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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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Haraldsdottir S, Goldberg RM. Conversion Therapy for Initially Borderline/Unresectable Metastases in Colon Cancer: What Is the Best Neoadjuvant Chemotherapy? CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0393-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Mao R, Zhao JJ, Zhao H, Zhang YF, Bi XY, Li ZY, Zhou JG, Wu XL, Xiao C, Cai JQ. Non-response to preoperative chemotherapy is a contraindication to hepatectomy plus radiofrequency ablation in patients with colorectal liver metastases. Oncotarget 2017; 8:75151-75161. [PMID: 29088853 PMCID: PMC5650408 DOI: 10.18632/oncotarget.20647] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/08/2017] [Indexed: 12/30/2022] Open
Abstract
The long-term outcome of 228 patients with colorectal liver metastases (CRLM) who underwent preoperative chemotherapy followed by hepatectomy ± RFA were retrospectively analyzed. Stratified by chemotherapy response, patients were divided into responding (n=129) and non-responding groups (n=99). Patients who underwent hepatectomy-RFA had a greater number of metastases (median of 4 vs. 2, p=0.000), a higher incidence of bilobar involvement (66.7% vs. 49.1%, p=0.014) and longer chemotherapy cycles (median of 6 vs. 4, p=0.000). In the responding group, the median overall survival (OS) and recurrence free survival (RFS) of hepatectomy-RFA and the hepatectomy alone subgroups were comparable (38.6 months vs. 43.2 months, p=0.824; 8.2 months vs. 11.4 months, p=0.623). In the non-responding group, the median OS and RFS of patients treated with hepatectomy-RFA were significantly shorter (18.5 months vs. 34.2 months, p=0.000; 5.1 months vs. 5.9 months, p=0.002). RFA was identified as the unfavorable independent factor for both OS (HR=3.60, 95%CI=1.81-7.16, p=0.039) and RFS (HR=1.70, 95%CI=1.00-2.86, p=0.048) in non-responsive patients. Local recurrence rate after hepatectomy-RFA was higher in the non-responding group (48.1% vs. 23.6%, p=0.018). Non-response to preoperative chemotherapy may be a contraindication to hepatectomy-RFA in patients with CRLM.
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Affiliation(s)
- Rui Mao
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Jian-Jun Zhao
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Hong Zhao
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Ye-Fan Zhang
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Xin-Yu Bi
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Zhi-Yu Li
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Jian-Guo Zhou
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Xiao-Long Wu
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Chen Xiao
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
| | - Jian-Qiang Cai
- Department of Hepatobiliary Surgery, Cancer Hospital, CAMS, Beijing 100021, P.R.China
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Giuliani J, Bonetti A. The Pharmacological Costs of Complete Liver Resections in Unselected Advanced Colorectal Cancer Patients: Focus on Targeted Agents. A Review of Randomized Clinical Trials. J Gastrointest Cancer 2017; 47:341-350. [PMID: 27488729 DOI: 10.1007/s12029-016-9862-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the pharmacological costs of conversion chemotherapy with targeted biological agents in an unselected population of advanced colorectal cancer (CRC) patients in order to achieve an R0 liver resection. METHODS Full reports and updates of randomized clinical trials (RCTs) that compared at least two front-line therapy regimens with targeted biological agents for advanced CRC patients were selected. The present evaluation was restricted to randomized phase II and III trials. The costs of drugs are at the Pharmacy Hospital and are expressed in euros (€). RESULTS Our study began with the evaluation of 683 abstracts. Forty-eight trials were considered appropriate for further analysis. A more in-depth evaluation looking for the trials reporting the liver resection rates following conversion chemotherapy brought to the exclusion of other 37 trials, leaving 11 randomized trials (three phase II trials, including 522 patients and eight phase III trials, including 7191 patients). The pharmacological costs of conversion therapy increased with the substitution of prolonged infusion 5-Fluorouracil by capecitabine and, to a much higher extent, with the introduction of biologicals. CONCLUSIONS Two key issues are presented in this review. First, the pharmacological costs of commonly used front line regimens based on the targeted biological agents for the treatment of advanced CRC are highly variable. Second, the performance of the published schemes, in terms of resection rates, depends on patient's selection, tumor characteristics, and on the type of the scheme.
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Affiliation(s)
- Jacopo Giuliani
- Department of Medical Oncology, Mater Salutis Hospital, AULSS 21 della Regione Veneto, Legnago, VR, Italy. .,Department of Medical Oncology, ASL 21 della Regione Veneto, Via Gianella 1, 37045, Legnago, VR, Italy.
| | - Andrea Bonetti
- Department of Medical Oncology, Mater Salutis Hospital, AULSS 21 della Regione Veneto, Legnago, VR, Italy.,Department of Medical Oncology, ASL 21 della Regione Veneto, Via Gianella 1, 37045, Legnago, VR, Italy
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Abstract
Until recently, hepatic arterial therapies (HAT) had been used for colorectal liver metastases after failure of first-, second-, and third-line chemotherapies. HAT has gained greater acceptance in patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The current data demonstrate that HAT is a safe and effective option for preoperative downsizing, optimizing the time to surgery, limiting non-tumor-bearing liver toxicity, and improving overall survival after surgery in patients with colorectal liver-only metastases. The aim of this review is to present the current data for HAT in liver-only and liver-dominant colorectal liver metastases.
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Affiliation(s)
- Neal Bhutiani
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA; Division of Surgical Oncology, Upper Gastrointestinal and Hepato-Pancreatico-Biliary Clinic, 315 East Broadway, #311, Louisville, KY 40202, USA.
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Okuno M, Hatano E, Nishino H, Seo S, Taura K, Uemoto S. Does response rate of chemotherapy with molecular target agents correlate with the conversion rate and survival in patients with unresectable colorectal liver metastases?: A systematic review. Eur J Surg Oncol 2016; 43:1003-1012. [PMID: 27624917 DOI: 10.1016/j.ejso.2016.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/08/2016] [Accepted: 08/23/2016] [Indexed: 12/17/2022] Open
Abstract
PURPOSE This study aimed to evaluate whether the response rate of chemotherapy with molecular target agents correlates with the conversion rate, R0 resection rate, and survival in patients with initially unresectable colorectal liver metastases (CRLM). METHODS We reviewed the literature of prospective, controlled trials of systemic chemotherapy for patients with unresectable liver-only CRLM, including resectable extrahepatic metastases. Pearson's correlation coefficients were calculated. RESULTS A total of 26 patient groups from 18 studies were reviewed. The response rate was significantly correlated with the conversion rate (r = 0.66) and R0 resection rate (r = 0.43) in overall patients. In subgroup analysis, only the conversion rate in patients with chemotherapy only (r = 0.75) and anti-EGFR therapy (r = 0.78) were significantly strongly correlated with the response rate. A non-significant strong trend toward correlation between response and conversion rates was observed in patients with bevacizumab (r = 0.73, p = 0.10). The regression line in the scatter plot of patients using bevacizumab showed a less steep slope. This indicated that conversion rates were relatively less affected by response rates under anti-VEGF therapy compared with the other patient groups. The response rate in chemotherapy-only patients was significantly correlated with median progression-free survival (r = 0.61) and overall survival (r = 0.66). CONCLUSIONS Chemotherapy without molecular target agents and with anti-EGFR agents shows similar results of correlation between response and conversion/R0 resection rates. Under anti-VEGF therapy, conversion would be expected, even with a relatively lower response rate.
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Affiliation(s)
- M Okuno
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - E Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan; Hepato-Biliary-Pancreas Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan.
| | - H Nishino
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - S Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - K Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - S Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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Transarterial chemoembolization (TACE) for colorectal liver metastases--current status and critical review. Langenbecks Arch Surg 2015; 400:641-59. [PMID: 26088872 DOI: 10.1007/s00423-015-1308-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/24/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transarterial liver-directed therapies are currently not recommended as a standard treatment for colorectal liver metastases. Transarterial chemoembolization (TACE), however, is increasingly used for patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The limited available data potentially reveals TACE as a valuable option for pre- and post-operative downsizing, minimizing time-to-surgery, and prolongation of overall survival after surgery in patients with colorectal liver only metastases. PURPOSE In this overview, the current status of TACE for the treatment of liver-dominant colorectal liver metastases is presented. Critical comments on its rationale, technical success, complications, toxicity, and side effects as well as oncologic outcomes are discussed. The role of TACE as a valuable adjunct to surgery is addressed regarding pre- and post-operative downsizing, conversion to resectability as well as improvement of the recurrence rate after potentially curative liver resection. Additionally, the concept of TACE for liver-dominant metastatic disease with a focus on new embolization technologies is outlined. CONCLUSIONS There is encouraging data with regard to technical success, safety, and oncologic efficacy of TACE for colorectal liver metastases. The majority of studies are non-randomized single-center series mostly after failure of systemic therapies in the 2nd line and beyond. Emerging techniques including embolization with calibrated microspheres, with or without additional cytotoxic drugs, degradable starch microspheres, and technical innovations, e.g., cone-beam computed tomography (CT) allow a new highly standardized TACE procedure. The real efficacy of TACE for colorectal liver metastases in a neoadjuvant, adjuvant, and palliative setting has now to be evaluated in prospective randomized controlled trials.
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Abstract
Colorectal cancer is a common malignancy and often presents with synchronous or metachronous distant spread. For patients with hepatic metastases, resection is the principal curative option. Liberalization of the indications for hepatic resection has introduced a number of challenges related to the size, distribution, and number of metastases as well as the condition of the future liver remnant. Advances in systemic therapy have solidified its role as both an important adjunct to surgery and also for many patients as a mechanism to facilitate resection. In patients whose disease is marginally resectable as a consequence of the distribution of hepatic lesions that precludes complete resection or out of concern for the future liver remnant, a number of strategies have been advocated, including prehepatectomy systemic therapy, staged surgical approaches, ablative technologies, and preoperative portal vein embolization. It is the purpose of this review to discuss ways in which to optimize the treatment of patients with potentially resectable disease, specifically those who are judged to have "borderline" resectable situations.
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Giuliani J, Mercanti A, Muraro S, Trolese AR, Durante E, Greco F, Piacentini P, Tognetto M, Bonetti A. The pharmacological costs of complete liver resections in unselected advanced colorectal cancer patients: a review of published Phase II and III trials. Expert Rev Pharmacoecon Outcomes Res 2014; 15:101-10. [PMID: 25399933 DOI: 10.1586/14737167.2015.982099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The pharmacological costs of regimens used as front-line therapy in advanced colorectal cancer patients and their impact on the liver resection rates have not been considered. In this paper, we made a review of published randomized Phase II and III trials that reported the liver resection rates following upfront chemotherapy and linked this outcome to the pharmacological costs of drugs used. The costs are calculated based on the price at Pharmacy of our Hospital in Legnago (Italy), and as a measure of activity, we used the number of patients needed to treat to get one complete liver resection. Number needed to treat is highly variable among the different trials according to patient's characteristics, tumor biology and the efficacy of chemotherapy administered. The range of activity is greatly amplified when the costs are compared.
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Affiliation(s)
- Jacopo Giuliani
- Mater Salutis Hospital-AULSS 21 della Regione Veneto - Medical Oncology, Legnago (VR), Italy
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Jones RP, Hamann S, Malik HZ, Fenwick SW, Poston GJ, Folprecht G. Defined criteria for resectability improves rates of secondary resection after systemic therapy for liver limited metastatic colorectal cancer. Eur J Cancer 2014; 50:1590-601. [DOI: 10.1016/j.ejca.2014.02.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/21/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023]
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Kim JY, Kim JS, Baek MJ, Kim CN, Choi WJ, Park DK, Namgung H, Lee SC, Lee SJ. Prospective multicenter phase II clinical trial of FOLFIRI chemotherapy as a neoadjuvant treatment for colorectal cancer with multiple liver metastases. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 85:154-60. [PMID: 24106681 PMCID: PMC3791357 DOI: 10.4174/jkss.2013.85.4.154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/18/2013] [Accepted: 07/22/2013] [Indexed: 12/26/2022]
Abstract
Purpose This study evaluated the efficacy of neoadjuvant chemotherapy combining 5-flurouracil/folinic acid with irinotecan (FOLFIRI) in colorectal multiple liver metastases regardless of resectability. Methods Forty-four patients with multiple (at least two) colorectal liver metastases were enrolled at seven tertiary referral hospitals between May 2007 and September 2010. All patients received the FOLFIRI chemotherapeutic regimen. Response to chemotherapy was assessed after three cycles (6 weeks) and once more after six cycles (12 weeks) of treatment. Results Objective response was noted in 27 patients (61.4%) and 4 patients (9.1%) had progressive disease. Of 44 patients, 10 patients (22.7%) underwent curative surgery (R0 resection) and 34 patients did not receive R0 resection. Grades 3 to 4 hematological toxicity was noted in 12 patients (27.3%) and grades 3 to 4 nonhematologic toxicity was identified in 5 patients (11.4%). Conclusion FOLFIRI chemotherapy as a neoadjuvant chemotherapy for multiple colorectal liver metastases regardless of resectability demonstrated the possibility of R0 resection, high rate of objective response, and tolerable toxicities in this study.
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Affiliation(s)
- Ji Yeon Kim
- Department of Surgery, Chungnam National University School of Medicine, Daejeon, Korea
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Haraldsdottir S, Wu C, Bloomston M, Goldberg RM. What is the optimal neo-adjuvant treatment for liver metastasis? Ther Adv Med Oncol 2013; 5:221-34. [PMID: 23858331 DOI: 10.1177/1758834013485111] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Colorectal cancer is the third most common cancer in the Western population and has a 5-year overall survival of 5-10% when metastatic. Approximately 30% of the patients with metastatic colorectal cancer have limited disease apparently isolated to the liver and, if this can be resected, the 5-year overall survival is improved to 30-60%. Therefore, it is important to identify patients who have both resectable disease and those with initially unresectable tumors who can potentially be downsized with chemotherapy to allow resection. First-line doublet chemotherapy regimens lead to response rates of 50-60%, triplet chemotherapy regimens may result in a response rate of up to 70%, and biological agents may add to responses or induce morphologic changes that facilitate disease resection. Surgical advances in recent years have also increased resectability rates and have challenged prior rules of resectability. Local therapies including ablation and radiation, often performed in conjunction with resection, may further aid in control of disease. The aim of this article is to focus on the role of neoadjuvant therapy in the treatment of colorectal liver metastases.
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Affiliation(s)
- Sigurdis Haraldsdottir
- Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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Voorthuizen TV, van Gulik TM, Punt CJA. Defining resectability of colorectal liver metastases: how and why? COLORECTAL CANCER 2013. [DOI: 10.2217/crc.12.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
SUMMARY Treatment outcome in metastatic colorectal carcinoma has improved because of advancements in medical therapy and increased use of liver resections. In primary nonresectable disease, prognosis improves when a secondary resection is performed after successful downsizing by neoadjuvant systemic therapy. Which patient groups may profit from a secondary liver resection and which neoadjuvant systemic therapy has the optimal chance of conversion to resectability has not been defined because various patient groups were selected in different studies and there is a lack of consensus on resectability. This invalidates cross-study comparisons of resection rates and survival rates. Prospective trials in which secondary resection rate is a predefined end point are needed and will allow more insight into this topic.
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Affiliation(s)
- Theo van Voorthuizen
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Cornelis JA Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
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Adam R, De Gramont A, Figueras J, Guthrie A, Kokudo N, Kunstlinger F, Loyer E, Poston G, Rougier P, Rubbia-Brandt L, Sobrero A, Tabernero J, Teh C, Van Cutsem E. The oncosurgery approach to managing liver metastases from colorectal cancer: a multidisciplinary international consensus. Oncologist 2012; 17:1225-39. [PMID: 22962059 DOI: 10.1634/theoncologist.2012-0121] [Citation(s) in RCA: 378] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
An international panel of multidisciplinary experts convened to develop recommendations for the management of patients with liver metastases from colorectal cancer (CRC). The aim was to address the main issues facing the CRC hepatobiliary multidisciplinary team (MDT) when managing such patients and to standardize the treatment patients receive in different centers. Based on current evidence, the group agreed on a number of issues including the following: (a) the primary aim of treatment is achieving a long disease-free survival (DFS) interval following resection; (b) assessment of resectability should be performed with high-quality cross-sectional imaging, staging the liver with magnetic resonance imaging and/or abdominal computed tomography (CT), depending on local expertise, staging extrahepatic disease with thoracic and pelvic CT, and, in selected cases, fluorodeoxyglucose positron emission tomography with ultrasound (preferably contrast-enhanced ultrasound) for intraoperative staging; (c) optimal first-line chemotherapy-doublet or triplet chemotherapy regimens combined with targeted therapy-is advisable in potentially resectable patients; (d) in this situation, at least four courses of first-line chemotherapy should be given, with assessment of tumor response every 2 months; (e) response assessed by the Response Evaluation Criteria in Solid Tumors (conventional chemotherapy) or nonsize-based morphological changes (antiangiogenic agents) is clearly correlated with outcome; no imaging technique is currently able to accurately diagnose complete pathological response but high-quality imaging is crucial for patient management; (f) the duration of chemotherapy should be as short as possible and resection achieved as soon as technically possible in the absence of tumor progression; (g) the number of metastases or patient age should not be an absolute contraindication to surgery combined with chemotherapy; (h) for synchronous metastases, it is not advisable to undertake major hepatic surgery during surgery for removal of the primary CRC; the reverse surgical approach (liver first) produces as good an outcome as the conventional approach in selected cases; (i) for patients with resectable liver metastases from CRC, perioperative chemotherapy may be associated with a modestly better DFS outcome; and (j) whether initially resectable or unresectable, cure or at least a long survival duration is possible after complete resection of the metastases, and MDT treatment is essential for improving clinical and survival outcomes. The group proposed a new system to classify initial unresectability based on technical and oncological contraindications.
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Affiliation(s)
- René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, UMR-S 776, Villejuf, France.
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Rossi L, Zullo A, Zoratto F, Papa A, Strudel M, Colonna M, Tomao S. Chemotherapy and target therapy as neo-adjuvant approach for initially unresectable colorectal liver metastases. Oncol Rev 2012; 6:e6. [PMID: 25992208 PMCID: PMC4419640 DOI: 10.4081/oncol.2012.e6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/23/2012] [Accepted: 05/28/2012] [Indexed: 01/05/2023] Open
Abstract
Although surgery is the most effective treatment for liver metastases in colorectal cancer patients, only 15-20% of these patients are suitable for a radical surgical approach, and metastases recurrence may occur at follow up. In the last decade, the use of pre-operative chemotherapy in combination with new biological drugs has been introduced. We reviewed data of neo-adjuvant chemotherapy strategies aimed at increasing the resection rate of liver metastases in colorectal cancer patients who were initially considered unresectable.
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Affiliation(s)
- Luigi Rossi
- Department of Medico-Surgical Sciences and Biotechnologies, Oncology Unit, S.M. Goretti Hospital, Latina - "Sapienza" University of Rome, Italy
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy; Nuovo Regina Margherita Hospital, Rome, Italy
| | - Federica Zoratto
- Department of Medico-Surgical Sciences and Biotechnologies, Oncology Unit, S.M. Goretti Hospital, Latina - "Sapienza" University of Rome, Italy
| | - Anselmo Papa
- Department of Medico-Surgical Sciences and Biotechnologies, Oncology Unit, S.M. Goretti Hospital, Latina - "Sapienza" University of Rome, Italy
| | - Martina Strudel
- Department of Medico-Surgical Sciences and Biotechnologies, Oncology Unit, S.M. Goretti Hospital, Latina - "Sapienza" University of Rome, Italy
| | | | - Silverio Tomao
- Department of Medico-Surgical Sciences and Biotechnologies, Oncology Unit, S.M. Goretti Hospital, Latina - "Sapienza" University of Rome, Italy
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Irinotecan Loaded in Eluting Beads: Preclinical Assessment in a Rabbit VX2 Liver Tumor Model. Cardiovasc Intervent Radiol 2012; 35:1448-59. [DOI: 10.1007/s00270-012-0343-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/15/2011] [Indexed: 10/28/2022]
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Abstract
Colorectal cancer (CRC) is the third most common cancer in the word. Liver metastasis is the most common site of colorectal metastases. The prognosis of resectable colorectal liver metastases (CRLM) was improved in the recent years with the consideration of chemotherapy and surgical resection as part of the multidisciplinary management of the disease; the current 5-year survival rates after resection of liver metastases are 25% to 40%. Resectable synchronous or metachronous liver metastases should be treated with perioperative chemotherapy based on three months of FOLFOX4 (5-fluorouracil [5FU], folinic acid [LV], and oxaliplatin) chemotherapy before surgery and three months after surgery. In the case of primary surgery, pseudo-adjuvant chemotherapy for 6 months, based on 5FU/LV, FOLFOX4, XELOX (capecitabine and oxaliplatin) or FOLFIRI (5FU/LV and irinotecan), should be indicated. In potentially resectable disease, primary chemotherapy based on more intensive regimens such as FOLFIRINOX (5FU/LV, irinotecan and oxaliplatin) should be considered to enhance the chance of cure. The palliative chemotherapy based on FOLFIRI, or FOLFOX4/XELOX with or without targeted therapies, is the mainstay treatment of unresectable disease. This review would provide additional insight into the problem of optimal integration of chemotherapy and surgery in the management of CRLM.
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Affiliation(s)
- Nabil Ismaili
- Department of medical oncology, Regional cancer center, Hassan II Hospital, Agadir-80000, Morocco.
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18
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Abstract
The treatment of metastatic colorectal cancer (mCRC) has become increasingly complex and nuanced as treatments have evolved over the last decade. During that time, treatment has evolved from single agent 5-fluorouracil (5FU) chemotherapy to combination chemotherapy, and more recently to the inclusion of monoclonal antibodies. As such, mCRC is evolving into a chronic disease in which the median overall survival (mOS) is in excess of 2 years and the 5-year survival is 10%. This review highlights the chemotherapy advances in the treatment of mCRC and focuses on the antibody therapies that have provided incremental improvements in survival. Additionally, we will discuss the management of resectable and unresectable liver metastases, and directed liver therapies. The treatment of metastatic colorectal cancer (mCRC) has become increasingly complex and nuanced as treatments have evolved over the last decade. During that time, treatment has evolved from single agent 5-fluorouracil (5FU) to combination chemotherapy and more recently the inclusion of monoclonal antibodies. As such, mCRC is evolving into a chronic disease in which the median overall survival (mOS) is in excess of 2 years and the 5-year survival is 10%. This review highlights the chemotherapy advances in the treatment of mCRC and focuses on the antibody therapies that have provided incremental improvements in survival. Additionally, we will discuss the management of resectable and unresectable liver metastases and directed liver therapies.
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Affiliation(s)
- Janine M Davies
- Drug Development/GI Oncology Fellow, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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19
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Colorectal liver metastases; the current scenario. Indian J Surg Oncol 2011; 1:350-5. [PMID: 22693391 DOI: 10.1007/s13193-011-0066-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 11/25/2010] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is the most common gastrointestinal malignancy. When metastases occurs, it most frequently occurs in the liver. Median survival without any treatment is poor, and until recently only a subset of patients were amenable to any form of surgical therapy. The following article aims to examine recent strategies used to increase the cohort of patients coming to curative oncological surgery.
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Nordlinger B, Vauthey JN, Poston G, Benoist S, Rougier P, Van Cutsem E. The timing of chemotherapy and surgery for the treatment of colorectal liver metastases. Clin Colorectal Cancer 2011; 9:212-8. [PMID: 20920992 DOI: 10.3816/ccc.2010.n.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Combining surgery and chemotherapy in the treatment of patients with colorectal hepatic metastases is increasingly becoming the standard of care. However, controversy remains regarding the juxtapositioning of chemotherapy and surgery, the duration of chemotherapy, and particularly, the use of preoperative chemotherapy in the treatment of patients with initially resectable metastases. The arguments for and against the different approaches presented are based on the data published in the medical literature and on the data presented at the most recent major oncology meetings, coupled with the personal experience of the authors. For patients with liver metastases that are resectable at presentation, perioperative chemotherapy has become the standard treatment in many institutions, with the recommendation that surgery is performed after a maximum of 6 cycles of systemic therapy. In the case of patients with initially unresectable liver metastases receiving preoperative systemic therapy, patients should be carefully monitored and surgery performed as soon as the metastases become resectable. All patients should, where possible, be treated by a multidisciplinary team. Going forward, it needs to be established whether more intensive treatment (ie, perioperative versus postoperative systemic therapy) is merited for the treatment of patients with initially resectable disease, and what the precise contribution of new therapeutic agents in these settings is, based on new prospective randomized trial data.
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Tsoulfas G, Pramateftakis MG, Kanellos I. Surgical treatment of hepatic metastases from colorectal cancer. World J Gastrointest Oncol 2011; 3:1-9. [PMID: 21267397 PMCID: PMC3026051 DOI: 10.4251/wjgo.v3.i1.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 12/09/2010] [Accepted: 12/16/2010] [Indexed: 02/05/2023] Open
Abstract
Colorectal carcinoma is one of the most frequent cancers in Western societies with an incidence of around 700 per million people. About half of the patients develop metastases from the primary tumor and liver is the primary metastatic site. Improved survival rates after hepatectomy for metastatic colorectal cancer have been reported in the last few years and these may be the result of a variety of factors, such as advances in systemic chemotherapy, radiographic imaging techniques that permit more accurate determination of the extent and location of the metastatic burden, local ablation methods, and in surgical techniques of hepatic resection. These have led to a more aggressive approach towards liver metastatic disease, resulting in longer survival. The goal of this paper is to review the role of various forms of surgery in the treatment of hepatic metastases from colorectal cancer.
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Affiliation(s)
- Georgios Tsoulfas
- Georgios Tsoulfas, Manousos Georgios Pramateftakis, Ioannis Kanellos, Department of Surgery, Aristoteleion University of Thessaloniki, Thessaloniki 54622, Greece
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22
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Davies JM, Goldberg RM. Optimum chemotherapy regimens for neoadjuvant therapy of hepatic colorectal metastases. J Surg Oncol 2010; 102:946-54. [DOI: 10.1002/jso.21653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Power DG, Kemeny NE. Chemotherapy for the conversion of unresectable colorectal cancer liver metastases to resection. Crit Rev Oncol Hematol 2010; 79:251-64. [PMID: 20970353 DOI: 10.1016/j.critrevonc.2010.08.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 08/01/2010] [Accepted: 08/19/2010] [Indexed: 02/06/2023] Open
Abstract
Resection of colorectal liver metastases (CLM) is the ultimate aim of treatment strategies in most patients with liver-confined metastatic colorectal cancer. Long-term survival is possible in selected patients with initially resectable or unresectable CLM. As a majority of patients have unresectable liver disease at the outset, there is a clear role for chemotherapy to downstage liver disease making resection possible. Studies of systemic chemotherapy with or without biologic therapy in patients with unresectable CLM have resulted in increased response rates, liver resection rates and survival. A sound physiologic rationale exists for the use of hepatic arterial infusion (HAI) therapy. Studies have shown that HAI with floxuridine combined with systemic chemotherapy increases response rates and liver resection rates in those patients with initially unresectable CLM. Toxicity from preoperative chemotherapy, biologic therapy and HAI therapy may adversely affect hepatic resection but can be kept minimal with appropriate monitoring. All conversion strategies should be decided by a multidisciplinary team.
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Affiliation(s)
- Derek G Power
- Department of Medicine, Gastrointestinal Oncology Division, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Neumann UP, Seehofer D, Neuhaus P. The surgical treatment of hepatic metastases in colorectal carcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:335-42. [PMID: 20532128 DOI: 10.3238/arztebl.2010.0335] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 07/21/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND Colorectal carcinoma with hepatic metastases was long considered an incurable disease. Recent advances in surgical treatment have substantially improved the affected patients' prognosis. At first, surgery was only performed in patients whose hepatic tumor burden was small (<4 nodes, <5 cm). Currently, however, the main issue is the feasibility of curative resection of all metastases. METHOD The PubMed literature database was selectively searched for articles with the keywords "colorectal liver metastases," "chemotherapy," and "surgery." Particular attention was devoted to studies of large groups of patients, randomized trials, the German guidelines, and an analysis of the authors' own patient population. RESULTS Only 10% to 20% of all patients are candidates for surgical therapy (hepatic resection), as the rest are disqualified either by extensive liver involvement or by extrahepatic neoplasia. A further 10% of patients have hepatic metastases that are primarily considered inoperable, yet later become amenable to surgery after interdisciplinary treatment involving preoperative chemotherapy, portal-vein embolization, two-stage hepatectomy, and/or locally ablative procedures. Chemotherapy is probably beneficial after hepatic resection, although the benefit has not yet been definitively demonstrated by clinical trials. Therefore, chemotherapy should only be given perioperatively in selected cases, when recommended by an interdisciplinary treatment team. CONCLUSION A multimodal approach to the treatment of hepatic metastases of colorectal carcinoma has led to an increase in the number of resections and to an improved long-term survival rate (currently more than 40% at 5 years).
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Affiliation(s)
- Ulf Peter Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.
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Importance of complete pathologic response to prehepatectomy chemotherapy in treating colorectal cancer metastases. Ann Surg 2010; 250:935-42. [PMID: 19953712 DOI: 10.1097/sla.0b013e3181b0c6e4] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We studied the influence of complete pathologic response of colorectal cancer liver metastases to prehepatectomy chemotherapy on longterm survival after hepatectomy. SUMMARY BACKGROUND DATA Although complete response seen on imaging may be a useful criterion for evaluating efficacy of chemotherapy, complete clinical response by imaging has shown limited predictive value for complete pathologic response in treating colorectal liver metastases. METHODS We retrospectively analyzed data from 63 patients who received preoperative chemotherapy and underwent hepatectomy. RESULTS Of 472 liver metastases evaluated, 86 were no more visible from images after chemotherapy. We excluded 14 of these metastasis treated with local ablation. Of the remaining 72 metastasis, 22 (30.6%) were microscopically persistent metastases or recurrences in situ. Liver metastases with complete pathologic response had smaller diameters at diagnosis than others (P < 0.001), and microscopic cancer deposits surrounding macroscopic tumors were less frequent in patients with complete pathologic response than others (P < 0.05). Outcomes were favorable in patients whose liver metastases all showed a complete pathologic response. Even patients with complete pathologic response in only some metastases showed higher overall and disease-free survival rates than pathologic nonresponders (P = 0.001 and P = 0.002, respectively). Presence or absence of metastases showing complete pathologic response was an independent prognostic factor (relative risk, 4.464; P = 0.0099). CONCLUSIONS Little correlation was observed between imaging response of colorectal cancer liver metastases to chemotherapy and pathologic response. Liver surgery should be undertaken even after a complete response by imaging. Outcome after hepatectomy was favorable in patients showing complete pathologic response of least one metastasis.
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Zhao R, Zhu J, Ji X, Cai J, Wan F, Li Q, Zhong B, Tucker S, Wang D. A phase II study of irinotecan and capecitabine for patients with unresectable liver-only metastases from colorectal cancer. Jpn J Clin Oncol 2009; 40:10-6. [PMID: 19773270 DOI: 10.1093/jjco/hyp114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the resectability rate of patients with initially unresectable liver-only metastases from colorectal cancer (CRC) after treatment with irinotecan/capecitabine. METHODS Patients received irinotecan (240 mg/m(2)) as a 30 min intravenous infusion on day 1 and capecitabine (1000 mg/m(2)) orally bid for 14 days beginning on day 2. Treatment was repeated every 3 weeks. The protocol encouraged two to four cycles of irinotecan/capecitabine after recovery from surgery. RESULTS Between May 2004 and February 2007, 48 patients entered in the study. Forty-seven (97.9%) of the 48 patients were assessable for response. The overall response rate before surgery was 56.3% (95% CI, 42.3-70.3%) in the treated population, including 2 non-confirmed complete response (CR), 18 partial responses (PR) and 7 non-confirmed PR. Twenty-three (47.9%) of 29 patients with tumor shrinkage proceeded to surgical intervention. Twenty of the 23 patients had a complete resection (S-CR). With a median follow-up time of 32 months (range, 24-38 months), the overall median time to progression and overall survival for all patients were 16.7 months (95% CI, 10.0-23.4 months) and 27.5 months (95% CI, 23.6-31.4 months) for all patients. The 1- 2- and 3-year overall survival estimates were 79.2% (95% CI, 67.7-90.7%), 60.4% (95% CI, 46.6-74.3%) and 29.2% (95% CI, 16.3-42.0%), respectively. Grade 3 diarrhea occurred in eight (17.0%) patients. The most common Grade 3/4 hematological adverse event was neutropenia in 8.5% of the patients. There were no treatment-related deaths during this study. CONCLUSIONS Irinotecan/capecitabine appears to be a safe and very effective regimen in selected patients with unresectable liver metastases from CRC, but who are treated with a curative intent.
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Affiliation(s)
- Ren Zhao
- Department of General Surgery, Ruijin Hospital, School of Medicine of Shanghai Jiaotong University, No. 197, Ruijin Er Road, Shanghai 200035, China.
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Abstract
Surgery is the only curative option for patients with liver metastases of colorectal cancer, but few patients present with resectable hepatic lesions. Chemotherapy is increasingly used to downstage initially unresectable disease and allow for potentially curative surgery. Standard chemotherapy regimens convert 10%-20% of cases to resectable disease in unselected populations and 30%-40% of those with disease confined to the liver. One strategy to further increase the number of candidates eligible for surgery is the addition of active targeted agents such as cetuximab and bevacizumab to standard chemotherapy. Data from a phase III trial indicate that cetuximab increases the number of patients eligible for secondary hepatic resection, as well as the rate of complete resection when combined with first-line treatment with the FOLFIRI regimen. The safety profiles of preoperative cetuximab or bevacizumab have not been thoroughly assessed, but preliminary evidence indicates that these agents do not increase surgical mortality or exacerbate chemotherapy-related hepatotoxicity, such as steatosis (5-fluorouracil), steatohepatitis (irinotecan), and sinusoidal obstruction (oxaliplatin). Secondary resection is a valid treatment goal for certain patients with initially unresectable liver metastases and an important end point for future clinical trials.
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28
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Kemeny NE, Melendez FDH, Capanu M, Paty PB, Fong Y, Schwartz LH, Jarnagin WR, Patel D, D'Angelica M. Conversion to resectability using hepatic artery infusion plus systemic chemotherapy for the treatment of unresectable liver metastases from colorectal carcinoma. J Clin Oncol 2009; 27:3465-71. [PMID: 19470932 DOI: 10.1200/jco.2008.20.1301] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To determine the conversion to resectability in patients with unresectable liver metastases from colorectal cancer treated with hepatic arterial infusion (HAI) plus systemic oxaliplatin and irinotecan (CPT-11). PATIENTS AND METHODS Forty-nine patients with unresectable liver metastases (53% previously treated with chemotherapy) were enrolled onto a phase I protocol with HAI floxuridine and dexamethasone plus systemic chemotherapy with oxaliplatin and irinotecan. Results Ninety-two percent of the 49 patients had complete (8%) or partial (84%) response, and 23 (47%) of the 49 patients were able to undergo resection in a group of patients with extensive disease (73% with > five liver lesions, 98% with bilobar disease, 86% with > or = six segments involved). For chemotherapy-naïve and previously treated patients, the median survival from the start of HAI therapy was 50.8 and 35 months, respectively. The only baseline variable significantly associated with a higher resection rate was female sex. Variables reflecting extensive anatomic disease, such as number of lesions or number of vessels involved, were not significantly associated with the probability of resection. CONCLUSION The combination of regional HAI floxuridine/dexamethasone and systemic oxaliplatin and irinotecan is an effective regimen for the treatment of patients with unresectable liver metastases from colorectal cancer, demonstrating a 47% conversion to resection (57% in chemotherapy-naïve patients). Future randomized trials should compare HAI plus systemic chemotherapy with systemic therapy alone to assess the additional value of HAI therapy in converting patients with hepatic metastases to resectability.
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Affiliation(s)
- Nancy E Kemeny
- Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, 1275 York Ave, New York, NY 10065, USA.
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Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg 2009; 248:994-1005. [PMID: 19092344 DOI: 10.1097/sla.0b013e3181907fd9] [Citation(s) in RCA: 273] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess feasibility, risks, and long-term outcome of 2-stage hepatectomy as a means to improve resectability of colorectal liver metastases (CLM). SUMMARY BACKGROUND DATA Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection. METHODS Between October 1992 and January 2007, among 262 patients with initially irresectable CLM, 59 patients (23%) were planned for 2-stage hepatectomy. Patients were eligible when single resection could not achieve complete treatment, even in combination with chemotherapy, portal embolization, or radiofrequency, but tumors could be totally removed by 2 sequential resections. Feasibility and outcomes were prospectively evaluated. RESULTS Two-stage hepatectomy was feasible in 41 of 59 patients (69%). Eighteen patients failed to complete the second hepatectomy because of disease progression (n = 17) or bad performance status (n = 1). The 41 successfully treated patients had a mean number of 9.1 metastases (mean diameter, 48.5 mm at diagnosis). Chemotherapy was delivered before (95%), in between (78%), and after (78%) the 2 hepatectomies. Mean delay between the 2 liver resections was 4.2 months. Postoperative mortality was 0% and 7% (3/41) after the first and second hepatectomy, respectively. Morbidity rates were also higher after the second procedure (59% vs. 20%) (P < 0.001). Five-year survival was 31% on an intention to treat basis, and all but 2 patients who did not complete the 2-stage strategy died within 19 months. After a median follow-up of 24.4 months (range, 3.7-130.3), overall 3- and 5-year survivals for patients that completed both hepatectomies were 60% and 42%, respectively, after the first hepatectomy (median survival, 42 months from first hepatectomy and 57 months from metastases diagnosis). Disease-free survivals were 26% and 13% at 3 and 5 years, respectively. CONCLUSIONS Two-stage hepatectomy provides a 5-year survival of 42% and a hope of long-term survival for selected patients with extensive bilobar CLM, irresectable by any other means.
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Sharma S, Camci C, Jabbour N. Management of hepatic metastasis from colorectal cancers: an update. ACTA ACUST UNITED AC 2008; 15:570-80. [PMID: 18987925 DOI: 10.1007/s00534-008-1350-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 02/20/2008] [Indexed: 12/17/2022]
Abstract
Approximately 50%-60% of patients with colorectal cancers will develop liver lesions in their life span. Despite the potential of surgical resection to provide long-term survival in this subset of patients, only 15%-20% are found to be resectable. The introduction of new neoadjuvant chemotherapeutic agents and the expanding criteria of resection have enhanced the overall 5-year survival from 30% to 60% in the past decade. The use of technical innovations such as staged resection; portal vein embolization, and repeat resection have allowed higher resection rates in patients with bilobar disease. Extrahepatic primary and liver-exclusive recurrent disease no longer represent an absolute contraindication to resection. The role of regional therapy using hepatic arterial infusion is being redefined for liver-exclusive unresectable disease. Adjuvant chemotherapy in combination with regional therapies is being looked at from fresh perspectives. Ablative approaches have gained a firm role both as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Overall, the management of hepatic metastasis from colorectal cancers requires a multimodal approach.
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Affiliation(s)
- Sharad Sharma
- Nazih Zuhdi Transplant Institute, 3300 North West Expressway, Oklahoma, OK 73112, USA
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Garcea G, Ong SL, Maddern GJ. Inoperable colorectal liver metastases: a declining entity? Eur J Cancer 2008; 44:2555-72. [PMID: 18755585 DOI: 10.1016/j.ejca.2008.07.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 07/14/2008] [Accepted: 07/17/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation. METHODS Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease. RESULTS Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection). CONCLUSION A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.
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Affiliation(s)
- G Garcea
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, The Queen Elizabeth Hospital, Adelaide, SA, Australia.
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Abstract
The liver is a frequent site of metastatic disease for colorectal cancer patients. Approximately 15% of patients have liver metastases at diagnosis and another 50% develop metastatic disease to the liver over the course of their disease. Advances in systemic chemotherapy and surgical techniques for hepatic resection have led to longer survival times for these patients. There is no doubt that unresectable patients benefit from systemic chemotherapy. For patients who have resectable disease, the timing of chemotherapy is still not clear. This review addresses the pros and cons of presurgical chemotherapy. The benefits of preoperative chemotherapy include decreasing tumor size, controlling micrometastatic disease, assessing activity of chemotherapy, improving chemotherapy tolerance, and perhaps allowing some prediction of the success of liver resection. The risks for presurgical chemotherapy include liver toxicity, the risk for progression or growth of new sites, secondary splenomegaly, selection of resistant clones, and the possibility of leaving behind active tumor that is no longer seen because of a complete radiographic response. The challenge for the future is to develop a multidisciplinary team approach that can design the best treatment plan for patients with liver metastases.
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Affiliation(s)
- Nancy Kemeny
- Memorial Sloan-Kettering Cancer Center, Gastrointestinal Oncology Service, New York, NY 10021, USA
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Preoperative prognostic score for predicting survival after hepatic resection for colorectal liver metastases. Ann Surg 2007; 246:806-14. [PMID: 17968173 DOI: 10.1097/sla.0b013e318142d964] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite indications for resection of colorectal liver metastases having expanded, debate continues about identifying patients that may benefit from surgery. METHODS Clinicopathologic data from a total of 700 patients was gathered between January 1993 and January 2006 from a prospectively maintained dataset. Of these, 687 patients underwent resection for colorectal liver metastases. RESULTS The median age of patient was 64 years and 36.8% of patients had synchronous disease. The overall 5-year survival was 45%. The presence of an inflammatory response to tumor (IRT), defined by an elevated C-reactive protein (>10 mg/L) or a neutrophil/lymphocyte ratio of >5:1, was noted in 24.5% of cases. Only the number of metastases and the presence or absence of an IRT influenced both overall and disease-free survival on multivariable analysis. A preoperative prognostic score was derived: 0 = less than 8 metastases and absence of IRT; 1 = 8 or more metastases or IRT, and 2 = 8 or more metastases and IRT-from the results of the multivariable analysis. The 5-year survival of those scoring 0 was 49% compared with 34% for those scoring 1. None of the patients that scored 2 were alive at 5 years. CONCLUSION The preoperative prognostic score is a simple and effective system allowing preoperative stratification.
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Abstract
The treatment of colorectal cancer has become increasingly complex over recent years. With the emergence of new chemotherapy drugs and targeted agents, there has been great improvement in the prognosis of patients with metastatic colorectal cancer. This review summarises the evidence supporting the use of combination chemotherapy with oxaliplatin and/or irinotecan with fluorouracil (5-FU) for the treatment of colorectal cancer and outlines the pivotal trials. Phase III trials have demonstrated the superiority of combination chemotherapy over single-agent 5-FU, but the optimal sequencing and combination of treatment is yet to be determined. Oral fluoropyrimidine derivatives have been shown to be equivalent to bolus 5-FU treatment and these offer another option for the treatment of colorectal cancer, but further studies are required to evaluate their use with irinotecan and oxaliplatin. The use of newer targeted therapies, such as bevacizumab and cetuximab, alone and in combination with chemotherapy are discussed, and the most recent data supporting their use is outlined. Bevacizumab-containing regimens have been shown to be superior to those without for the first-line treatment of colorectal cancer, and cetuximab has demonstrated activity in combination with chemotherapy in both the first- and second-line setting. Other targeted agents, such as vatalanib and panitumumab, are discussed and early clinical studies with these agents show promising results.
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Affiliation(s)
- Ruth E Board
- Department of Medical Oncology, Cancer Research UK, Christie Hospital, Manchester, UK.
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35
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Bringing unresectable liver disease to resection with curative intent. Eur J Surg Oncol 2007; 33 Suppl 2:S42-51. [DOI: 10.1016/j.ejso.2007.09.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 09/26/2007] [Indexed: 12/31/2022] Open
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Benoist S, Nordlinger B. Neoadjuvant treatment before resection of liver metastases. Eur J Surg Oncol 2007; 33 Suppl 2:S35-41. [PMID: 17981428 DOI: 10.1016/j.ejso.2007.09.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 09/26/2007] [Indexed: 01/22/2023] Open
Abstract
Surgical resection remains the only treatment of colorectal liver metastases that can ensure long-term survival and cure in some patient. However, only a minority of patients with liver metastases are amenable to surgery. Other patients can benefit from modern chemotherapy regimens, which achieve high response rates but are rarely sufficient for cure. In patients with unresectable metastases, neoadjuvant chemotherapy may increase the number of candidates for potentially curative resection, hence affording these patients the possibility of prolonged survival. For patients with resectable metastases, it is likely that the benefit of neoadjuvant chemotherapy before surgery will be demonstrated in the near future but is not yet validated. The integration of novel targeted agents will probably transform the therapeutic strategy for colorectal liver metastases.
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Affiliation(s)
- S Benoist
- AP-HP, Hôpital Ambroise Paré, Department Digestive and Oncologic Surgery, Université Versailles Saint Quentin en Yvelines, Versailles, France
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Barone C, Nuzzo G, Cassano A, Basso M, Schinzari G, Giuliante F, D'Argento E, Trigila N, Astone A, Pozzo C. Final analysis of colorectal cancer patients treated with irinotecan and 5-fluorouracil plus folinic acid neoadjuvant chemotherapy for unresectable liver metastases. Br J Cancer 2007; 97:1035-9. [PMID: 17895897 PMCID: PMC2360439 DOI: 10.1038/sj.bjc.6603988] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/27/2007] [Accepted: 08/14/2007] [Indexed: 12/22/2022] Open
Abstract
We have previously reported that neoadjuvant therapy with modified FOLFIRI enabled nearly a third of patients with metastatic colorectal cancer (mCRC) to undergo surgical resection of liver metastases. Here, we present data from the long-term follow-up of these patients. Forty patients received modified FOLFIRI: irinotecan 180 mg m(-2), day 1; folinic acid, 200 mg m(-2); and 5-fluorouracil: as a 400 mg m(-2) bolus, days 1 and 2, and a 48-h continuous infusion 1200 mg m(-2), from day 1. Treatment was repeated every 2 weeks, with response assessed every six cycles. Resected patients received six further cycles of chemotherapy postoperatively. Nineteen (47.5%) of 40 patients achieved an objective response; 13 (33%) underwent resection. After a median follow-up of 56 months, median survival for all patients was 31.5 months: for non-resected patients, median survival was 24 months and was not reached for resected patients. Median time to progression was 14.3 and 5.2 months for all and non-resected patients, respectively. Median disease-free (DF) survival in resected patients was 52.5 months. At 2 years, all patients were alive (8 DF), and at last follow-up, eight were alive (6 DF). Surgical resection of liver metastases after neoadjuvant treatment with modified FOLFIRI in CRC patients achieved favourable survival times.
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Affiliation(s)
- C Barone
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome, Italy.
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Malik HZ, Farid S, Al-Mukthar A, Anthoney A, Toogood GJ, Lodge JPA, Prasad KR. A critical appraisal of the role of neoadjuvant chemotherapy for colorectal liver metastases: a case-controlled study. Ann Surg Oncol 2007; 14:3519-26. [PMID: 17912590 DOI: 10.1245/s10434-007-9533-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 06/26/2007] [Accepted: 06/27/2007] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to analyze the outcome of patients that received neoadjuvant chemotherapy prior to resection for colorectal liver metastases (CRLM) and compare them with a matched cohort of patients that underwent resection followed by adjuvant chemotherapy. METHODS 687 patients have undergone curative resection between January 1993 and January 2006. In this period, 84 patients received neo-adjuvant chemotherapy and 71 of this group went on to resection. A control group was chosen, matched with these patients, made up of patients who underwent resection followed by adjuvant chemotherapy. RESULTS There was no difference in clinico-pathological features between the neoadjuvant and the control group. However patients in the control group had more-extended resections and longer hospital stays than those in the neoadjuvant group (p = 0.015). Patients in the control group had an increased incidence of early recurrences (p < 0.001). Despite this, there was no significant difference in either the cancer-specific or the disease-free survival between the two groups of patients. CONCLUSION Neoadjuvant chemotherapy has a role in the management of patients with disease that is considered initially unresectable as a down-sizing technique. In patients with resectable disease, the test-of-time approach that neoadjuvant therapy offers is yet to be proven.
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Affiliation(s)
- H Z Malik
- Hepatobiliary and Transplantation Unit, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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Nordlinger B, Van Cutsem E, Rougier P, Köhne CH, Ychou M, Sobrero A, Adam R, Arvidsson D, Carrato A, Georgoulias V, Giuliante F, Glimelius B, Golling M, Gruenberger T, Tabernero J, Wasan H, Poston G. Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group. Eur J Cancer 2007; 43:2037-45. [PMID: 17766104 DOI: 10.1016/j.ejca.2007.07.017] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 07/12/2007] [Accepted: 07/18/2007] [Indexed: 12/11/2022]
Abstract
Liver resection offers the only chance of cure for patients with advanced colorectal cancer (CRC). Typically, the 5-year survival rates following liver resection range from 25% to 40%. Unfortunately, approximately 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. However, the rapid expansion in the use of improved combination therapy regimens has increased the percentage of patients eligible for potentially curative surgery. Despite this, the selection criteria for patients potentially suitable for resection are not well documented and patient management by multidisciplinary teams, although essential, is still evolving. The goal of the European Colorectal Metastases Treatment Group is to establish pan-European guidelines for the treatment of patients with CRC liver metastases that can be adopted more widely by established treatment centres and to develop more accurate staging systems and evaluation criteria.
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Hriesik C, Ramanathan RK, Hughes SJ. Update for surgeons: recent and noteworthy changes in therapeutic regimens for cancer of the colon and rectum. J Am Coll Surg 2007; 205:468-78 (Quiz 524). [PMID: 17765164 DOI: 10.1016/j.jamcollsurg.2007.04.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 03/29/2007] [Accepted: 04/24/2007] [Indexed: 01/16/2023]
Affiliation(s)
- Claudia Hriesik
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh School of Medicine, and University of Pittsburgh Cancer Institute, Pittsburgh, PA 15261, USA
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Piltch A, Zhang F, Hayashi J. Culture and characterization of thymic epithelium from autoimmune NZB and NZB/W mice. Cell Immunol 1991; 84:59-70. [PMID: 2242501 DOI: 10.1016/j.critrevonc.2012.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/31/2012] [Accepted: 02/22/2012] [Indexed: 12/15/2022]
Abstract
Autoimmune NZB and NZB/W mice display early abnormalities in thymus histology, T cell development, and mature T cell function. Abnormalities in the subcapsular/medullary thymic epithelium (TE) can also be inferred from the early disappearance of thymulin from NZB. It has also been reported that NZB thymic epithelial cells do not grow in culture conditions that support the growth of these cells from other strains of mice. In order to study the contribution of TE to the abnormal T cell development and function in NZB and NZB/W mice, we have devised a culture system which supports the growth of TE cells from these mice. The method involves the use of culture vessels coated with extracellular matrix produced by a rat thymic epithelial cell line. TEA3A1, and selective low-calcium, low-serum medium. In addition TEA3A1 cells have been used as an antigen to generate monoclonal antibodies specific for subcapsular/medullary TE. These antibodies, as well as others already available, have been used to show that the culture conditions described here select for cells displaying subcapsular/medullary TE markers, whereas markers for cortical TE and macrophages are absent.
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Affiliation(s)
- A Piltch
- W. Alton Jones Cell Science Center, Lake Placid, New York 12946
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