The treatment of hepatic metastases in colorectal carcinoma

Liver Ablation: Best Practice

Tumor ablation in the liver has evolved to become a well-accepted tool in the management of increasing complex oncologic patients. At present, percutaneous ablation is considered first-line therapy for very early and early hepatocellular carcinoma and second-line therapy for colorectal carcinoma liver metastasis. Because thermal ablation is a treatment option for other primary and secondary liver tumors, an understanding of the underlying tumor biology is important when weighing the potential benefits of ablation. This article reviews ablation modalities, indications, patient selection, and imaging surveillance, and emphasizes technique-specific considerations for the performance of percutaneous ablation.

Patient fears of tumor cell dissemination secondary to surgical interventions-part II

Patient fears are an ever-present factor of patient care, and addressing those fears is a responsibility of the healthcare provider. One such fear may be of tumor cell dissemination secondary to surgical interventions. Preparing for such discussions will allow the healthcare provider to speak with authority on the topic of tumor dissemination secondary to breast biopsy or surgery, even in a situation where a patient has underlying fears.

Regulatory T-cell-mediated inhibition of antitumor immune responses is associated with clinical outcome in patients with liver metastasis from colorectal cancer

Adaptive regulatory T cells (Tregs) contribute to an immunosuppressive microenvironment in colorectal cancer (CRC). Here, we examined whether the level of Treg-mediated inhibition of antitumor immune responses in patients with metastatic CRC (metCRC) selected for liver resection is associated with clinical outcome. Preoperatively and at follow-ups, we did flow-based phenotyping, examined antitumor immunity using peptides from carcinoembryonic antigen (CEA) protein in the presence or absence of CD4(+)CD25(+)CD127(dim/-) cells (Tregs) and determined cytokine and PGE(2) levels in patient blood samples. At 18 months post-surgery, 8 patients were disease free (7 alive and 1 dead of unrelated cause) and 10 had experienced disease recurrence (7 alive and 3 dead of metCRC). Prior to surgery, the patients demonstrated Treg-mediated suppression of TNFα and IFNγ expression that could be perturbed through the PGE(2)/cAMP pathway and the immune suppression was significantly higher in the group that later developed disease recurrence (P = 0.046). Furthermore, the post-surgery plasma PGE(2) levels were related to the clinical outcome (PGE(2) levels of 280 ± 47 vs. 704 ± 153 pg/ml (mean ± SEM) for disease free and recurrent disease, respectively). T-cell phenotyping revealed higher frequencies of COX-2(+) cells in the patients with recurrent disease. These findings support the notion that the level of Treg-mediated suppression of adaptive antitumor immune responses at the time of surgery may influence later clinical outcome of metCRC and provide valuable prognostic information.

Outcome of patients with colorectal liver metastasis: analysis of 1,613 consecutive cases

OBJECTIVE

This study was designed to evaluate the long-time outcome of patients with colorectal liver metastasis (CRLM) undergoing different types of therapy and identify prognosis factors.

METHODS

From 2000 to 2010, 1,613 consecutive patients with CRLM were identified. Clinicopathological and outcome data were collected and analyzed by univariate and multivariate analyses.

RESULTS

Synchronous liver metastasis (SLM), female, grade III-IV, T4 and N positive of primary tumor, bilobar disease, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, serum CEA level ≥ 5 ng/ml, and CA19-9 level ≥ 37 u/ml were the predictors of adverse outcome using univariate analysis. The median survival and 5-year survival rate for patients after resection of liver metastases was 49.8 months and 47%, better than that for those after other therapy. In addition, patients without treatment had the poorest survival. Sixty-four initially unresectable patients underwent surgery after conversion therapy with a median survival of 36.9 months and a 5-year survival of 30%. By multivariate analysis, SLM, poorly differentiated primary tumor, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, and no surgical treatment of liver metastases were found to be independent predictors of poor survival.

CONCLUSIONS

Patients with CRLM could get long-term survival benefit from different types of therapy, and resection of liver metastases was the optimal strategy. A predictive model using these above five factors may be of use in stratifying patients who may benefit from intensive surveillance and adjuvant therapy.

Ablative therapies for colorectal liver metastases

Ablative therapies remain a useful adjunct in the multidisciplinary treatment of patients with colorectal liver metastases not amenable to hepatic resection. This review summarizes the rationale, underlying mechanisms, techniques, complications, and outcomes of current and emerging ablative modalities.

Hepatic resection for colorectal liver metastases

Colorectal adenocarcinoma remains the third most common cause of cancer death in the United States, with an estimated 146,000 new cases and 50,000 deaths annually. Survival is stage dependent, and the presence of liver metastases is a primary determinant in patient survival. Approximately 25% of new cases will present with synchronous colorectal liver metastases (CLM), and up to one-half will develop CLM during the course of their disease. The importance of safe and effective therapies for CLM cannot be overstated. Safe and appropriately aggressive multimodality therapy for CLM can provide most patients with liver-dominant colorectal metastases with extended survival and an improved quality of life.

Should hepatic metastatic colorectal cancer patients with extrahepatic disease undergo liver resection/ablation?

BACKGROUND

Surgical therapy has been proven to be the mainstay of treatment for hepatic metastases from colorectal cancer (CRM) in the appropriate patient. Previous contraindications were patients with extrahepatic disease (EHD) do not benefit from liver resection or ablation. We hypothesized that the survival of patients with EHD who receive aggressive multimodality care would be the same as those without EHD.

METHODS

A review of our 1305 patient prospective hepato-pancreatico-biliary database from August 1995 to April 2008 identified 383 patients with surgical management of metastatic CRM to the liver.

RESULTS

A total of 39 patients with limited EHD underwent liver resection/ablation vs 344 patients without EHD. There were no significant differences in hepatic disease burden (mean clinical risk score of 2.3 and 2.1 in patients with and without EHD, P=.19, and median number of hepatic metastases of 2 in each group, P=.88) or size of the largest lesion (mean 4.6 vs 4.5 cm with and without EHD, P=.84). EHD consisted of lung metastases in 33%, nodal metastases in 21%, peritoneal in 15%, unknown in 15%, and other in 15%. There was no difference in patients with and without EHD undergoing surgical with resection only in 41% vs 48%, ablation only in 31% vs 30%, and combined resection and ablation in 28% vs 22% (P=.61). Overall survival in patients with EHD was not significantly different (median survival 24 vs 33 months, P=.06).

CONCLUSIONS

A thorough understanding of the biology of disease and appropriate multimodality care can lead to improved survival in patients with EHD, when compared with chemotherapy alone.

Activation of immature hepatic NK cells as immunotherapy for liver metastatic disease

NK cells can identify and eliminate emerging tumors due to altered expression of activating and inhibitory ligands on aberrant cells, a process that is greatly enhanced following NK cell activation. As a principal site of both tumor metastases and immature NK cells, the liver represents a unique anatomic location in which activation of the innate immune system could provide substantial therapeutic benefit. We describe here the NK cell-dependent destruction of a primary hepatic tumor following infection with an attenuated intracellular bacterium derived from Listeria monocytogenes. NK cell-mediated immunity correlated with the ordered migration and maturation of NK cells within the liver. Cytolytic activity was partially dependent on NKG2D-mediated tumor cell recognition, but surprisingly was still effective in the absence of type I IFN. Significantly, NK cell-mediated destruction of a primary hepatic tumor in infected mice led to long-lived CD4- and CD8 T cell-dependent tumor-specific adaptive immunity. These findings establish that activation and differentiation of immature NK cells using complex microbial stimuli can elicit potent anti-tumor activity within the liver, promote cross-presentation of tumor-derived Ags leading to long-lived systemic anti-tumor immunity, and suggests a paradigm for clinical intervention of liver metastatic carcinoma.

Changing patterns of recurrence after treatment for colorectal cancer

BACKGROUND

The management of patients with colorectal cancer has changed appreciably over the last 16 years. The aims of this study were to compare the rates and patterns of disease recurrence over the last 10 years with a historical control group.

MATERIALS AND METHODS

Data was obtained from a prospective database that had recorded all patients presenting with colorectal cancer from 1996 to 2006. This data was compared with a retrospective data set that included all patients treated with colorectal cancer at the same institution from 1989 to 1995. The Kaplan-Meier technique was used to calculate the 5 year recurrence and local recurrence rates for the two groups.

RESULTS

There were 710 patients in the study group and 475 patients in the control group. There were more patients with rectal cancer and stage I cancer in the study group. When comparing the study group vs the control group, there was an increase in the time to recurrence (2.1 vs 1.6 years, n.s.) and a decrease in the 5 year recurrence rate for patients undergoing curative resections (17% [95% CI 12%-20%] vs 42% [95% CI 36%-49%], p < 0.001). These changes were noted for both colon (16% vs 34%, p < 0.001) and rectal cancers (18% vs 50%, p < 0.001). There was also a decrease in local recurrence in patients with rectal cancer (8.8% [95% CI 4.5%-13.1%] vs 33.6% [95% CI 23.6%-43.6%], p < 0.001).

CONCLUSIONS

Within this institution, there has been a significant trend during the last 16 years towards reduced disease recurrence, both local and metastatic, and a prolongation in the time to develop recurrence.

Evaluation of SAT-1, SAT-2 and GalNAcT-1 mRNA in colon cancer by real-time PCR

By qualitative and quantitative PCR, we evaluated the expression of three messengers coding for SAT-1, SAT-2 and GalNAcT-1 in human samples of intestinal cancer and some cell lines (breast cancer and melanomas). Qualitative PCR demonstrated, in human tissues but not in the cell lines examined, the presence of an mRNA that lacks hexon 3; experiments performed on transfected SKMEL-28 excluded a regulative role of this noncanonical mRNA. Data from real-time PCR, statistically analysed by ANOVA indicated that the mRNA expression of all the considered glycosyltransferases (SAT-1, SAT-2 and GalNAcT-1) was significantly different in tumours versus their own control. The ganglioside patterns in the examined samples did not correlate with mRNA expression; this finding demonstrates that ganglioside expression is the result of a very complex balance between anabolic and catabolic enzyme activities. Although this study is still preliminary, it opens a new possibility for neoplastic prognosis finding potential molecular markers among the mRNAs that codify for glycosyltransferases.