Application of Tumor Burden Score for predicting conversion outcome in patients with initially unresectable colorectal liver metastases after first-line systemic therapy

Sexual dimorphism of colorectal cancer in humans and colorectal tumors in a murine model

Introduction

In colorectal cancer, men exhibit a higher incidence than women, and there is a disturbance in the levels of sex steroids in serum in patients with this disease. Consistently, in animals, males have greater tumor growth than females in diverse models. Nevertheless, the role of sex steroids is not well established. For that, we analyzed the effect of the principal gonadal sex steroids in both sexes. We determined sex as a statistically risk factor for colorectal cancer with data obtained from GLOBOCAN database.

Methods

To induce colorectal tumors, we used the gold standard chemical method of azoxymethane and dextran sulphate of sodium. To evaluate the role of sex steroids, we gonadectomized independent males and female animals, reconstituting and substituting them with 17β estradiol and dihydrotestosterone. Finally, we determined, in vitro, the proliferation of a human cell line exposed to 17β estradiol, testosterone, or dihydrotestosterone. Sex, as a risk factor for colorectal cancer, showed a statistically significant susceptibility of men over 50 years old.

Results

In vivo, males develop a greater number of tumors and with a larger size than females. In males, orchiectomy prevents tumor growth, whereas in females, ovariectomy promotes the development of neoplasms. DHT acts as a protumoral agent in both sexes. 17β estradiol reduces tumor growth in females but enhances it in males, showing a dimorphic effect. In vitro studies reveal that estradiol decreases the proliferation of the HCT-116 colon cancer cell line, while testosterone boosts proliferation in these cells. Interestingly, dihydrotestosterone does not influence proliferation.

Prognostic factors associated with early recurrence following liver resection for colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

Colorectal cancer (CRC) is the 3rd most common malignancy with the liver being the most common site of metastases. The recurrence rate of colorectal liver metastases (CRLM) after liver resection (LR) is notably high, with an estimated 40% of patients experiencing recurrence within 6 months. In this context, we conducted a meta-analysis to synthesize and evaluate the reliability of evidence pertaining to prognostic factors associated with early recurrence (ER) in CRLM following LR.

METHODS

Systematic searches were conducted from the inception of databases to July 14, 2023, to identify studies reporting prognostic factors associated with ER. The Quality in Prognostic Factor Studies (QUIPS) tool was employed to assess risk-of-bias for included studies. Meta-analysis was then performed on these prognostic factors, summarized by forest plots. The grading of evidence was based on sample size, heterogeneity, and Egger's P value.

RESULTS

The study included 24 investigations, comprising 12705 individuals, during an accrual period that extended from 2007 to 2023. In the evaluation of risk-of-bias, 22 studies were rated as low/moderate risk, while two studies were excluded because of high risk. Most of the studies used a postoperative interval of 6 months to define ER, with 30.2% (95% confidence interval [CI], 24.1-36.4%) of the patients experiencing ER following LR. 21 studies were pooled for meta-analysis. High-quality evidence showed that poor differentiation of CRC, larger and bilobar-distributed liver metastases, major hepatectomy, positive surgical margins, and postoperative complications were associated with an elevated risk of ER. Additionally, moderate-quality evidence suggested that elevated levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA199), lymph node metastases (LNM) of CRC, and a higher number of liver metastases were risk factors for ER.

CONCLUSION

This review has the potential to enhance the efficacy of surveillance strategies, refine prognostic assessments, and guide judicious treatment decisions for CRLM patients with high risk of ER. Additionally, it is essential to undertake well-designed prospective investigations to examine additional prognostic factors and develop salvage therapeutic approaches for ER of CRLM.

Multimodal Management of Colorectal Liver Metastases: State of the Art

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

PIVKA-II combined with tumor burden score to predict long-term outcomes of AFP-negative hepatocellular carcinoma patients after liver resection

BACKGROUND

This study aimed to establish a simple prognostic scoring model based on tumor burden score (TBS) and PIVKA-II to predict long-term outcomes of α-fetoprotein (AFP)-negative hepatocellular carcinoma (HCC) patients.

METHODS

511 patients were divided into the training cohort (n = 305) and the validation cohort (n = 206) at a ratio of 6:4. Receiver operating characteristic curves (ROC) were established to identify cutoff values of TBS and PIVKA-II. Kaplan-Meier curves were used to analyze survival outcomes. The multivariable Cox regression was used to identify variables independently associated with survival outcomes. The predictive performance of the TBS-PIVKA II score (TPS) model was compared with Barcelona clinic liver cancer (BCLC) stage and American Joint Committee on Cancer (AJCC TNM) stage.

RESULTS

The present study established the TPS model using a simple scoring system (0, 1 for low/high TBS [cutoff value: 4.1]; 0, 1 for low/high PIVKA-II [cutoff value: 239 mAU/mL]). The TPS scoring model was divided into three levels according to the summation of TBS score and PIVKA-II score: TPS 0, TPS 1, and TPS 2. The TPS scoring model was able to stratify OS (training: p < 0.001, validation: p < 0.001) and early recurrence (training: p < 0.001; validation: p = 0.001) in the training cohort and the validation cohort. The TPS score was independently associated with OS (TPS 1 vs. 0, HR: 2.28, 95% CI: 1.01-5.17; TPS 2 vs. 0, HR: 4.21, 95% CI: 2.01-8.84) and early recurrence (TPS 1 vs. 0, HR: 3.50, 95% CI: 1.71-7.16; TPS 2 vs. 0, HR: 3.79, 95% CI: 1.86-7.75) in the training cohort. The TPS scoring model outperformed BCLC stage and AJCC TNM stage in predicting OS and early recurrence in the training cohort and the validation cohort. But the TPS scoring model was unable to stratify the late recurrence in the training cohort (p = 0.872) and the validation cohort (p = 0.458).

CONCLUSIONS

The TPS model outperformed the BCLC stage and AJCC TNM stage in predicting OS and early recurrence of AFP-negative HCC patients after liver resection, which might better assist surgeons in screening AFP-negative HCC patients who may benefit from liver resection.

Evaluation of total tumor volume reduction ratio in initially unresectable colorectal liver metastases after first-line systemic treatment

PURPOSE

Total tumor volume (TTV) may play an essential role in the estimation of tumor burden. This study is aimed to investigate the clinical value of the reduction ratio of TTV as a valuable indicator of clinical outcomes in patients with colorectal liver metastases (CRLM).

METHODS

A total of 240 initially unresectable CRLM patients who underwent first-line systemic treatment were enrolled in this study. TTV at baseline and at the end of first-line treatment were assessed using a three-dimensional reconstruction system according to CT or MRI images. Survival was evaluated using Kaplan-Meier analysis and compared using Cox proportional hazard ratios (HR).

RESULTS

A total of 212 (88.3%) patients achieved tumor regression with a median reduction ratio of TTV of 86.0%. An increasing reduction ratio of TTV was associated with a gradually ascending successful conversion outcome. Patients with a reduction ratio >86.0% had better survival than those with a reduction ratio 0-86.0% or <0 (5-year overall survival (OS) rates, 64.4% vs. 44.9% vs. 23.5%, P < 0.001; 5-year progression-free survival (PFS) rates, 36.3% vs. 28.2% vs. 6.5%, P < 0.001). Multivariate analysis indicated that the reduction ratio of TTV ≤ 86.0% (OR [95%CI]: 4.956 [2.654-9.253], P < 0.001) was an independent factor for conversion failure outcome. Cox analyses revealed that the reduction ratio of TTV ≤ 86.0% was an independent factor for both unfavorable OS (HR [95%CI]: 2.216 [1.332-3.688], P = 0.002) and PFS (HR [95%CI]: 2.023 [1.376-2.974], P < 0.001).

CONCLUSIONS

The reduction ratio of TTV was an effective indicator for conversion outcome and long-term prognosis in patients with initially unresectable CRLM after first-line systemic treatment.

Nomogram predicting early recurrence defined by the minimum P value approach for colorectal liver metastasis patients receiving colorectal cancer resection with simultaneous liver metastasis resection: development and validation

Background

Simultaneous resections have been increasingly performed for colorectal liver metastasis patients. However, studies explored risk stratification for these patients are scarce. Among which, a clear definition of early recurrence remains controversial and models for predicting early recurrence in these patients are lacking.

Methods

Colorectal liver metastasis patients who developed recurrence followed by simultaneous resection were enrolled. Early recurrence was determined by the minimum P value method, and patients were divided into an early recurrence group and late recurrence group. Standard clinical data were collected from each patient including demographics features, preoperative laboratory tests and postoperative regular follow-up results. All the data were accessed by clinicians and recorded accordingly. The nomogram for early recurrence was constructed in the training cohort and validated externally in the test cohort.

Results

The optimal value of early recurrence by the minimum P value method was 13 months. A total of 323 patients were included in the training cohort, of which 241 (74.6%) experienced early recurrence. Seventy-one patients were included in the test cohort, of which 49 (69.0%) experienced early recurrence. Significantly worse post-recurrence survival (median 27.0 vs. 52.8 months, P=0.00083) and overall survival (median 33.8 vs. 70.9 months, P<0.0001) were observed in patients with early recurrence in the training cohort. Positive lymph node metastases (P=0.003), tumour burden scores ≥4.09 (P=0.001), preoperative neutrophil-to-lymphocyte ratios ≥1.44 (P=0.006), preoperative blood urea nitrogen levels ≥3.55 µmol/L (P=0.017) and postoperative complications (P=0.042) were independently associated with early recurrence, and all these predictors were included in the nomogram. The nomogram for predicting early recurrence had a receiver operating characteristic curve of 0.720 in the training cohort and a receiver operating characteristic curve of 0.740 in the test cohort. The Hosmer-Lemeshow test and calibration curves showed acceptable model calibration in the training set (P=0.7612) and in the test set (P=0.8671). The decision curve analysis results for the training cohort and test cohort also indicated that the nomogram showed good clinical applicability.

Conclusions

Our findings provide clinicians with new insights into accurate risk stratification for colorectal liver metastasis patients receiving simultaneous resection and contributing to the management of patients.

Clinical strategy of conversion therapy and surgical treatment for liver metastases from colorectal cancer

Colorectal cancer is one of the common malignant tumors of the digestive system in clinical practice. Due to the anatomical characteristics of the colorectum itself, colorectal cancer is prone to liver metastasis. Approximately 15%-25% of colorectal cancer cases are complicated with liver metastasis at diagnosis, 15%-25% are complicated with liver metastasis after radical resection of colorectal cancer, and 80%-90% with liver metastasis cannot undergo radical resection initially. The 5-year survival rate is less than 5%, and liver metastasis is the main cause of death in patients with colorectal cancer. In recent years, with the clinical application of effective chemotherapy and molecular targeted drugs, as well as the rapid development of surgical techniques, an individualized safe, efficient, fast, treatment plan can be formulated according to patients' age, primary colorectal tumor location, degree of differentiation, Ras and B-Raf gene status, tumor size, number and distribution of metastases in the liver. By shrinking the tumor volume in the liver and increasing the residual liver volume, liver metastatic tumors can undergo surgical resection or disease-free status can be achieved in patients with liver metastasis. As a result, patients with colorectal liver metastases can achieve a 5-year survival rate of 30%-57%, which greatly improves the prognosis after operation. According to the postoperative adverse factors, individualized preventive measures are worked out to reduce the impact of adverse factors and improve the prognosis of patients with colorectal liver metastases. In this paper, we systematically discuss the clinical strategy of conversion therapy and surgical treatment for unresectable colorectal cancer liver metastases by reviewing the relevant domestic and foreign literature, so as to provide a theoretical reference for the selection of clinical treatment and program for patients with unresectable colorectal cancer liver metastases.

The Role of Biomarkers in the Management of Colorectal Liver Metastases

Simple Summary

Colorectal cancer remains one of the most significant sources of cancer-related morbidity and mortality worldwide. The liver is the most common site of metastatic spread. Multiple modalities exist to manage and potentially cure patients with metastatic colorectal cancer. However, reliable biomarkers to assist with clinical decision-making are limited. Recent advances in genomic sequencing technology have greatly expanded our knowledge of colorectal cancer carcinogenesis and significantly reduced the cost and timing of the investigation. In this article, we discuss the current utility of biomarkers in the management of colorectal cancer liver metastases.

Abstract

Surgical management combined with improved systemic therapies have extended 5-year overall survival beyond 50% among patients with colorectal liver metastases (CRLM). Furthermore, a multitude of liver-directed therapies has improved local disease control for patients with unresectable CRLM. Unfortunately, a significant portion of patients treated with curative-intent hepatectomy develops disease recurrence. Traditional markers fail to risk-stratify and prognosticate patients with CRLM appropriately. Over the last few decades, advances in molecular sequencing technology have greatly expanded our knowledge of the pathophysiology and tumor microenvironment characteristics of CRLM. These investigations have revealed biomarkers with the potential to better inform management decisions in patients with CRLM. Actionable biomarkers such as RAS and BRAF mutations, microsatellite instability/mismatch repair status, and tumor mutational burden have been incorporated into national and societal guidelines. Other biomarkers, including circulating tumor DNA and radiomic features, are under active investigation to evaluate their clinical utility. Given the plethora of therapeutic modalities and lack of evidence on timing and sequence, reliable biomarkers are needed to assist clinicians with the development of patient-tailored management plans. In this review, we discuss the current evidence regarding biomarkers for patients with CRLM.