p=0.027). Remained as independent negative predictive factors: lymphovascular invasion (HR=2.7; CI 95% 1.106-6.768; p=0.029), synchronous metastasis (HR=2.8; CI 95% 1.069-7.365; p=0.036) and four or more liver metastasis (HR=1.7; CI 95% 1.046-2.967; p=0.033).

CONCLUSION

The resection of liver metastasis of colorectal adenocarcinoma leads to good survival rates. Lymphovascular invasion was the single prognostic factor related to the primary tumor. Synchronous disease and four or more metastasis were the most significant factors related to the secondary tumor.

The optimal cut-off values for tumor size, number of lesions, and CEA levels in patients with surgically treated colorectal cancer liver metastases: An international, multi-institutional study

BACKGROUND AND OBJECTIVES

Despite the long-standing consensus on the importance of tumor size, tumor number and carcinoembryonic antigen (CEA) levels as predictors of long-term outcomes among patients with colorectal liver metastases (CRLM), optimal prognostic cut-offs for these variables have not been established.

METHODS

Patients who underwent curative-intent resection of CRLM and had available data on at least one of the three variables of interest above were selected from a multi-institutional dataset of patients with known KRAS mutational status. The resulting cohort was randomly split into training and testing datasets and recursive partitioning analysis was employed to determine optimal cut-offs. The concordance probability estimates (CPEs) for these optimal cut offs were calculated and compared to CPEs for the most widely used cut-offs in the surgical literature.

RESULTS

A total of 1643 patients who met eligibility criteria were identified. Following recursive partitioning analysis in the training dataset, the following cut-offs were identified: 2.95 cm for tumor size, 1.5 for tumor number and 6.15 ng/ml for CEA levels. In the entire dataset, the calculated CPEs for the new tumor size (0.52), tumor number (0.56) and CEA (0.53) cut offs exceeded CPEs for other commonly employed cut-offs.

CONCLUSION

The current study was able to identify optimal cut-offs for the three most commonly employed prognostic factors in CRLM. While the per variable gains in discriminatory power are modest, these novel cut-offs may help produce appreciable increases in prognostic performance when combined in the context of future risk scores.

Histopathological prognostic factors for colorectal liver metastases: A systematic review and meta-analysis of observational studies

INTRODUCTION

Resection is the mainstay of treatment for colorectal liver metastases (CRLMs). Many different histopathological factors related to the primary colorectal tumour have been well studied; however, histopathological prognostic factors related to CRLMs are still under evaluation.

OBJECTIVE

To identify histopathological factors related to overall survival (OS) and disease-free survival (DFS) in patients with resected CRLMs.

METHODS

A systematic review was performed with the following databases up to August 2020: PubMed, EMBASE, Web of Science, SciELO, and LILACS. The GRADE approach was used to rate the overall certainty of evidence by outcome.

RESULTS

Thirty-three studies including 4,641 patients were eligible. We found very low certainty evidence that the following histopathological prognostic factors are associated with a statistically significant decrease in OS: presence of portal vein invasion (HR, 0,50 [95% CI, 0,37 to 0,68]; I²=0%), presence of perineural invasion (HR, 0,55 [95% CI, 0,36 to 0,83]; I²=0%), absence of pseudocapsule (HR, 0,41 [CI 95%, 0,29 to 0,57], p<0,00001; I²=0%), presence of satellite nodules (OR, 0,45 [95% CI, 0,26 to 0,80]; I²=0%), and the absence of peritumoural inflammatory infiltrate (OR, 0,20 [95% CI, 0,08 to 0,54]; I²=0%). Outcome data on DFS were scarce, except for tumour borders, which did not present a significant impact, precluding the meta-analysis.

CONCLUSION

Of the histopathological prognostic factors studied, low- to moderate-certainty evidence shows that vascular invasion, perineural invasion, absence of pseudocapsule, presence of satellite nodules, and absence of peritumoral inflammatory infiltrate are associated with shorter overall survival in CRLMs.

MRI Findings of Liver Parenchyma Peripheral to Colorectal Liver Metastasis: A Potential Predictor of Long-term Prognosis

Background Gadoxetic acid (Gd-EOB-DTPA)-enhanced MRI is superior to CT in the detection of colorectal liver metastases (CRLMs) smaller than 10 mm. However, few studies have used MRI findings to predict patients' long-term prognosis. Purpose To investigate the relationship between Gd-EOB-DTPA-enhanced MRI findings in the liver parenchyma peripheral to CRLM and both pathologic vessel invasion and long-term prognosis. Materials and Methods This retrospective study included patients who underwent Gd-EOB-DTPA-enhanced MRI before curative surgery for CRLM, without neoadjuvant chemotherapy, between July 2008 and June 2015. Early enhancement, reduced Gd-EOB-DTPA uptake, and bile duct dilatation peripheral to the CRLM at MRI were evaluated by three abdominal radiologists. All tumor specimens were reevaluated for the presence or absence of portal vein, hepatic vein, and bile duct invasion. Predictors of recurrence-free survival (RFS) and overall survival (OS) after surgery were identified with Cox proportional hazard model with the Bayesian information criterion. Previously reported prognosticators were selected for multivariable analyses. The median follow-up period was 60 months (range, 9-127 months). Results Overall, 106 patients (mean age, 65 years ± 12 [standard deviation]; 68 men) with 148 CRLMs were evaluated. Bile duct dilatation peripheral to the tumor was associated with pathologic portal vein invasion (sensitivity, 12 of 50 [24%]; specificity, 89 of 98 [91%]; P = .02), bile duct invasion (sensitivity, eight of 19 [42%]; specificity, 116 of 129 [90%]; P = .001), poor RFS (P = .03; hazard ratio [HR] = 2.4 [95% confidence interval {CI}: 1.3, 4.2]), and poor OS (P = .01; HR = 2.4 [95% CI: 1.2, 4.9]). For RFS and OS, early enhancement and reduced Gd-EOB-DTPA uptake peripheral to the CRLM were eliminated by means of variable selection in the multivariable analysis, but the combination of these findings with bile duct dilatation provided a predictor of poor OS (P = .001; HR = 3.3 [95% CI: 1.6, 6.8]). Conclusion MRI signal intensity changes peripheral to the colorectal liver metastasis were predictors of long-term prognosis after curative surgery without neoadjuvant chemotherapy. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Bashir in this issue.

Liver resection is beneficial for patients with colorectal liver metastases and extrahepatic disease

Background

Liver metastases are the most common cause of death for patients with colorectal cancer and affect up to half of the patients. Liver resection is an established method that can potentially be curative. For patients with extrahepatic disease (EHD), the role of liver surgery is less established.

Methods

This is a retrospective study based on data from the national quality registry SweLiv. Data were obtained between 2009 and 2015. SweLiv is a validated registry and has been in use since 2009, with coverage above 95%. Patients with liver metastases and EHD were analyzed and cross-checked against the national death cause registry for survival analysis.

Results

During the study period, 2,174 patients underwent surgery for colorectal liver metastases (CRLM), and 277 patients with EHD were treated with resection or ablation. The estimated median survival time for the entire cohort from liver resection/ablation was 40 months (95% CI, 32-47). The survival time for patients treated with liver resection was 45 months compared to 26 months for patients treated with ablation (95% CI 38-53, 18-33, P=0.001). A subgroup analysis of resected patients revealed that the group with pulmonary metastases had a significantly longer estimated median survival (50 months; 95% CI, 39-60) than the group with lymph node metastases (32 months; 95% CI, 7-58) or peritoneal carcinomatosis (28 months; 95% CI, 14-41) (P=0.022 and 0.012, respectively). Other negative prognostic factors were major liver resection and nonradical liver resection.

Conclusions

For patients with liver metastases and limited EHD, liver resection results in prolonged survival compared to what can be expected from chemotherapy alone.

The outcome of primary tumor resection in the unresectable stage IV colorectal cancer patients who received the bevacizumab-containing chemotherapy

Primary tumor resection (PTR) for unresectable metastatic colorectal cancer (mCRC) patients has been documented to be associated with postoperative hyper-neovascularization and enhanced growth of metastases, which may be prevented by bevacizumab. This study aimed to investigate the survival outcome of PTR in patients who received palliative bevacizumab-containing chemotherapy (BCT).From January 2006 to December 2018, medical records of 240 mCRC patients who received palliative BCT at a single tertiary colorectal cancer center were retrospectively reviewed. Patients were classified into three groups: PTR-a (PTR before BCT, n = 60), PTR-b (PTR during BCT, n = 17), and BCT-only group (n = 163). Resectable mCRCs or recurrent diseases were excluded, and the end-point was overall survival (OS) rate.Three groups had similar age, cell differentiation, location of the primary tumor, and the number of metastatic organs. More than two-thirds of patients who received PTR experienced disease-progressions (PD) during their postoperative chemotherapy-free time (PTR-a vs PTR-b; 66.7% vs 76.5%, P = .170), but OS was not inferior to the BCT-only group (PTR-a vs BCT-only; HR 0.477 [95% CI 0.302-0.754], P = .002/PTR-b vs BCT-only; HR 0.77 [95% CI 0.406-1.462], P = .425). The postoperative chemotherapy-free time was similar between PTR-a and PTR-b (median 32.0 [14-98] days vs 41.0 [18-71] days, P = .142), but non-obstructive indications (perforation, bleeding, pain) were the more frequent in the PTR-b than PTR-a. Young age, the number of BCT, and PTR-a were the independent factors for OS.The efficacy of the PTR for unresectable mCRC has been controversial, but this study demonstrated that PTR should be considered for the unresectable mCRC patients regardless before and during BCT.

Different variables predict the outcome of patients with synchronous versus metachronous metastases of colorectal cancer

PURPOSE

Timing of metastasis is a controversial prognostic factor for patients with metastatic colorectal cancer (mCRC), as well as the performance of the common prognostic variables within patients with synchronous (SMs) or metachronous metastases (MMs). The aim of the current study is to evaluate outcome by the timing of metastases and to explore different tumor characteristics associated with SMs and MMs.

METHODS

Data were collected from the clinical records of patients with mCRC, which were referred to the Department of Oncology of the Ospedale Civile di Sanremo from 2006 to 2011. A comparison of the characteristics of tumors of patients, overall and by the timing of metastases, and a Cox regression analysis have been performed to select the most relevant prognostic factors. Finally, the characteristics of the variables associated with the outcome were analyzed through a logistic regression.

RESULTS

Two hundreds fifteen patients with SMs and two hundreds ten with MMs were included. Patients with SMs reported a poor prognosis (18.5 versus 62.8 months; p value < 0.001). Among patients with SMs there was a significant difference in overall survival between patients with a CEA-positive or negative disease, while no difference was present among patients with MMs. After multivariate analysis, only within the SMs group the occurrence of liver metastases was related to a CEA-positive disease.

CONCLUSIONS

Within the cohort of SMs high CEA levels, occurrence of liver metastases and right-sided colon tumors were associated with a very poor prognosis, whereas no relationship was detectable in the group of patients with MMs.

Synchronous and metachronous liver metastases in patients with colorectal cancer-towards a clinically relevant definition

Background

Approximately 25% of patients with colorectal cancer (CRC) will have liver metastases classified as synchronous or metachronous. There is no consensus on the defining time point for synchronous/metachronous, and the prognostic implications thereof remain unclear. The aim of the study was to assess the prognostic value of differential detection at various defining time points in a population-based patient cohort and conduct a literature review of the topic.

Methods

All patients diagnosed with CRC in the counties of Stockholm and Gotland, Sweden, during 2008 were included in the study and followed for 5 years or until death to identify patients diagnosed with liver metastases. Patients with liver metastases were followed from time of diagnosis of liver metastases for at least 5 years or until death. Different time points defining synchronous/metachronous detection, as reported in the literature and identified in a literature search of databases (PubMed, Embase, Cochrane library), were applied to the cohort, and overall survival was calculated using Kaplan-Meier curves and compared with log-rank test. The influence of synchronously or metachronously detected liver metastases on disease-free and overall survival as reported in articles forthcoming from the literature search was also assessed.

Results

Liver metastases were diagnosed in 272/1026 patients with CRC (26.5%). No statistically significant difference in overall survival for synchronous vs. metachronous detection at any of the defining time points (CRC diagnosis/surgery and 3, 6 and 12 months post-diagnosis/surgery) was demonstrated for operated or non-operated patients. In the literature search, 41 publications met the inclusion criteria. No clear pattern emerged regarding the prognostic significance of synchronous vs. metachronous detection.

Conclusion

Synchronous vs. metachronous detection of CRC liver metastases lacks prognostic value. Using primary tumour diagnosis/operation as standardized cut-off point to define synchronous/metachronous detection is semantically correct. In synchronous detection, it defines a clinically relevant group of patients where individualized multimodality treatment protocols will apply.

Factors predicting ablation site recurrence following percutaneous microwave ablation of colorectal hepatic metastases

BACKGROUND

Microwave ablation (MWA) is a recognised treatment option for liver metastases. The size of the tumour is a well-established factor that influences the success of MWA. However, the effect of "heat sink" on the success of MWA for hepatic metastases is unclear. The aim of this study was to determine whether heat sink effect is a factor that contributes to ablation site recurrence (ASR).

METHODS

A prospectively maintained database of patients who underwent percutaneous MWA for treatment of colorectal liver metastases was analysed. Imaging and demographic characteristics were compared between metastases that recurred following ablation and those that did not. Proximity to a large hepatic vein was defined as <10 mm.

RESULTS

126 ablations in 87 patients met the inclusion criteria and were studied over a median follow-up period of 28 (12-75) months. ASR was detected in 43 ablations (34%) and was associated with clinical risk score (CRS) ≥2 (OR 2.2 95% CI 1.3-3.3, p = 0.029), metastasis size (OR 0.953 95% CI (0.929-0.978), p < 0.001) and proximity to a large hepatic vein (OR 7.5 95%CI 2.4-22.8, p < 0.001). Proximity to a large hepatic vein was not associated with reduced overall survival (OS) but was associated with liver-specific recurrence (HR 4.7 95%CI 1.7-12.5, p = 0.004).

CONCLUSIONS

In addition to tumour size proximity to large hepatic venous structures is an independent predictor of ASR and liver-specific recurrence following MWA. However, this was not associated with overall survival.

The histopathologic report of surgically resected colorectal liver metastases: What is clinically relevant?

Colorectal carcinoma (CRC) is one of the most common malignancies and a major cause of cancer-related death worldwide. The liver is the most frequent site of metastatic spread, so that about half of the patients with CRC have or develop liver metastases (LM) during the clinical course of the disease. Colorectal LM can potentially be cured by surgery, but most patients still experience disease progression and recurrence after the surgical treatment. Prediction of a patient's post-surgical clinical course is mainly based on clinical parameters or the histopathological features of the primary tumor, while little attention is given to the pathological characteristics of the LM. In this paper, we review the prognostic relevance of the gross and microscopic pathological features observed in surgically resected LM and propose which information should be included in the histopathological report to guide surgeons and oncologists for the subsequent therapeutic management.

Prognostic factors in patients treated with transarterial radioembolization for unresectable and chemorefractory colorectal cancer with liver metastases

Background: Transarterial radioembolization (TARE) is used to treat unresectable colorectal cancer with liver metastases (CRCLM). This study aimed to assess survival after TARE and to identify potential prognostic factors in this patient population. Methods: Patients with unresectable and chemorefractory CRCLM treated with TARE at our institution between February 2006 and September 2015 were included in the study. Survival rate, hepatic tumor response, and potential prognostic factors were analyzed. Results: In the 43 study patients, the mean follow-up was 15.0 ± 14.2 months, with a median survival of 13.0 months and 1-, 2-, 3-, 4-, and 5-year survival rates of 52.1%, 24.9%, 21.4%, 21.4%, and 7.1%, respectively. The mean activity of yttrium-90 administered was 1.55 ± 0.28 GBq for the disease-controlled group and 1.19 ± 0.27 GBq for the progressive disease group (p= 0.031). Survival was correlated with Child-Pugh class (p< 0.001), hepatic tumor response (p= 0.001), and baseline carcinoembryonic antigen (CEA) level (p= 0.013). Conclusion: Child-Pugh class B, low degree of hepatic tumor response, and normal baseline CEA levels are prognostic factors for poorer survival after TARE in patients with unresectable and chemorefractory CRCLM. Hepatic tumor response is related to radiation activity delivered to the liver.

Predictive factors of histological response of colorectal liver metastases after neoadjuvant chemotherapy

BACKGROUND

Colorectal cancer is the third most common cancer in men and the second most common in women worldwide. Almost a third of the patients has or will develop liver metastases. Neoadjuvant chemotherapy (NAC) has recently become nearly systematic prior to surgery of colorectal livers metastases (CRLMs). The response to NAC is evaluated by radiological imaging according to morphological criteria. More recently, the response to NAC has been evaluated based on histological criteria of the resected specimen. The most often used score is the tumor regression grade (TRG), which considers the necrosis, fibrosis, and number of viable tumor cells.

AIM

To analyze the predictive factors of the histological response, according to the TRG, on CRLM surgery performed after NAC.

METHODS

From January 2006 to December 2013, 150 patients who had underwent surgery for CRLMs after NAC were included. The patients were separated into two groups based on their histological response, according to Rubbia-Brandt TRG. Based on their TRG, each patient was either assigned to the responder (R) group (TRG 1, 2, and 3) or to the non-responder (NR) group (TRG 4 and 5). All of the histology slides were re-evaluated in a blind manner by the same specialized pathologist. Univariate and multivariate analyses were performed.

RESULTS

Seventy-four patients were classified as responders and 76 as non-responders. The postoperative mortality rate was 0.7%, with a complication rate of 38%. Multivariate analysis identified five predictive factors of histological response. Three were predictive of non-response: More than seven NAC sessions, the absence of a radiological response after NAC, and a repeat hepatectomy (P < 0.005). Two were predictive of a good response: A rectal origin of the primary tumor and a liver-first strategy (P < 0.005). The overall survival was 57% at 3 yr and 36% at 5 yr. The disease-free survival rates were 14% at 3 yr and 11% at 5 yr. The factors contributing to a poor prognosis for disease-free survival were: No histological response after NAC, largest metastasis > 3 cm, more than three preoperative metastases, R1 resection, and the use of a targeted therapy with NAC (P < 0.005).

CONCLUSION

A non-radiological response and a number of NAC sessions > 7 are the two most pertinent predictive factors of non-histological response (TRG 4 or 5).

Outcomes after hypofractionated stereotactic radiotherapy for colorectal cancer oligometastases

BACKGROUND AND OBJECTIVES

To assess the efficacy and the effect of biologic effective dose (BED) on outcomes treated by hypofractionated stereotactic radiotherapy for colorectal cancer (CRC) oligometastases.

METHODS

Patients with CRC oligometastases treated at our hospital between 2009 and 2016 were included. The relationship between BED and risk of local recurrence was assessed. Recursive partitioning analysis (RPA) was used to evaluate the effect of BED on outcomes.

RESULTS

A total of 48 patients were included in this study. Median follow-up time of surviving patient was 15 months (range, 3-82 months). The 1-year local control rate was 85%. The risk of local recurrence decreased sharply when BED was >90 Gy₁₀ . RPA showed BED of 100 Gy ₁₀ was the appropriate dose for recurrence risk stratification. BED ≥ 100 Gy ₁₀ was significantly better than BED < 100 Gy ₁₀ for achieving 1-year local control (94.4% vs 63.2%; P = 0.022) and 1-year OS (100% vs 73.4%; P = 0.028). One patient who received long-term antiangiogenic treatment died of massive intestinal hemorrhage; no other grade 3 or above early or late events were observed.

CONCLUSIONS

Hypofractionated stereotactic radiotherapy provides favorable outcomes with acceptable toxicities in CRC oligometastases. BED ≥ 100 Gy is associated with better outcomes.

Higher Tumor Burden Neutralizes Negative Margin Status in Hepatectomy for Colorectal Cancer Liver Metastasis

OBJECTIVE

The aim of this study was to examine if the prognostic significance of margin status in hepatectomy for colorectal cancer liver metastasis (CRLM) varies for different levels of tumor burden because hepatectomy indications for CRLM have been recently expanded to include patients with a higher tumor burden in whom achieving an R0 resection is difficult.

METHODS

Clinicopathological variables in an exploration cohort of 290 patients receiving hepatectomy in Japan for CRLM were investigated. R0 resection was defined as a margin width > 0 mm. Tumor burden was assessed using the recently introduced Tumor Burden Score (TBS), which was calculated as TBS² = (maximum tumor diameter in cm)² + (number of lesions)². The principal findings were validated using a cohort from the United States.

RESULTS

R1 resection rates significantly increased as TBS increased: 4/86 (4.7%) in patients with TBS < 3, 29/171 (17.0%) in patients with TBS ≥ 3 and < 9, and 9/33 (27.3%) in patients with TBS ≥ 9 (p < 0.001). R0 resection was significantly superior to R1 resection in patients with TBS ≥ 5; however, this was not the case for TBS ≥ 6, as confirmed by both univariate and multivariate analyses. Furthermore, prehepatectomy chemotherapy was associated with significantly improved survival for patients with TBS ≥ 8. Analysis of the validation cohort yielded similar results.

CONCLUSIONS

R0 resection appeared to have a positive impact on prognosis among patients with low tumor burden; however, this was not the case for patients with high tumor burden. As such, systemic treatment, in addition to surgery, may be central to achieving satisfactory outcomes in the latter patient population.

Resection of small bowel adenocarcinoma metastases: Results of the ARCAD-NADEGE cohort study

INTRODUCTION

Data are lacking with regard to curative resection of metastasis from small bowel adenocarcinoma (SBA). This study evaluated outcomes and prognostic factors in patients with curatively resected metastatic SBA.

METHODS

A series of 34 patients undergoing resection of metastatic SBA from January 2009 to November 2014 at French centers were included into this cohort study. The primary endpoint was overall survival (OS). Secondary endpoints were recurrence-free survival (RFS) and prognostic factors. Univariate analyses were performed to determine prognostic risk factors.

RESULTS

The sites of SBA metastases were peritoneal (29.4%), liver (26.5%), lymph nodes (11.8%), lung (2.9%), multiple (14.7%), and other (14.7%). Thirty (88.2%) patients received adjuvant or perioperative chemotherapy, mainly was oxaliplatin-based (76.5%). The median OS was 28.6 months and RFS was 18.7 months. Fourteen (41.2%) patients survived for more than 36 months. In univariate analysis, poor differentiation (P = 0.006), invaded margins (P = 0.003), and lymphatic invasion in the primary tumor (P = 0.039) were associated with decreased OS.

CONCLUSION

Overall survival of patients after resection of metastatic SBA remains poor, but long-term survivors are observed. Resection of metastatic SBA should be consider if patients are expected to be operated on with curative intent and have moderately or well-differentiated tumors.

Histologically Verified Biliary Invasion was Associated with Impaired Liver Recurrence-Free Survival in Resected Colorectal Cancer Liver Metastases

Background and Aims:

The impact of biliary invasion on recurrence and survival, after resection of colorectal cancer liver metastases, is not well known as publications are limited to small patient series. The aim was to investigate if biliary invasion in liver resected patients associated with liver relapses and recurrence-free survival. Secondary endpoints included association with other prognostic factors, disease-free survival and overall survival.

Materials and Methods:

All patients with histologically verified biliary invasion (n = 31, 9%) were identified among 344 patients with liver resection between January 2009 and March 2015. Controls (n = 78) were selected from the same time period and matched for, among others, size and number of colorectal cancer liver metastasis.

Results:

Median liver recurrence-free survival was significantly shorter in patients with biliary invasion than in controls (15.3 months versus not reached; p = 0.031) and more relapses were noted in the liver (61.3% versus 33.3%; p = 0.010), respectively. In univariate analyses for liver recurrence-free survival, biliary invasion was the only significant prognostic factor; p = 0.034. There were no statistical differences in disease-free and overall survival between the groups.

Conclusion:

Biliary invasion was associated with higher liver recurrence rates and shorter liver recurrence-free survival in patients with resected colorectal cancer liver metastasis.

The Shifting Paradigm of Prognostic Factors of Colorectal Liver Metastases: From Tumor-Centered to Host Immune-Centered Factors

The determinants of prognosis in patients with colorectal liver metastases (CLM) have been traditionally searched among the tumoral factors, either of the primary colorectal tumor or of the CLM. While many different scoring systems have been developed based on those clinic-pathological factors with disparate results, there has been the introduction of genetic biological markers that added a theranostic perspective. More recently, other important elements, such as those factors related to the host immune system, have been proposed as determinants of prognosis of CLM patients. In the present work, we review the current prognostic factors of CLM patients as well as the burgeoning shifting paradigm of prognostication that relies on the host immune system.

Analysis of prognostic factors after resection of solitary liver metastasis in colorectal cancer: a 22-year bicentre study

PURPOSE

The investigation of the predictors of outcome after hepatic resection for solitary colorectal liver metastasis.

METHODS

We recruited 350 patients with solitary colorectal liver metastasis at the University Hospitals of Jena and Magdeburg, who underwent curative liver resection between 1993 and 2014. All patients had follow-up until death or till summer 2016.

RESULTS

The follow-up data concern 96.6% of observed patients. The 5- and 10-year overall survival rates were 47 and 28%, respectively. The 5- and 10-year disease-free survival rates were 30 and 20%, respectively. The analysis of the prognostic factors revealed that the pT category of primary tumour, size and grade of the metastasis and extension of the liver resection had no statistically significant impact on survival and recurrence rates. In multivariate analysis, age, status of lymph node metastasis at the primary tumour, location of primary tumour, time of appearance of the metastasis, the use of preoperative chemotherapy and the presence of extrahepatic tumour proved to be independent statistically significant predictors for the prognosis. Moreover, patients with rectal cancer had a lower intrahepatic recurrence rate, but a higher extrahepatic recurrence rate.

CONCLUSION

The long-term follow-up of patients with R0-resected liver metastasis is multifactorially influenced. Age and comorbidity have a role only in the overall survival. More than three lymph node metastasis reduced both the overall and disease-free survival. Extrahepatic tumour had a negative influence on the extrahepatic recurrence and on the overall survival. Neither overall survival nor recurrence rates was improved using neoadjuvant chemotherapy.

Survival time and prognostic factors of patients with initial noncurative colorectal liver metastases

The true survival benefit of different curative strategies involving type of operative procedure and timing for patients with initial noncurative colorectal liver metastases remains uncertain. The goal of this study was to examine the effect of primary tumor resection on patients' survival and to clarify the predictive factors related to overall survival (OS).This was a retrospective study that included 219 patients with initial noncurative colorectal liver metastases without extrahepatic disease. The clinicopathological characteristics of patients and their survival were examined. Survival analysis was performed using the Kaplan-Meier method. All variables associated with P <.05 in univariate analysis were included in multivariate analysis using a Cox proportional-hazard regression model.The 1-, 3-, 5-year OS rates of patients with simultaneous liver resection were 79.1%, 39.1%, and 28.4%, respectively, and those of patients with staged liver resection were 83.3%, 46.7%, and 36.8%, respectively (P = .380). The 1-, 3-, 5-year OS rates of patients with primary tumor resection were 57.0%, 18.2%, and 12.3%, respectively, while for the patients without primary tumor resection were 38.9%, 5.6%, and 0%, respectively (P = .012). Independent prognostic factors for OS were carbohydrate antigen19-9, primary tumor resection, tumor differentiation, and adjuvant chemotherapy.No difference in OS was observed between simultaneous liver resection and staged liver resection, while primary tumor resection was beneficial to noncurative colorectal liver metastases.

Microscopic biliary and perineural invasion and clinical outcome after neoadjuvant bevacizumab-based chemotherapy and liver resection in patients with colorectal liver metastases

BACKGROUND

The value of microscopic biliary and perineural invasion as prognostic biomarkers in patients with resectable colorectal liver metastases (CLM) who undergo neoadjuvant chemotherapy and liver resection is still unclear. This retrospective study was performed to elucidate this issue.

METHODS

Histologic slides of resected CLM of patients who underwent neoadjuvant bevacizumab-based chemotherapy and liver resection were investigated with respect to biliary and perineural invasion. Presence of invasion was correlated with radiologic and histologic response, recurrence-free survival (RFS) and overall survival (OS).

RESULTS

One hundred forty-one patients were enrolled. There was a significant association between biliary and perineural invasion, respectively (P = 0.001). Moreover, both biliary and perineural invasion were associated with bilobar metastatic spread and higher number of metastases, while perineural invasion was also associated with a higher Fong score. No significant association was found with response. In univariable analysis, biliary and perineural invasion were associated with shorter RFS (median 10.1 vs. 13.5 months, HR 2.09, P = 0.010 and 7.6 vs. 14.0, HR 2.23, P = 0.001, respectively). Biliary invasion was also associated with shorter OS (median 32.8 months vs. not reached, HR 2.78, P = 0.010), however these results did not remain significant in multivariable analysis.

CONCLUSIONS

In patients with resectable colorectal liver metastases undergoing neoadjuvant bevacizumab-based chemotherapy and liver resection, biliary and perineural invasion are associated with higher tumor load but may not be prognostic biomarkers.

Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol

Colorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.

Clinical Significance of Preoperative Virtual Colonoscopy for Evaluation of the Proximal Colon in Patient With Obstructive Colorectal Cancer

Purpose

Virtual colonoscopy is the most recently developed tool for detecting colorectal cancers and polyps, but its effectiveness is limited. In our study, we compared the result of preoperative virtual colonoscopy to result of preoperative and postoperative colonoscopy. We evaluated also the accuracy of preoperative virtual colonoscopy in patients who had obstructive colorectal cancer that did not allow passage of a colonoscope.

Methods

A total of 164 patients who had undergone preoperative virtual colonoscopy and curative surgery after the diagnosis of a colorectal adenocarcinoma between November 2008 and August 2013 were pooled. We compared the result of conventional colonoscopy with that of virtual colonoscopy in the nonobstructive group and the results of preoperative virtual colonoscopy with that of postoperative colonoscopy performed at 6 months after surgery in the obstructive group.

Results

Of the 164 patients, 108 were male and 56 were female patients. The mean age was 62.7 years. The average sensitivity, specificity, and accuracy of virtual colonoscopy for all patients were 31.0%, 67.2%, and 43.8%, respectively. In the nonobstructive group, the average sensitivity, specificity, and accuracy were 36.6%, 66.2%, and 48.0%, respectively, whereas in the obstructive group, they were 2%, 72.4%, and 25.4%. Synchronous cancer was detected via virtual colonoscopy in 4 of the 164 patients.

Conclusion

Virtual colonoscopy may not be an effective method for the detection of proximal colon polyps, but it can be helpful in determining the therapeutic plan when its results are correlated with the results of other studies.

Comparison of Total Tumor Volume, Size and Number of Colorectal Liver Metastases in Prediction of Survival in Patients after Liver Resection

Liver is the most common location of the colorectal cancer metastases occurrence. Liver resection is the only curative method of treatment. Unfortunately it is feasible only in 25% of patients with colorectal liver metastases, often because of the extensiveness of the disease. The aim of the study was to evaluate the predictive value of total tumor volume, size and number of colorectal liver metastases in patients treated with right hemihepatectomy.

MATERIAL AND METHODS

A retrospective analysis was performed in a group of 135 patients with colorectal liver metastases, who were treated with right hemihepatectomy. Total tumor volume was estimated based on the formula (4/3)πr³. Moreover, the study included an analysis of data on the number and size of tumors, radicality of the resection, time between primary tumor resection and liver resection, pre-operative blood serum concentration of carcinoembryonal antigen (CEA) and carcinoma antigen Ca 19-9. The predictive value of the factors was evaluated by applying a Cox proportional hazards model and the area under the ROC curve.

RESULTS

The univariate analysis has shown the predictive value of size of the largest tumor (p=0.033; HR=1.065 per each cm) on the overall survival, however no predictive value of number of tumors (p=0.997; HR=1.000) and total tumor volume (p=0.212; HR=1.002) was observed. The multivariate analysis did not confirm the predictive value of the size of the largest tumor (p=0.141; HR=1.056). In the analysis of ROC curves, AUROC for the total tumor volume, the size of the largest tumor and the number of tumors were 0.629, 0.608, 0.520, respectively.

CONCLUSIONS

Total tumor volume, size and number of liver metastases are not independent risk factors for the worse overall survival of patients with colorectal liver metastases treated with liver resection, therefore increased values of these factors should not be a contraindication for surgical treatment.

Neoadjuvant chemotherapy does not affect future liver remnant growth and outcomes of associating liver partition and portal vein ligation for staged hepatectomy

BACKGROUND

The only potentially curative treatment for patients with colorectal liver metastases is hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy has emerged as a method of treatment for patients with inadequate future liver remnant. One concern about associating liver partition and portal vein ligation for staged hepatectomy is that preoperative chemotherapy may negatively affect the volume increase of the future liver remnant and outcomes.

METHODS

This study from the International Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Registry (NCT01924741) includes 442 patients with colorectal liver metastases registered from 2012-2016. Future liver remnant hypertrophy (absolute increase, percent increase, and kinetic growth rate) and clinical outcome were analyzed retrospectively in relation to type and amount of chemotherapy. The analyzed groups included patients with no chemotherapy, 1 regimen of chemotherapy, >1 regimen, and a group that received monoclonal antibodies in addition to chemotherapy.

RESULTS

Ninety percent of the patients received neoadjuvant oncologic therapy including 42% with 1 regimen of chemotherapy, 44% with monoclonal antibodies, and 4% with >1 regimen. Future liver remnant increased between 74-92% with the largest increase in the group with 1 regimen of chemotherapy. The increase in milliliters was between 241 mL (>1 regimen) and 306 mL (1 regimen). Kinetic growth rate was between 14-18% per week and was greatest for the group with 1 regimen of chemotherapy. No statistical significance was found between the groups with any of the measurements of future liver remnant hypertrophy.

CONCLUSION

Neoadjuvant chemotherapy, including monoclonal antibodies, does not negatively affect future liver remnant growth. Patients with colorectal liver metastases who might be potential candidates for associating liver partition and portal vein ligation for staged hepatectomy should be considered for neoadjuvant chemotherapy.

Pre-hepatectomy carcinoembryonic antigen (CEA) levels among patients undergoing resection of colorectal liver metastases: do CEA levels still have prognostic implications?

BACKGROUND

The impact of prehepatectomy carcinoembryonic antigen (CEA) levels in the era of modern chemotherapy and expanded surgical indications for colorectal liver metastasis (CRLM) remains not well defined.

METHODS

484 patients were identified and divided into two groups by surgical time period (group 1: 2000-2007 vs. group 2: 2008-2015). The prognostic significance of pre-hepatectomy CEA was determined by assessing the HRs associated with various cut-off levels ranging from 5 to 200 ng/mL.

RESULTS

Median CRLM number was comparable in both groups (group 1: 2 vs. group 2: 2, P = 0.504). Bilobar disease was more frequent in group 2 (30.1% vs. 42.5%, P = 0.006). The administration of modern chemotherapy and/or biologic agents increased over time (49.5% vs. 67.9%, P < 0.001). Preoperative CEA independently predicted OS in group 1, even with a cut-off as low as >5 ng/mL. However, in group 2 it predicted recurrence and survival only after exceeding 70 and 50 ng/mL, respectively. Of note, in group 2, CEA was strongly associated with survival when CEA levels exceeded 70 ng/mL (HR 4.84).

CONCLUSIONS

While pre-hepatectomy CEA level may still have prognostic utility in CRLM resection, the optimal cut-off value has increased in the era of modern chemotherapy.

Pattern of tumour growth of the primary colon cancer predicts long-term outcome after resection of liver metastases

OBJECTIVE

To identify significant predictive factors for overall survival (OS) and disease-free survival (DFS) after liver resection for colon cancer metastases, with special focus on features of the primary colon cancer, such as lymph node ratio (LNR), vascular invasion, and perineural invasion.

METHODS

Patients operated for colonic cancer liver metastases between 2006 and 2014 were included. Details on patient characteristics, the primary colon cancer operation and metastatic disease were collected. Multivariate analysis was performed to select predictive variables for OS and DFS.

RESULTS

Median OS and DFS were 67 and 20 months, respectively. 1-, 3- and 5-year OS were 97, 76, and 52%. 1-, 3- and 5-year DFS were 65, 42, and 37%. Multivariate analysis showed LNR to be an independent predictive factor for DFS but not for OS. Other identified predictive factors were vascular and perineural invasion of the primary colon cancer, size of the largest metastasis and severe complications after liver surgery for OS, and perineural invasion, number of liver metastases and preoperative CEA-level for DFS. Traditional N-stage was also considered to be an independent predictive factor for DFS in a separate multivariate analysis.

CONCLUSIONS

LNR and perineural invasion of the primary colon cancer can be used as a prognostic variable for DFS after a concomitant liver resection for colon cancer metastases. Vascular and perineural invasion of the primary colon cancer are predictive for OS.

Impact of surgical margin clearance for resection of secondary hepatic malignancies

Over the past several decades, there has been increasing discussion regarding the optimal management of secondary liver malignancies. Traditionally, resection has only been recommended if it could be accomplished with negative microscopic margins of at least 10 mm. However, many investigators have pushed this limit to offer resection to patients with narrower margins. We review the data regarding the impact of margin clearance on outcomes for patients undergoing hepatic metastasectomy.

Negative surgical margin improved long-term survival of colorectal cancer liver metastases after hepatic resection: a systematic review and meta-analysis

OBJECTIVE

The need to achieve a tumor-free margin of ≥1 mm (R0) for colorectal liver metastases (CRLM) after hepatic resection has been questioned recently. This study conducted a meta-analysis to determine whether status of the surgical margin still influenced the long-term outcome of survival and recurrence rate.

METHODS

Eligible trials that compared survival and recurrence rates of R0 versus the tumor-free margin <1 mm (R1) were identified from Embase, PubMed, the Web of Science, and the Cochrane Library since their inception to 1 March 2015. The study outcomes included long-term outcome of survival and recurrence rate. Hazard ratio (HR) with a 95 % confidence interval was used to measure the pooled effect according to a random-effects model or fixed-effects model, depending on the heterogeneity among the included studies. The heterogeneity among these trials was statistically evaluated using the χ(2) and I(2) tests. Sensitivity analyses and publication bias were also carried out.

RESULTS

A total of 18 studies containing 6790 patients were included. The comparison between R1 and R0 revealed that a pooled HR for 5-year overall survival was 1.603 (95 % CI; 1.464-1.755; p = 0.000; I(2) = 31.2 %, p = 0.141). For patients received modern chemotherapy; a pooled HR of R1 resection for 5-year overall survival was 1.924 (95 % CI; 1.567-2.361, p = 0.000; I(2) = 20.5 %, p = 0.273). The pooled HR for 5-year OS of ≥1 cm in the included studies calculated using the random-effects model was 0.819 (95 % CI; 0.715-0.938, p = 0.004; I(2) = 0 %, p = 0.492).

CONCLUSIONS

R1 resections decreased long-term survival, and modern chemotherapy did not alter an adverse outcome. Surgeons should attempt to obtain a 1-cm margin.

Lymphatic Invasion is an Independent Adverse Prognostic Factor in Patients with Colorectal Liver Metastasis

BACKGROUND

For a selection of patients with colorectal liver metastases (CRLM), liver resection is a curative option. In order to predict long-term survival, clinicopathologic risk scores have been developed, but little is known about histologic factors and their prognostic value for disease-free and overall survival. The objective of the present study was to assess possible prognostic histologic factors in patients with solitary CRLM treated with liver resection who did not receive neoadjuvant treatment.

METHODS

Patients with solitary CRLM who underwent liver resection between 1992 and 2011 were evaluated for clinical prognostic factors. Histologic analyses on tumor thickness at the tumor-normal interface, presence of a fibrotic capsule, intrahepatic vascular invasion, lymphatic invasion, or bile duct invasion and perineural growth were performed, using immunohistochemistry.

RESULTS

A total of 124 patients were analyzed with a median follow-up of 41 months (range 1-232 months). There was no association between histologic factors and disease-free survival in multivariate analysis. In multivariate analysis, intrahepatic lymphatic invasion was associated with a decreased overall survival (41.9 vs. 61.0 months; p = 0.041), especially in combination with vascular invasion (n = 15) (28.1 vs. 62.2 months; p < 0.0001). In addition, size over 50 mm (29.2 vs. 65.9 months; p = 0.004) and interval less than 12 months between resection of the primary tumor and diagnosis of liver metastasis (49.0 vs. 91.5 months: p = 0.019) were also independent adverse prognostic factors.

CONCLUSIONS

Intrahepatic lymphatic invasion, especially in combination with vascular invasion, is an important adverse prognostic factor for overall survival in patients with solitary CRLM after liver resection.

Predictors of early recurrence after resection of colorectal liver metastases

Background

Early recurrence after resection of colorectal liver metastases (CLM) is common. Patients at risk of early recurrence may be candidates for enhanced preoperative staging and/or earlier postoperative imaging. The aim of this study was to determine if there are any risk factors that specifically predict early liver-only and systemic recurrence.

Methods

Retrospective analysis of prospective database of patients undergoing liver resection (LR) for CLM from 2004 to 2006 was undertaken. Early recurrence was defined as occurring within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors were compared between patients with and without early recurrence.

Results

Two hundred and forty-three consecutive patients underwent LR for CLM. Twenty-seven patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence (P < 0.05). Sixty-six patients (27%) developed early systemic recurrence. Tumour size ≥3.6 cm and tumour number (>2) were significantly associated with early systemic recurrence (P < 0.001).

Conclusions

It is possible to stratify patients according to the risk of early liver-only or systemic recurrence after resection of CLM. High-risk patients may be candidates for preoperative MRI and/or computed tomography-positron emission tomography (CT-PET) scan and should receive intensive postoperative surveillance.

Intraoperative surgical margin re-resection for colorectal liver metastasis: is it worth the effort?

OBJECTIVE

This study was conducted to evaluate recurrence and survival among patients who underwent intraoperative margin re-resection for colorectal cancer liver metastases (CRLM).

BACKGROUND

Among patients who receive intraoperative margin re-resection, the relation between final margin status, pattern of recurrence, and survival is largely unknown.

METHODS

Three hundred thirty-two patients who underwent hepatic resection for CRLM between 2000 and 2013 were identified. Demographics, operative data, pathologic margin status, site of recurrence, and long-term survival data were collected and analyzed. Patients were stratified in three groups based on their margin status: R0, R1, and R1 → R0.

RESULTS

R0 resections were achieved in 247 (74.4%) patients, 61 (18.4%) patients had an R1 resection, whereas 24 (7.2%) had an R1 → R0. Median survival for patients undergoing R0 resections was 50.2 (95% confidence interval (CI) 49.2-66.2) months versus 63.0 (95% CI 50.3-70.5) months for patients undergoing R1 resections versus 49.2 (95% CI 29.9-NA) months for patients undergoing intraoperative margin re-resection (P > 0.05). Differences in recurrence rate and pattern were not significant between the three groups (P > 0.05).

CONCLUSION

In the era of modern systemic chemotherapy, it seems that the impact of margin status on outcomes may be minimal compared to that of patient and tumor factors. In this scenario, margin re-resection to achieve R0 status does not improve long-term outcomes.

The Preoperative Lymphocyte-to-Monocyte Ratio is Prognostic of Clinical Outcomes for Patients with Liver-Only Colorectal Metastases in the Neoadjuvant Setting

BACKGROUND

Circulating monocyte-derived, tumor-associated macrophages are associated with a poor prognosis for various cancers. Conversely, circulating lymphocytes are the source of tumor-infiltrating lymphocytes, which are associated with an improved prognosis. This study evaluated the prognostic value of the preoperative blood lymphocyte-to-monocyte ratio (LMR) for patients undergoing hepatectomy for liver-only colorectal metastases.

METHODS

This retrospective study examined 140 consecutive patients with liver-only colorectal metastases. Disease-free survival (DFS), post-recurrence survival (PRS), cancer-specific survival (CSS), and overall survival (OS) were analyzed in relation to LMR values using both Kaplan-Meier and multivariate Cox-regression methods.

RESULTS

In the multivariate analysis, high LMR (>3) was significantly associated with increased OS [hazard ratio (HR), 2.43; 95 % confidence interval (CI), 1.32-4.48; P = 0.004], CSS (HR 2.15; 95 % CI 1.13-4.10; P = 0.020), and PRS (HR 2.15; 95 % CI 1.15-4.01; P = 0.016) but not with DFS. An LMR lower than 3 may have been associated with decreased CSS and PRS by increasing the rate of multifocal recurrence (P = 0.063). In the multivariate analysis comparing LMR, the neutrophil-lymphocyte ratio, and the platelet-lymphocyte ratio, LMR remained the only significant prognostic variable of CSS.

CONCLUSION

This study identified preoperative LMR as an independent prognostic factor for PRS, CSS, and OS but not for DFS in patients undergoing hepatectomy for liver-only colorectal metastases. In the future, interventions to augment immune function could improve survival for low-LMR patients.

Determinants of long-term outcome in patients undergoing simultaneous resection of synchronous colorectal liver metastases

Background

It remains unclear which patients can benefit from simultaneous resection of synchronous colorectal liver metastases (SCRLMs). This study aimed to examine the prognostic value of patient- and tumor-related factors in predicting long-term outcomes of patients undergoing simultaneous resection of SCRLMs and to help patients select a suitable therapeutic regimen and proper surveillance.

Methods

Clinicopathological and outcome data of 154 consecutive SCRLM patients who underwent simultaneous resection between July 2003 and July 2013 were collected from our prospectively established SCRLM data and analyzed with univariate and multivariate methods, and the prognostic index (PI) was formulated based on the regression coefficients (β) of the Cox model. The patients were classified into high- and low-risk groups according to the PI value; the cut-off point was the third quartile.

Results

The 5-year overall survival rate was 46%, and the 5-year disease-free survival rate was 35%. Five factors were found to be independent predictors of poor overall survival (OS) by multivariate analysis: positive lymph node status, vascular invasion, BRAF mutation, the distribution of bilobar liver metastases (LMs) and non-R0 resection of LMs. Compared to low PI (≤5.978), high PI (>5.978) was highly predictive of shorter OS. Three factors were found to be independent predictors of poor disease-free survival (DFS) by multivariate analysis: tumor deposits, BRAF mutation and bilobar LM distribution. We also determined the PI for DFS. Compared to low PI (≤2.945), high PI (>2.945) was highly predictive of shorter DFS.

Conclusions

Simultaneous resection of SCRLM may lead to various long-term outcomes. Patients with low PI have longer OS and DFS, while those with high PI have shorter OS and DFS. Thus, patients with high PI may receive more aggressive treatment and intensive surveillance, This model needs further validation.