Multi-modality treatment of colorectal liver metastases

4D-MRI assisted stereotactic body radiation therapy for unresectable colorectal cancer liver metastases

This study evaluated the feasibilities and outcomes following four-dimensional magnetic resonance imaging (4D-MRI) assisted stereotactic body radiation therapy (SBRT) for unresectable colorectal liver metastases (CRLMs). From March 2018 to January 2022, we identified 76 unresectable CRLMs patients with 123 lesions who received 4D-MRI guided SBRT in our institution. 4D-MRI simulation with or without abdominal compression was conducted for all patients. The prescription dose was 50-65 Gy in 5-12 fractions. The image quality of computed tomography (CT) and MRI were compared using the Clarity Score. Clinical outcomes and toxicity profiles were evaluated. 4D-MRI improved the image quality compared with CT images (mean Clarity Score: 1.67 vs 2.88, P < 0.001). The abdominal compression reduced motions in cranial-caudal direction (P = 0.03) with two phase T2 weighted images assessing tumor motion. The median follow-up time was 12.5 months. For 98 lesions assessed for best response, the complete response, partial response and stable disease rate were 57.1 %, 30.6 % and 12.2 %, respectively. The local control (LC) rate at 1 year was 97.3 %. 46.1 % of patients experienced grade 1-2 toxicities and only 2.6 % patients experienced grade 3 hematologic toxicities. The 4D-MRI technique allowed accurate target delineation and motion tracking in unresectable CRLMs patients. Favorable LC rate and mild toxicities were achieved. This study provided evidence for using 4D-MRI assisted SBRT as an alternative treatment in unresectable CRLMs.

CDX2 inhibits epithelial-mesenchymal transition in colorectal cancer by modulation of Snail expression and β-catenin stabilisation via transactivation of PTEN expression

Background

Emerging evidence suggests the involvement of caudal-related homoeobox transcription factor 2 (CDX2) in tumorigenesis of various cancers. Although CDX2 functions in cancer invasion and metastasis, fewer studies focus on the role of CDX2 during the induction of epithelial–mesenchymal transition (EMT) in colorectal cancer (CRC).

Methods

Immunohistochemical analysis of CDX2 was performed. A series of in vitro and in vivo experiments were conducted to reveal the role of CDX2 in the invasion and metastasis of CRC.

Results

CDX2 was downregulated in CRC tissues and reduced CDX2 correlated with poor prognosis. Knockdown of CDX2 promoted colon cancer cell invasion in vitro and facilitated liver metastasis in vivo with inducing EMT phenotypes. Further investigation indicated that CDX2 retarded Akt and GSK-3β phosphorylation, and thereby diminished Snail expression, β-catenin stabilisation and nuclear translocation. The depletion of β-catenin neutralised the regulation of Slug and ZEB1 by CDX2 knockdown. Mechanistically, CDX2 antagonised PI3K/Akt activity in CRC by modulating PTEN expression. CDX2 directly bound to the promoter of PTEN and transactivated its expression.

Conclusions

Our study first uncovered that CDX2 inhibits EMT and metastasis of CRC by regulation of Snail expression and β-catenin stabilisation via transactivation of PTEN expression.

Effect of Chinese Herbal Medicine on the Survival of Colorectal Cancer Patients With Liver-Limited Metastases: A Retrospective Cohort Study, 2008 to 2017

Background: Colorectal cancer (CRC) remains one of the leading contributors to cancer-related mortality and morbidity worldwide. Traditional Chinese medicines have been widely employed to treat various types of cancer in China. This investigation aims to determine the association between Chinese herbal medicine (CHM) therapy and survival outcomes in CRC patients with liver-limited metastases. Methods: A retrospective cohort study was performed among patients with colorectal liver metastases at the First Affiliated Hospital of Guangzhou University of Chinese Medicine in Guangzhou, China. Data from a series of consecutive patients were collected via an electronic medical record system or telephone follow-up. We defined high exposure as a period of CHM therapy lasting more than 6 months. The primary outcome was overall survival. Results: The study included the data of 191 patients from January 2008 to December 2017; 126 patients (65.97%) met the inclusion criteria of high exposure to CHM. Multivariate analyses revealed that high exposure to CHM was associated with better overall survival (hazard ratio = 0.444, 95% confidence interval = [0.213, 0.926], P = .030). The association was further confirmed by a subgroup exploratory analysis. Conclusion: Long-term CHM therapy is correlated with improved survival outcomes in CRC patients with liver-limited metastases.

Short-course neoadjuvant chemoradiotherapy and surgery are beneficial in Chinese patients: A retrospective study

Preoperative neoadjuvant chemoradiotherapy (NACR) is used to reduce tumor size for easier resection or improved resectability rates. Considering the difficulties regarding health insurance and health resources in China, an evidence-based short-course neoadjuvant chemoradiotherapy with surgery to cure patients was performed. This study compared the postoperative effects between short-course neoadjuvant chemoradiotherapy and surgery and surgery without neoadjuvant chemoradiotherapy.The current retrospective study was based on a rectal cancer database, including 274 patients diagnosed with rectal cancer between January 2014 and October 2016. Data were analyzed with respect to curative rate, postoperative recovery indicators (times to nasogastric tube, urinary catheter, and drainage tube removal and times to first oral feeding and passing of flatus postsurgery), chemoradiotherapy-related indicators [white blood cell count (WBC) and carcinoembryonic antigen (CEA) levels], and adverse effects indicators, evaluated according to Common Terminology Criteria for Adverse Events Version 4.0.There was no significant difference between the combined therapy and surgery groups (P > .05) in terms of radical resection rates and the times to urinary catheter removal and passing flatus (P > .05). Statistically significant differences (P < .05) in terms of earlier time for removal of the nasogastric and drainage tubes and time to first oral feeding were observed in the combined therapy group. The decreases in WBC and CEA levels in the combined therapy group were significantly greater than those in the surgery group 1 week after surgery (P < .05); after 1 month, the CEA decrease in the combined therapy group was significantly greater than that in the surgery group (P < .05). More patients in the combined therapy group experienced vomiting, indigestion, dehydration, oral mucositis, sensory neuritis, and alopecia compared with those in the surgery group 1 week after surgery (P < .05); after 1 month, only the incidence of alopecia was higher in the combined therapy group (P < .05).The combined therapy group demonstrated earlier postoperative recovery compared with the surgery group. Short-course neoadjuvant chemoradiotherapy with surgery may lead to postoperative treatment-related adverse effects of varying degrees; however, these adverse effects eventually improve with time.

Laparoscopic hepatectomy significantly shortens the time to postoperative chemotherapy in patients undergoing major hepatectomies

BACKGROUND

The benefit of adjuvant chemotherapy occurs with early initiation, but is commonly delayed due to postoperative complications. Minimally invasive surgery is proven to significantly reduce complications and hospital length of stay. This study compares open versus laparoscopic liver resection in patients requiring adjuvant chemotherapy.

METHODS

120 consecutive patients with metastatic colorectal liver cancer who underwent liver resection between 2007 through 2012 were reviewed from an IRB prospective database.

RESULTS

44 laparoscopic cases were compared to 76 open cases having equivalent resections. Laparoscopic liver resection patients had lower blood loss (276 ml) than patients with open resection (614 ml). Patients with laparoscopy had shorter length of hospital stay (5 days) than patients with open resection (9 days). Patients with laparoscopic resection had a shorter time of chemotherapy initiation postoperatively (24 days v 39 days). Overall complication rates were higher, but statistically insignificant in patients with open resection.

CONCLUSIONS

Our data showed that the shorter LOS with laparoscopic major hepatectomies allows earlier initiation of chemotherapy compared to the open group, without jeopardizing surgical margins or extent of resection.

SUMMARY

Over the past decade multiple authors have established that, despite occasional longer operating times, laparoscopic liver surgery is associated with reduced blood loss, reduced postoperative morbidity and shorter hospital stay. The purpose of this analysis was to determine if the advantages of a minimally invasive approach correspond to shorter initiation of adjuvant chemotherapy versus an open approach.

Transarterial Therapy for Colorectal Liver Metastases

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.

Transarterial chemoembolization (TACE) for colorectal liver metastases--current status and critical review

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.

Robot-assisted one-stage resection of rectal cancer with liver and lung metastases

The Da Vinci Surgical System may help to overcome some of the difficulties of laparoscopy for complicated abdominal surgery. The authors of this article present a case of robot-assisted, one-stage radical resection of three tumors, including robotic anterior resection for rectal cancer, segmental hepatectomy for liver metastasis, and wedge-shaped excision for lung metastasis. A 59-year-old man with primary rectal cancer and liver and lung metastases was operated upon with a one-stage radical resection approach using the Da Vinci Surgical System. Resection and anastomosis of rectal cancer were performed extracorporeally after undocking the robot. The procedure was successfully completed in 500 min. No surgical complications occurred during the intervention and postoperative period, and no conversion to laparotomy or additional trocars were required. To the best of our knowledge, this is the first case of simultaneous resection for rectal cancer with liver and lung metastases using the Da Vinci Surgery System to be reported. The procedure is feasible and safe and its main advantages for patient are avoiding repeated operation, reducing surgical trauma, shortening recovery time, and early implementation of postoperative adjuvant therapy.

Patterns of recurrence following selective intraoperative radiofrequency ablation as an adjunct to hepatic resection for colorectal liver metastases

BACKGROUND AND OBJECTIVES

The purpose of this study was to analyze the patterns of recurrence following intraoperative radiofrequency ablation (RFA) combined with hepatic resection for patients with colorectal liver metastases (CLM).

METHODS

Patients undergoing liver resection (with or without RFA) for CLM were examined. Rates and patterns of disease recurrence, as well as overall survival were assessed using Kaplan-Meier and Cox analyses.

RESULTS

A total of 174 patients underwent liver resection for CLM (150 without and 24 with intraoperative RFA). RFA was used to treat 41 tumors (median 1.6 cm). The 3-year overall survival was 65.5% and 61.4% (adjusted HR 1.02, 95% CI 0.55-1.88). Median recurrence-free survival was 7.4 versus 12.7 months with RFA versus non-RFA, respectively (adjusted HR 1.51, 95% CI 0.94-4.42). On multivariate analysis, neither survival nor recurrence-free survival was significantly associated with RFA. In total, there were two RFA ablation zone local failures. An ablation site recurrence was the sole site in one patient (4.2%).

CONCLUSION

RFA was used as an adjunct to resection in patients with greater disease burden. Despite this, RFA was not significantly associated with a higher risk of local failure and was not associated with worse survival, when compared with liver resection alone.

Efficacy of ex vivo activated and expanded natural killer cells and T lymphocytes for colorectal cancer patients

Immune cell-based therapies using natural killer (NK) cells and cytotoxic T cells are under constant scrutiny, with the aim to design an effective and reduced-toxicity therapy, which will benefit patients via improved quality of life and improved prognosis. Four patients with stage IV colon cancer were administered 1, 3, 5 and 6 effector cell intravenous infusions, respectively. Peripheral blood was collected from the patients and the ex vivo activation and expansion of NK and T cells was performed in Good Manufacturing Practice-certified clean rooms for ~12-15 days. Immunophenotypic analysis of the peripheral blood mononuclear cells (PBMCs) and expanded NK and T cells was conducted using flow cytometry and the patients were followed up. On average, 4.8×10⁷ initial PBMCs and 2.7×10⁹ total expanded cells were obtained. The intravenous infusions of the expanded cells were not accompanied by adverse reactions. Improved prognosis, reflected by a considerable decrease in the cancer markers, accompanied by an improved quality of life in the patients were observed. In conclusion, potential strategies are currently under development for the large-scale production of effectors cells; therefore, autologous immune enhancement therapy (AIET) may be considered as a viable approach to cancer treatment.

Posthepatectomy liver failure after simultaneous versus staged resection of colorectal cancer and synchronous hepatic metastases

BACKGROUND

Posthepatectomy liver failure (PHLF) is the third most frequent complication and the major cause of postoperative mortality after resection of colorectal cancer liver metastases (CRLM). In case of synchronous resectable CRLM, it is still unclear if surgical strategy (simultaneous versus staged resection of colorectal cancer and hepatic metastases) influences the incidence and severity of PHLF. The aim of this study was to evaluate the impact of surgical strategy on PHLF and on the early and long-term outcome.

PATIENTS AND METHODS

Retrospective study on 106 consecutive patients undergoing hepatectomy for synchronous CRLM between 1997 and 2012.

RESULTS

Of 106 patients, 46 underwent simultaneous resection and 60 had staged hepatectomy. The rate of PHLF was similar between groups (16.7% vs 15.2%; p=1) and subgroup analysis restricted to patients undergoing major hepatectomy confirmed this observation (31.8% vs 23.8%; p=0.56). Propensity-score analysis showed that preoperative total bilirubin level and the amount of intra-operative blood transfusion were independently associated with an increased risk of PHLF. Nevertheless, the risk of severe PHLF (grade B - C) was increased in patients who underwent simultaneous resection and major hepatectomy (OR: 4.82; p=0.035). No significant differences were observed in severe (Dindo - Clavien 3 - 4) postoperative morbidity (23.9% vs 20.0%; p=0.64) and survival (3 and 5-year survival: 55% and 34% vs 56% and 33%; p=0.83).

CONCLUSIONS

The risk of PHLF is not associated with surgical strategy in the treatment of synchronous CRLM. Nevertheless, the risk of severe PHLF is increased in patients undergoing simultaneous resection and major hepatectomy.

Modified Glasgow prognostic score in patients with incurable stage IV colorectal cancer

BACKGROUND

The modified Glasgow prognostic score is an inflammation-based prognostic score. This study examined whether this score, measured before surgical procedures, could predict postoperative cancer-specific survival.

METHODS

We retrospectively studied 79 colorectal cancer patients who underwent a surgical procedure for incurable stage IV disease. The modified Glasgow prognostic score (0 to 2) comprises C-reactive protein (≤10 vs >10 mg/L) and albumin (<35 vs ≥35 g/L) measurements.

RESULTS

In terms of overall survival, univariate analysis revealed significant differences in the status of lung metastasis, peritoneal dissemination, distant metastasis, hemoglobin, C-reactive protein, albumin, tumor resection, adjuvant chemotherapy, and modified Glasgow prognostic score. Multivariate analysis revealed that hemoglobin (P = .019), adjuvant chemotherapy (P = .002), and modified Glasgow prognostic score (0 and 1, low; 2, high) (P = .0001) were significant predictive factors for postoperative mortality.

CONCLUSIONS

The modified Glasgow prognostic score is simple to obtain and useful in predicting survival in incurable stage IV colorectal cancer patients undergoing surgery.

Liver resection in selected patients with metastatic breast cancer: a single-centre analysis and review of literature

PURPOSE

Despite the development of modern chemotherapeutics and target-specific drugs as well as improved surgical techniques, prognosis of metastatic breast cancer remains poor. Only a small number of selected patients will be eligible for liver resection and/or alternative metastatic ablation. Data on prognostic factors for patients with surgically resectable liver metastases of breast cancer are scarce at present.

METHODS

From 1997 to 2010, 50 patients with hepatic metastases of breast cancer have undergone laparotomy with the intention to undergo a curative liver resection at our institution. Data from these patients were collected in a prospectively maintained standardized liver resection data base.

RESULTS

Liver resection was performed in 34 patients. Resection margins were clear in 21 cases (R0). Nine patients lived for more than 60 months after liver resection. The observed 5-year survival rate was 21% for all 50 patients, 28% for resected patients and 38% after R0-resection. On univariate analysis, survival rates of the resected patients were statistically significantly influenced by R-classification, age, extrahepatic tumour at the time of liver resection, size of metastases and HER2 expression of liver metastases. Multivariate analysis revealed absence of HER2 expression, presence of extrahepatic tumour and patient's age ≥50 years as independent factors of poor prognosis.

CONCLUSIONS

Breast cancer patients younger than 50 years with technically resectable hepatic metastases, minimal extrahepatic tumour and positive HER2 expression appear to be suitable candidates for liver resection with curative intent. An aggressive multi-disciplinary management of those patients including surgical treatment may improve long-term survival.