Recurrent colorectal liver metastasis patients could benefit from repeat hepatic resection

Patterns of recurrence after curative intent hepatic resection for colorectal liver metastasis

BACKGROUND

Improved surgical techniques and more intensive systemic therapy have increased the number of patients with oligometastatic colorectal cancer eligible for resection, but a significant percentage of these cases will ultimately recur. Furthermore, distinct recurrence patterns have been associated with different outcomes.

METHODS

Data for 195 patients who underwent curative-intent colorectal liver metastasis (CRLM) resection between 2016 and 2022 at Johns Hopkins Hospital were retrospectively collected. Cox regression univariate and multivariate analyses identified features associated with survival outcomes. Association between risk factors and site of recurrences was conducted via logistic regression with initial recurrences grouped into intrahepatic-only, extrahepatic-only, and concurrent intra- and extrahepatic recurrence.

RESULTS

The 1- and 2-year recurrence-free survival (RFS) rates were 46% and 22%, respectively. The 1- and 2-year overall survival (OS) rates were 95% and 88%, respectively. The median OS was 71.7 months. Multivariate analysis identified age <60 years, N2 nodal status, R1 liver margin, and higher preoperative carcinoembryonic antigen as top prognostic factors for worse RFS. Additionally, patients with left-sided primary tumors had a higher risk of intrahepatic-only recurrence, whereas mutant KRAS was associated with a higher risk of extrahepatic recurrence with or without liver recurrence.

CONCLUSION

These results from a recent cohort of patients treated with current standard-of-care therapies identify features associated with elevated risk and specific patterns of recurrence. These insights into CRLM recurrence patterns support a larger prospective study to identify subgroups of patients who may require additional therapies to prevent recurrence.

Pre-hepatectomy dynamic circulating tumor DNA to predict pathologic response to preoperative chemotherapy and post-hepatectomy recurrence in patients with colorectal liver metastases

OBJECTIVE

To evaluate the predictive value of pre-hepatectomy dynamic circulating tumor DNA (ctDNA) on pathologic response to preoperative chemotherapy and recurrence after liver resection for colorectal liver metastases (CRLM).

BACKGROUND

Pathologic response is a predictor of clinical outcomes for patients undergoing hepatectomy for CRLM. Postoperative ctDNA has been proven to be sensitive for recurrence detection. However, few studies investigate the impact of pre-hepatectomy ctDNA on pathologic response and recurrence.

METHODS

Patients with potential resectable CRLM underwent preoperative chemotherapy and hepatectomy between 2018 and 2021 was considered for inclusion. Plasma ctDNA was collected before and after preoperative chemotherapy. Pathologic response was analyzed for all patients after liver resection. Recurrence free survival was compared between patients with different ctDNA status and different pathologic response. The relation between ctDNA and pathologic response was also analyzed.

RESULTS

A total of 114 patients were included. ctDNA was detectable in 108 of 114 patients (94.7%) before chemotherapy, in 56 of 114 patients (49.1%) after chemotherapy. Patients with ctDNA positive at baseline and negative after chemotherapy had significantly longer RFS (median RFS 17 vs 7 months, p = 0.001) and HRFS (median HRFS unreached vs 8 months, p < 0.001) than those with ctDNA persistently positive after chemotherapy. Two patients (1.6%) had a pathologic complete response and 56 patients (45.2%) had a pathologic major response. Post-chemotherapy ctDNA- was associated with improved major pathologic response (53.4% vs 32.1%, p = 0.011). In the multivariable analysis, ctDNA- after chemotherapy (HR 0.51, 95% CI 0.28-0.93), major pathologic response (HR 0.34, 95% CI 0.19-0.62) and surgery combined with radiofrequency ablation (HR 2.62, 95% CI 1.38-5.00) were independently associated with RFS (all p < 0.05).

CONCLUSIONS

Pre-hepatectomy dynamic monitoring of ctDNA could predict pathologic response to preoperative chemotherapy and post-hepatectomy recurrence in CRLM patients. Negative ctDNA after preoperative chemotherapy was associated with better tumor regression grade and recurrence-free survival, which might be used to guide pre-hepatectomy chemotherapy and predict prognosis.

Personalized circulating tumor DNA monitoring improves recurrence surveillance and management after curative resection of colorectal liver metastases: a prospective cohort study

BACKGROUND

Approximately 60% of patients with colorectal liver metastases (CRLM) experience relapse within 2 years after radical resection, previous studies have proven that repeat local treatment (LT) could prolong survival, however, it is difficult to seize the window for LT due to the lack of a high-sensitive surveillance method. In this study, the authors aim to examine the value of longitudinal circulating tumor DNA (ctDNA) in guiding adjuvant chemotherapy, optimizing clinical surveillance strategy, and thereby improving CRLM outcomes.

MATERIALS AND METHODS

The authors conducted a prospective clinical trial using a personalized, tumor-informed ctDNA assay to monitor 60 CRLM patients undergoing resection with curative intent. Formalin-fixed paraffin-embedded tumor samples were collected after surgery. Blood samples were collected before surgery, 30 days after surgery (post-OP), and every third month until relapse or up to 2 years.

RESULTS

A total of 394 plasma samples from 60 eligible patients were analyzed, with a median follow-up time of 31.3 months. Landmark analyses revealed that detectable ctDNA at post-OP (HR, 4.8), postadjuvant chemotherapy (HR, 6.0), and end-of-treatment (HR, 5.6) were associated with higher recurrence risk ( P <0.001). Post-OP ctDNA positivity served as the only independent prognostic marker in the multivariant analysis (HR, 5.1; P <0.001). Longitudinal ctDNA analysis identified relapsed patients at both sensitivity and specificity of 100%. Most (75%) patients were found with radiological relapse within 6 months after the first detectable ctDNA with a median lead time of 3.5 months. In relapsed patients, 73.2% had oligometastatic disease and 61% were liver-restricted, of which 72.0% received repeat LTs, and 60.0% achieved a secondary no evidence of disease status.

CONCLUSIONS

Longitudinal ctDNA monitoring assists in early prediction of relapse, and thereby improves survival of CRLM patients by increased secondary resection rate and secondary no evidence of disease rate.

New insights into macrophage polarization and its prognostic role in patients with colorectal cancer liver metastasis

BACKGROUND

As liver metastasis is the most common cause of mortality in patients with colorectal cancer, studying colorectal cancer liver metastasis (CLM) microenvironment is essential for improved understanding of tumor biology and to identify novel therapeutic targets.

METHODS

We used a multiplex immunofluorescence platform to study tumor associated macrophage (TAM) polarization and adaptive T cell subtypes in tumor samples from 105 CLM patients (49 without and 56 with preoperative chemotherapy).

RESULTS

CLM exhibited M2 macrophage polarization, and helper T cells were the prevalent adaptive T cell subtype. The density of total, M2 and TGFβ-expressing macrophages, and regulatory T cells was lower in CLM treated with preoperative chemotherapy. CLM with right-sided primary demonstrated enrichment of TGFβ-expressing macrophages, and with left-sided primary had higher densities of helper and cytotoxic T cells. In multivariate analysis, high density of M2 macrophages correlated with longer recurrence-free survival (RFS) in the entire cohort [hazard ratio (HR) 0.425, 95% CI 0.219-0.825, p = 0.011) and in patients without preoperative chemotherapy (HR 0.45, 95% CI 0.221-0.932, p = 0.032). High pSMAD3-expressing macrophages were associated with shorter RFS in CLM after preoperative chemotherapy.

CONCLUSIONS

Our results highlight the significance of a multi-marker approach to define the macrophage subtypes and identify M2 macrophages as a predictor of favorable prognosis in CLM.

Clinical Prediction Models for Prognosis of Colorectal Liver Metastases: A Comprehensive Review of Regression-Based and Machine Learning Models

Colorectal liver metastasis (CRLM) is a disease entity that warrants special attention due to its high frequency and potential curability. Identification of "high-risk" patients is increasingly popular for risk stratification and personalization of the management pathway. Traditional regression-based methods have been used to derive prediction models for these patients, and lately, focus has shifted to artificial intelligence-based models, with employment of variable supervised and unsupervised techniques. Multiple endpoints, like overall survival (OS), disease-free survival (DFS) and development or recurrence of postoperative complications have all been used as outcomes in these studies. This review provides an extensive overview of available clinical prediction models focusing on the prognosis of CRLM and highlights the different predictor types incorporated in each model. An overview of the modelling strategies and the outcomes chosen is provided. Specific patient and treatment characteristics included in the models are discussed in detail. Model development and validation methods are presented and critically appraised, and model performance is assessed within a proposed framework.

Local Therapy Improves Survival for Early Recurrence After Resection of Colorectal Liver Metastases

BACKGROUND

Early recurrence following hepatectomy for colorectal liver metastases (CLM) is associated with worse survival; yet, impact of further local therapy is unclear. We sought to evaluate whether local therapy benefits patients with early recurrence following hepatectomy for CLM.

METHODS

Clinicopathologic and survival outcomes of patients managed with hepatectomy for CLM (1/2001-12/2020) were queried from a prospectively maintained database. Timing of recurrence was stratified as early (recurrence-free survival [RFS] < 6 months), intermediate (RFS 6-12 months), and later (RFS > 12 months). Local therapy was defined as ablation, resection, or radiation.

RESULTS

Of 671 patients, 541 (81%) recurred with 189 (28%) early, 180 (27%) intermediate, and 172 (26%) later recurrences. Local therapy for recurrence resulted in improved survival, regardless of recurrence timing (early 78 vs. 32 months, intermediate 72 vs. 39 months, later 132 vs. 65 months, all p < 0.001). Following recurrence, treatment with local therapy (hazard ratio [HR] = 0.24), liver and extrahepatic recurrence (HR = 1.81), RAS + TP53 co-mutation (HR = 1.52), and SMAD4 mutation (HR = 1.92) were independently associated with overall survival (all p ≤ 0.002). Among patients with recurrence treated by local therapy, patients older than 65 years (HR 1.79), liver and extrahepatic recurrence (HR 2.05), primary site or other recurrence (HR 1.90), RAS-TP53 co-mutation (HR 1.63), and SMAD4 mutation (HR 2.06) had shorter post-local therapy survival (all p ≤ 0.04).

CONCLUSIONS

While most patients recur after hepatectomy for CLM, local therapy may result in long-term survival despite early recurrence. Somatic mutational profiling may help to guide the multidisciplinary consideration of local therapy after recurrence.

Predictive nomograms of repeat intrahepatic recurrence and overall survival after radiofrequency ablation of recurrent colorectal liver metastases

OBJECTIVES

This study was conducted to develop nomograms for predicting repeat intrahepatic recurrence (rIHR) and overall survival (OS), after radiofrequency ablation (RFA), treatment in patients with recurrent colorectal liver metastases (CLMs) after hepatectomy based on clinicopathologic features.

METHODS

A total of 160 consecutive patients with recurrent CLMs after hepatectomy who were treated with ultrasound-guided percutaneous RFA from 2012 to 2022 were retrospectively included. Patients were randomly divided into a training cohort and a validation cohort, with a ratio of 8:2. Potential prognostic factors associated with rIHR and OS, after RFA, were identified by using the competing-risks and Cox proportional hazard models, respectively, and were used to construct the nomogram. The nomogram was evaluated by Harrell's C-index and a calibration curve.

RESULTS

The 1-, 2-, and 3-year rIHR rates after RFA were 58.8%, 70.2%, and 74.2%, respectively. The 1-, 3- and 5-year OS rates were 96.3%, 60.4%, and 38.5%, respectively. In the multivariate analysis, mutant RAS, interval from hepatectomy to intrahepatic recurrence ≤ 12 months, CEA level >5 ng/ml, and ablation margin <5 mm were the independent predictive factors for rIHR. Mutant RAS, largest CLM at hepatectomy >3 cm, CEA level >5 ng/ml, and extrahepatic disease were independent predictors of poor OS. Two nomograms for rIHR and OS were constructed using the respective significant variables. In both cohorts, the nomogram demonstrated good discrimination and calibration.

CONCLUSIONS

The established nomograms can predict individual risk of rIHR and OS after RFA for recurrent CLMs and contribute to improving individualized management.

Value of prognostic scoring systems in the era of multimodal therapy for recurrent colorectal liver metastases

BACKGROUND

Various predictive scoring systems have been developed to estimate outcomes of patients undergoing surgery for colorectal liver metastases (CRLM). However, data regarding their effectiveness in recurrent CRLM (recCRLM) are very limited.

METHODS

Patients who underwent repeat hepatectomy for recCRLM at the University Hospital RWTH Aachen, Germany from 2010 to 2021 were included. Nine predictive scoring systems (Fong's, Nordlinger, Nagashima, RAS mutation, Tumor Burden, GAME, CERR, and Glasgow Prognostic score, Basingstoke Index) were evaluated by likelihood ratio (LR) χ2, linear trend (LT) χ2 and Akaike Information Criterion (AIC) for their predictive value regarding overall survival (OS) and recurrence free survival (RFS).

RESULTS

Among 150 patients, median RFS was 9 (2-124) months with a 5-year RFS rate of 10%. Median OS was 39 (4-131) months with a 5-year OS rate of 32%. For RFS and OS, the Nagashima score showed the best prognostic ability (LT χ2 3.00, LR χ2 9.39, AIC 266.66 and LT χ2 2.91, LR χ2 20.91, 290.36).

DISCUSSION

The Nagashima score showed the best prognostic stratification to predict recurrence as well as survival, and therefore might be considered when evaluating patients with recCRLM for repeat hepatectomy.

New Insights into Macrophage Polarization and its Prognostic Role in Patients with Colorectal Cancer Liver Metastasis

Background

As liver metastasis is the most common cause of mortality in patients with colorectal cancer, studying colorectal cancer liver metastasis (CLM) microenvironment is essential for improved understanding of tumor biology and to identify novel therapeutic targets.

Methods

We used multiplex immunofluorescence platform to study tumor associated macrophage (TAM) polarization and adaptive T cell subtypes in tumor samples from 105 CLM patients (49 without and 56 with preoperative chemotherapy).

Results

CLM exhibited M2 macrophage polarization, and helper T cells were the prevalent adaptive T cell subtype. The density of total, M2 and TGFβ-expressing macrophages, and regulatory T cells was lower in CLM treated with preoperative chemotherapy. CLM with right-sided primary demonstrated enrichment of TGFβ-expressing macrophages, and with left-sided primary had higher densities of helper and cytotoxic T cells. In multivariate analysis, high density of M2 macrophages correlated with longer recurrence-free survival (RFS) in the entire cohort [hazard ratio (HR) 0.425, 95% CI 0.219-0.825, p=0.011) and in patients without preoperative chemotherapy (HR 0.45, 95% CI 0.221-0.932, p=0.032). High pSMAD3-expressing macrophages were associated with shorter RFS in CLM after preoperative chemotherapy.

Conclusions

Our results highlight the significance of a multi-marker approach to define the macrophage subtypes and identify M2 macrophages as a predictor of favorable prognosis in CLM.

The impact of recurrence timing and tumor burden score on overall survival among patients undergoing repeat hepatectomy for colorectal liver metastases

INTRODUCTION

Approximately 15% of patients experience a resectable intrahepatic recurrence after an index curative-intent hepatectomy for colorectal liver metastases (CRLM). We sought to investigate the impact of recurrence timing and tumor burden score (TBS) at the time of recurrence on overall survival among patients undergoing repeat hepatectomy.

METHODS

Patients with CRLM who experienced recurrent intrahepatic disease after initial hepatectomy between 2000 and 2020 were identified from an international multi-institutional database. The impact of time-TBS, defined as TBS divided by the time interval of recurrence, was assessed relative to overall survival.

RESULTS

Among 220 patients, the median age was 60.9 years (interquartile range [IQR]: 53.0-69.0), and 144 (65.5%) patients were male. Most patients experienced multiple recurrences (n = 120, 54.5%) within 12 months after the initial hepatectomy (n = 139, 63.2%). The median tumor size of the recurrent CRLM was 2.2 cm (IQR: 1.5-3.0 cm) with a median TBS of 3.5 (2.3-4.9) at the time of recurrence. Overall, 121 (55.0%) patients underwent repeat hepatectomy, whereas 99 (45.0%) individuals were treated with systemic chemotherapy or other nonsurgical treatments; repeat hepatectomy was associated with better postrecurrence survival (PRS) (p < 0.001). Three-year PRS incrementally worsened (low time-TBS: 71.7%, 95% confidence interval [CI], 57.9-88.8 vs. medium: 63.6%, 95% CI, 47.7-84.8 vs. high: 49.2%, 95% CI, 31.1-77.7, p = 0.02) as time-TBS values increased. Each unit increase in time-TBS score was independently associated with a 41% higher possibility of death (hazard ratio: 1.41; 95% CI, 1.04-1.90, p = 0.03).

CONCLUSIONS

Time-TBS was associated with long-term outcomes after repeat hepatectomy for recurrent CRLM. Time-TBS may be an easy tool to help select patients who may benefit the most from repeat hepatic resection of recurrent CRLM.

Survival of patients with colorectal liver metastases treated with and without preoperative chemotherapy: Nationwide propensity score-matched study

INTRODUCTION

Routine treatment with preoperative systemic chemotherapy (CTx) in patients with colorectal liver metastases (CRLM) remains controversial due to lack of consistent evidence demonstrating associated survival benefits. This study aimed to determine the effect of preoperative CTx on overall survival (OS) compared to surgery alone and to assess hospital and oncological network variation in 5-year OS.

METHODS

This was a population-based study of all patients who underwent liver resection for CRLM between 2014 and 2017 in the Netherlands. After 1:1 propensity score matching (PSM), OS was compared between patients treated with and without preoperative CTx. Hospital and oncological network variation in 5-year OS corrected for case-mix factors was calculated using an observed/expected ratio.

RESULTS

Of 2820 patients included, 852 (30.2%) and 1968 (69.8%) patients were treated with preoperative CTx and surgery alone, respectively. After PSM, 537 patients remained in each group, median number of CRLM; 3 [IQR 2-4], median size of CRLM; 28 mm [IQR 18-44], synchronous CLRM (71.1%). Median follow-up was 80.8 months. Five-year OS rates after PSM for patients treated with and without preoperative chemotherapy were 40.2% versus 38.3% (log-rank P = 0.734). After stratification for low, medium, and high tumour burden based on the tumour burden score (TBS) OS was similar for preoperative chemotherapy vs. surgery alone (log-rank P = 0.486, P = 0.914, and P = 0.744, respectively). After correction for non-modifiable patient and tumour characteristics, no relevant hospital or oncological network variation in five-year OS was observed.

CONCLUSION

In patients eligible for surgical resection, preoperative chemotherapy does not provide an overall survival benefit compared to surgery alone.

Five-year survival post hepatectomy for colorectal liver metastases in a real-world Chinese cohort: Recurrence patterns and prediction for potential cure

BACKGROUND

Patients with a 5-year recurrence-free survival post liver resection for colorectal cancer liver metastases (CRLM) are considered to be potentially cured. However, there is a deficit of data on long-term follow-up and the recurrence status among these patients in the Chinese population. We analyzed real-world follow-up data of patients with CRLM who underwent hepatectomy, explored the recurrence patterns, and established a prediction model for a potential cure scenario.

METHODS

Patients who underwent radical hepatic resection for CRLM during 2000-2016, with actual follow-up data for at least 5 years, were enrolled. The observed survival rate was calculated and compared among the groups with different recurrence patterns. The predictive factors for 5-year non-recurrence were determined using logistic regression analysis; a recurrence-free survival model was developed to predict long-term survival.

RESULTS

A total of 433 patients were included, of whom 113 patients were found non-recurrence after 5 years follow-up, with a potential cure rate of 26.1%. Patients with late recurrence (>5 months) and lung relapse showed significantly superior survival. Repeated localized treatment significantly improved the long-term survival of patients with intrahepatic or extrahepatic recurrences. Multivariate analysis showed that RAS wild-type CRC, preoperative CEA <10 ng/ml, and liver metastases ≤3 were independent factors for a 5-year disease-free recurrence. A cure model was developed based on the above factors, achieving good performance in predicting long-term survival.

CONCLUSIONS

About one quarter patients with CRLM could achieve potential cure with non-recurrence at 5-year after surgery. The recurrence-free cure model could well distinguish the long-term survival, which would aid clinicians in determining the treatment strategy.

Surgical management of liver metastasis from colorectal cancer

This short review illustrates the benefits of a multidisciplinary team approach, especially when it comes to the treatment of patients with colorectal cancer liver metastasis. Therefore, the classification to resectable and primarily unresectable disease has to be determined prior to the first treatment decision. Particularly the use of conversion chemotherapy has the potential of altering initially unresectable liver metastasis to a potentially resectable disease. The three possible therapy choices for synchronously metastasized colorectal cancer will be reflected in this review, as well as local therapeutic alternatives or combinations.

Comparison Between Minimally Invasive Right Anterior and Right Posterior Sectionectomy vs Right Hepatectomy: An International Multicenter Propensity Score-Matched and Coarsened-Exact-Matched Analysis of 1,100 Patients

BACKGROUND

The role of minimally invasive right anterior and right posterior sectionectomy (MI-RAS/MI-RPS) for right-sided liver lesions remains debatable. Although technically more demanding, these procedures might result in faster recovery and lower postoperative morbidity compared with minimally invasive right hemihepatectomy.

STUDY DESIGN

This is an international multicenter retrospective analysis of 1,114 patients undergoing minimally invasive right hemihepatectomy, MI-RAS, and MI-RPS at 21 centers between 2006 and 2019. Minimally invasive surgery included pure laparoscopic, robotic, hand-assisted, or a hybrid approach. A propensity-matched and coarsened-exact-matched analysis was performed.

RESULTS

A total of 1,100 cases met study criteria, of whom 759 underwent laparoscopic, 283 robotic, 11 hand-assisted, and 47 laparoscopic-assisted (hybrid) surgery. There were 632 right hemihepatectomies, 373 right posterior sectionectomies, and 95 right anterior sectionectomies. There were no differences in baseline characteristics after matching. In the MI-RAS/MI-RPS group, median blood loss was higher (400 vs 300 mL, p = 0.001) as well as intraoperative blood transfusion rate (19.6% vs 10.7%, p = 0.004). However, the overall morbidity rate was lower including major morbidity (7.1% vs 14.3%, p = 0.007) and reoperation rate (1.4% vs 4.6%, p = 0.029). The rate of close/involved margins was higher in the MI-RAS/MI-RPS group (23.4% vs 8.9%, p < 0.001). These findings were consistent after both propensity and coarsened-exact matching.

CONCLUSIONS

Although technically more demanding, MI-RAS/MI-RPS is a valuable alternative for minimally invasive right hemihepatectomy in right-sided liver lesions with lower postoperative morbidity, possibly due to the preservation of parenchyma. However, the rate of close/involved margins is higher in these procedures. These findings might guide surgeons in preoperative counselling and in selecting the appropriate procedure for their patients.

Surgery combined with intra-operative microwaves ablation for the management of colorectal cancer liver metastasis: A case-matched analysis and evaluation of recurrences

Background

Hepatic resection is the only chance of cure for a subgroup of patients with colorectal cancer liver metastasis. As the oncologic outcomes of intra-operative microwaves ablation combined with hepatic resection still remain uncertain in this setting, we aimed to compare this approach with surgery alone in patient's candidate to metastases resection with radical intent.

Methods

Using a case-matched methodology based on age, gender, American Society of Anesthesiology score, Body Mass Index, and burden that take in consideration the number and maximum size of lesions, 20 patients undergoing hepatic resection plus intra-operative microwaves (SURG + IMW group) and 20 patients undergoing hepatic resection alone (SURG group), were included. Relapse-free Survival and post-resection Overall Survival were compared between patients of two groups.

Results

At the median follow up of 22.4 ± 17.8, 12/20 patients (60%) in SURG +IMW group and 13/20 patients (65%) in the SURG group experienced liver metastasis recurrence (p=0.774). None of them had recurrence at the same surgical or ablation site of the first hepatic treatment. 7/12 patients in the SURG+IMW group and 7/13 patients in the SURG group underwent at least one further surgical treatment after relapse (p = 1.000). No difference was reported between the two groups in terms of Relapse-free Survival (p = 0.685) and post-resection Overall Survival (p = 0.151). The use of intra-operative microwaves was not an independent factor affecting Relapse-free Survival and post-resection Overall Survival at univariate and multivariate analysis.

Conclusions

Patients with colorectal cancer liver metastasis undergoing surgery plus intra-operative microwaves have similar post-operative results compared with surgery alone group. The choice between the two approaches could be only technical, depending on the site, number, and volume of the metastases. This approach could also be used in patients with liver metastasis relapse who have already undergone hepatic surgery.

Outcomes of simultaneous resection for elderly patients with colorectal liver metastasis: A propensity score matching analysis

BACKGROUND

Evidence on simultaneous resection for elderly patients (age ≥ 70 years) with colorectal liver metastasis (CRLM) is lacking.

METHODS

Four hundred and eighty-two CRLM patients treated by simultaneous resection were categorised into young group (age < 70 years) and elderly group (age ≥ 70 years). Propensity score matching (PSM1) was performed to adjust for differences in baseline characteristics and compare short-term outcomes. An additional propensity score matching (PSM2) including short-term outcomes was performed to analyse survival. Subgroup analysis was performed in patients stratified by the Clinical Risk Score (CRS).

RESULTS

After PSM1, 87 young group patients were matched to 50 elderly group patients. Patients in the elderly group had a significantly higher rate of overall post-operative complications (68.0% vs. 46.0%, p = 0.013). After PSM2, 89 young group patients were matched to 47 elderly group patients. Progression-free survival (PFS) was comparable between the two groups (median 11.0 months vs. 9.8 months, p = 0.346). Age ≥ 70 independently predicted worse overall survival (OS) (Hazard ratio, HR = 2.57, 95% confidence interval, CI 1.37-4.82) in multivariate analysis. In the subgroup multivariate analysis of patients with CRS score 3-5, age ≥ 70 was independently associated with worse PFS (HR = 1.62, 95% CI 1.01-2.62) and OS (HR = 2.34, 95% CI 1.26-4.35).

CONCLUSIONS

Simultaneous resection for elderly CRLM patients is acceptable. Further studies are required to determine the optimal treatment for elderly CRLM patients with high CRS scores.

Laparoscopic Resection of Synchronous Liver Metastasis Involving the Left Hepatic Vein and the Common Trunk Bifurcation: A Strategy of Parenchyma-Sparing Resection with Left Sectionectomy and 4a Subsegmentectomy by Arantius Approach

When colorectal cancer presents with liver metastasis, hepatic resection remains the most important factor in prolonging survival, and new paradigms have been proposed to augment resectability. An adequate liver remnant and vascularisation are the only limits in complex liver resection, and parenchyma-sparing surgery is a strategy for minimising the complications, preserving liver function, and allowing patients to undergo further liver resection. The laparoscopic approach represents a new challenge, especially when lesions are located in the superior or posterior part of the liver. We discuss the case of an 81-year-old patient with a single synchronous liver metastasis involving the left hepatic vein and leaning into the middle hepatic vein at the common trunk, where we performed a simultaneous laparoscopic colonic resection with a left sectionectomy extended to segment 4a. The strategic approach to the Arantius ligament by joining the left and middle hepatic vein allowed us to avoid a major liver hepatectomy, preserve the liver parenchyma, reduce complications, enhance patient recovery, and perform the entire procedure by laparoscopy. Our example suggests that the Arantius approach to the left hepatic vein and the common trunk could be a feasible approach to consider in laparoscopic surgery for lesions located in their proximity.