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Serradilla-Martín M, Villodre C, Falgueras-Verdaguer L, Zambudio-Carroll N, Castell-Gómez JT, Blas-Laina JL, Borrego-Estella V, Domingo-del-Pozo C, García-Plaza G, González-Rodríguez FJ, Montalvá-Orón EM, Moya-Herraiz Á, Paterna-López S, Suárez-Muñoz MA, Alkorta-Zuloaga M, Blanco-Fernández G, Dabán-Collado E, Gómez-Bravo MA, Miota-de-Llamas JI, Rotellar F, Sánchez-Pérez B, Sánchez-Cabús S, Pacheco-Sánchez D, Rodríguez-Sanjuan JC, Varona-Bosque MA, Carrión-Álvarez L, de la Serna-Esteban S, Dopazo C, Martín-Pérez E, Martínez-Cecilia D, Castro-Santiago MJ, Dorcaratto D, Gutiérrez-Díaz ML, Asencio-Pascual JM, Burdío-Pinilla F, Carracedo-Iglesias R, Escartín-Arias A, Ielpo B, Rodríguez-Laiz G, Valdivieso-López A, De-Vicente-López E, Alonso-Orduña V, Ramia JM. Feasibility and Short-Term Outcomes in Liver-First Approach: A Spanish Snapshot Study (the RENACI Project). Cancers (Basel) 2024; 16:1676. [PMID: 38730631 PMCID: PMC11082946 DOI: 10.3390/cancers16091676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background: The liver-first approach may be indicated for colorectal cancer patients with synchronous liver metastases to whom preoperative chemotherapy opens a potential window in which liver resection may be undertaken. This study aims to present the data of feasibility and short-term outcomes in the liver-first approach. (2) Methods: A prospective observational study was performed in Spanish hospitals that had a medium/high-volume of HPB surgeries from 1 June 2019 to 31 August 2020. (3) Results: In total, 40 hospitals participated, including a total of 2288 hepatectomies, 1350 for colorectal liver metastases, 150 of them (11.1%) using the liver-first approach, 63 (42.0%) in hospitals performing <50 hepatectomies/year. The proportion of patients as ASA III was significantly higher in centers performing ≥50 hepatectomies/year (difference: 18.9%; p = 0.0213). In 81.1% of the cases, the primary tumor was in the rectum or sigmoid colon. In total, 40% of the patients underwent major hepatectomies. The surgical approach was open surgery in 87 (58.0%) patients. Resection margins were R0 in 78.5% of the patients. In total, 40 (26.7%) patients had complications after the liver resection and 36 (27.3%) had complications after the primary resection. One-hundred and thirty-two (89.3%) patients completed the therapeutic regime. (4) Conclusions: There were no differences in the surgical outcomes between the centers performing <50 and ≥50 hepatectomies/year. Further analysis evaluating factors associated with clinical outcomes and determining the best candidates for this approach will be subsequently conducted.
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Affiliation(s)
- Mario Serradilla-Martín
- Department of Surgery, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Department of Surgery, School of Medicine, University of Granada, 18016 Granada, Spain
| | - Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
- ISABIAL, Instituto de Investigación Sanitaria y Biomédica de Alicante, 03010 Alicante, Spain
- Department of Surgery, Universidad Miguel Hernández, 03202 Alicante, Spain
| | | | | | | | | | | | | | - Gabriel García-Plaza
- Department of Surgery, Hospital Universitario Insular, 35016 Las Palmas de Gran Canaria, Spain;
| | | | - Eva M. Montalvá-Orón
- Department of Surgery, Hospital Universitario y Politécnico La Fe, IIS La Fe, Ciberehd ISCIII, 46026 Valencia, Spain;
| | - Ángel Moya-Herraiz
- Department of Surgery, Hospital Universitario de Castellón, 12004 Castelló de la Plana, Spain;
| | - Sandra Paterna-López
- Department of Surgery, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - Miguel A. Suárez-Muñoz
- Department of Surgery, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | | | | | | | - Miguel A. Gómez-Bravo
- Department of Surgery, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain;
| | | | - Fernando Rotellar
- Department of Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
| | - Belinda Sánchez-Pérez
- Department of Surgery, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain;
| | - Santiago Sánchez-Cabús
- Department of Surgery, Hospital Universitario de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | | | | | - María A. Varona-Bosque
- Department of Surgery, Hospital Universitario Nuestra Señora de la Candelaria, 38010 Santa Cruz de Tenerife, Spain;
| | | | | | - Cristina Dopazo
- Department of Surgery, Hospital Universitario Vall d’Hebron, 08035 Barcelona, Spain;
| | - Elena Martín-Pérez
- Department of Surgery, Hospital Universitario La Princesa, 28006 Madrid, Spain; (E.M.-P.); (D.M.-C.)
| | - David Martínez-Cecilia
- Department of Surgery, Hospital Universitario La Princesa, 28006 Madrid, Spain; (E.M.-P.); (D.M.-C.)
- Department of Surgery, Hospital Universitario Virgen de la Salud, 45004 Toledo, Spain
| | | | - Dimitri Dorcaratto
- Department of Surgery, Hospital Clínico Universitario, 46010 Valencia, Spain;
| | | | | | - Fernando Burdío-Pinilla
- Department of Surgery, Hospital Universitario del Mar, 08003 Barcelona, Spain; (F.B.-P.); (B.I.)
| | | | | | - Benedetto Ielpo
- Department of Surgery, Hospital Universitario del Mar, 08003 Barcelona, Spain; (F.B.-P.); (B.I.)
- Department of Surgery, Hospital Universitario de León, 24008 León, Spain
| | - Gonzalo Rodríguez-Laiz
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
| | | | | | - Vicente Alonso-Orduña
- Department of Medical Oncology, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - José M. Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, 03010 Alicante, Spain; (C.V.); (J.M.R.)
- ISABIAL, Instituto de Investigación Sanitaria y Biomédica de Alicante, 03010 Alicante, Spain
- Department of Surgery, Universidad Miguel Hernández, 03202 Alicante, Spain
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Ikuta S, Nakajima T, Aihara T, Fujikawa M, Yamanaka N. A Liver-First Approach Using Ablation for Oligometastatic Pancreatic Cancer: A Report of a Successful Case. Cureus 2023; 15:e46671. [PMID: 37942384 PMCID: PMC10628600 DOI: 10.7759/cureus.46671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
Pancreatic cancer (PC) is a highly aggressive malignancy, often accompanied by liver metastases as a common manifestation. While palliative chemotherapy remains the mainstay treatment for liver metastatic PC, local treatment approaches have gained attention, especially for patients with oligometastasis who exhibit a positive response to chemotherapy. This case report illustrates the successful application of a liver-first strategy in a 79-year-old male diagnosed with liver oligometastatic PC, originating in the pancreatic tail. The strategy encompassed percutaneous microwave ablation for liver metastases, followed by FOLFIRINOX (5-fluorouracil, folic acid, irinotecan, and oxaliplatin) chemotherapy, and subsequent primary tumor resection. The patient has remained disease-free for over a year post-surgery. This multidisciplinary approach may hold promise for selected patients with liver oligometastatic PC, although further research and case studies are needed for comprehensive evaluation.
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Zeyara A, Torén W, Søreide K, Andersson R. The liver-first approach for synchronous colorectal liver metastases: A systematic review and meta-analysis of completion rates and effects on survival. Scand J Surg 2021; 111:14574969211030131. [PMID: 34605325 DOI: 10.1177/14574969211030131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients presenting with synchronous colorectal liver metastases are increasingly being considered for a curative treatment, and the liver-first approach is gaining popularity in this context. However, little is known about the completion rates of the liver-first approach and its effects on survival. METHODS A systematic review and meta-analysis of liver-first strategy for colorectal liver metastasis. The primary outcome was an assessment of the completion rates of the liver-first approach. Secondary outcomes included overall survival, causes of non-completion, and clinicopathologic data. RESULTS Seventeen articles were amenable for inclusion and the total study population was 1041. The median completion rate for the total population was 80% (range 20-100). The median overall survival for the completion and non-completion groups was 45 (range 12-69) months and 13 (range 10.5-25) months, respectively. Metadata showed a significant survival benefit for the completion group, with a univariate hazard ratio of 12.0 (95% confidence interval, range 5.7-24.4). The major cause of non-completion (76%) was liver disease progression before resection of the primary tumor. Pearson tests showed significant negative correlation between median number of lesions and median size of the largest metastasis and completion rate. CONCLUSIONS The liver-first approach offers a complete resection to most patients enrolled, with an overall survival benefit when completion can be assured. One-fifth fails to return to intended oncologic therapy and the major cause is interim metastatic progression, most often in the liver. Risk of non-completion is related to a higher number of lesions and large metastases. The majority of studies stem from primary rectal cancers, which may influence on the return to intended oncologic therapy as well.PROSPERO id no: 170459.
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Affiliation(s)
- Adam Zeyara
- Department of Surgery, Ystad Hospital, Ystad, Sweden Department of Clinical Sciences, Lund University, Lund, Sweden
| | - William Torén
- Department of Clinical Sciences, Lund University, Lund, Sweden Department of Surgery, Skåne University Hospital, Lund, SwedenKjetil Søreide
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Roland Andersson
- Department of Surgery, Skåne University Hospital, Lund SE-222 42, Sweden
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mSEPT9 Can Monitor the Response and Predict the Prognosis of Stage IV colorectal cancer Patients with Liver Metastasis Undergoing Potentially Curative Surgery. J Surg Res 2021; 267:485-494. [PMID: 34246842 DOI: 10.1016/j.jss.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/10/2021] [Accepted: 06/09/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Stage IV colorectal cancer (CRC) patients with liver metastasis undergoing potentially curative surgery represent a subgroup of patients with a relatively good prognosis. In this study, we aimed to evaluate the performance of mSEPT9 to monitor response to treatment and predict prognosis. METHODS In total, we recruited 51 stage IV CRC patients with liver metastasis, including 20 patients who underwent simultaneous surgery and 31 patients who underwent staged surgery. We measured the blood levels of mSEPT9 and CEA prior to surgery and then seven days after surgery. RESULTS mSEPT9 and CEA were detected prior to surgery in 92.2% (47/51) and 70.6% (36/51) of patients, respectively. Following simultaneous and staged surgery, levels of mSEPT9 fell significantly by 923-fold (P<0.001) and 11-fold (P<0.001), respectively. Levels of CEA also fell significantly by 17-fold (P<0.001) and 1.7-fold (P<0.01) following simultaneous and staged surgery, respectively. The mean percentage reduction of mSEPT9 levels after simultaneous surgery (12.3%) was significantly lower than that of staged surgery (33.8%) (P<0.001) while the mean percentage reduction of CEA levels after simultaneous surgery (35.5%) were significantly lower than that of staged surgery (64.6%) (P<0.05). The levels of mSEPT9 in the blood were quantitatively correlated with tumor burden. Survival analysis showed that patients who tested negative for mSEPT9 pre- and post-surgery had a better survival rate than those who tested positive, thus suggesting that mSEPT9 can act as a prognostic indicator. CONCLUSIONS mSEPT9 showed good quantitative efficacy, higher applicability, and sensitivity, than CEA in assessing treatment response and prognosis prediction in patients with stage IV CRC and liver metastasis.
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Elfrink AK, van Zwet EW, Swijnenburg RJ, den Dulk M, van den Boezem PB, Mieog JSD, te Riele WW, Patijn GA, Leclercq WK, Lips DJ, Rijken AM, Verhoef C, Kuhlmann KF, Buis CI, Bosscha K, Belt EJ, Vermaas M, van Heek NT, Oosterling SJ, Torrenga H, Eker HH, Consten EC, Marsman HA, Wouters MW, Kok NF, Grünhagen DJ, Klaase JM, Besselink MG, de Boer MT, Dejong CH, van Gulik TM, Hagendoorn J, Hoogwater FH, Molenaar IQ, Liem MS. Case-mix adjustment to compare nationwide hospital performances after resection of colorectal liver metastases. Eur J Surg Oncol 2021; 47:649-659. [DOI: 10.1016/j.ejso.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/23/2023] Open
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Giannis D, Sideris G, Kakos CD, Katsaros I, Ziogas IA. The role of liver transplantation for colorectal liver metastases: A systematic review and pooled analysis. Transplant Rev (Orlando) 2020; 34:100570. [DOI: 10.1016/j.trre.2020.100570] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023]
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de Jong MC, Beckers RCJ, van Woerden V, Sijmons JML, Bemelmans MHA, van Dam RM, Dejong CHC. The liver-first approach for synchronous colorectal liver metastases: more than a decade of experience in a single centre. HPB (Oxford) 2018; 20:631-640. [PMID: 29456199 DOI: 10.1016/j.hpb.2018.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 10/19/2017] [Accepted: 01/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The feasibility of the liver-first approach for synchronous colorectal liver metastases (CRLM) has been established. We sought to assess the short-term and long-term outcomes for these patients. METHODS Outcomes of patients who underwent a liver-first approach for CRLM between 2005 and 2015 were retrospectively evaluated from a prospective database. RESULTS Of the 92 patients planned to undergo the liver-first strategy, the paradigm could be completed in 76.1%. Patients with concurrent extrahepatic disease failed significantly more often in completing the protocol (67% versus 21%; p = 0.03). Postoperative morbidity and mortality were 31.5% and 3.3% following liver resection and 30.9% and 0% after colorectal surgery. Of the 70 patients in whom the paradigm was completed, 36 patients (51.4%) developed recurrent disease after a median interval of 20.9 months. The median overall survival on an intention-to-treat basis was 33.1 months (3- and 5-year overall survival: 48.5% and 33.1%). Patients who were not able to complete their therapeutic paradigm had a significantly worse overall outcome (p = 0.03). CONCLUSION The liver-first approach is feasible with acceptable perioperative morbidity and mortality rates. Despite the considerable overall-survival-benefit, recurrence rates remain high. Future research should focus on providing selection tools to enable the optimal treatment sequence for each patient with synchronous CRLM.
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Affiliation(s)
- Mechteld C de Jong
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.
| | - Rianne C J Beckers
- Department of Radiology - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Victor van Woerden
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Julie M L Sijmons
- Faculty of Health, Medicine & Life Sciences - Maastricht University, The Netherlands
| | - Marc H A Bemelmans
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Ronald M van Dam
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery - Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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Berardi G, De Man M, Laurent S, Smeets P, Tomassini F, Ariotti R, Hoorens A, van Dorpe J, Varin O, Geboes K, Troisi RI. Radiologic and pathologic response to neoadjuvant chemotherapy predicts survival in patients undergoing the liver-first approach for synchronous colorectal liver metastases. Eur J Surg Oncol 2018; 44:1069-1077. [PMID: 29615295 DOI: 10.1016/j.ejso.2018.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/26/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To investigate the short- and long-term outcomes of liver first approach (LFA) in patients with synchronous colorectal liver metastases (CRLM), evaluating the predictive factors of survival. METHODS Sixty-two out of 301 patients presenting with synchronous CRLM underwent LFA between 2007 and 2016. All patients underwent neoadjuvant chemotherapy. After neoadjuvant treatment patients were re-evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST). Liver resection was scheduled after 4-6 weeks. Changes in non-tumoral parenchyma and the tumor response according to the Tumor Regression Grade score (TRG) were assessed on surgical specimens. Primary tumor resection was scheduled 4-8 weeks following hepatectomy. RESULTS Five patients out of 62 (8.1%) showed "Progressive Disease" at re-evaluation after neoadjuvant chemotherapy, 22 (35.5%) showed "Stable Disease" and 35 (56.5%) "Partial Response"; of these latter, 29 (82%) showed histopathologic downstaging. The 5-year survival (OS) rate was 55%, while the 5-year disease-free survival (DFS) rate was 16%. RECIST criteria, T-stage, N-stage and TRG were independently associated with OS. Bilobar presentation of disease, RECIST criteria, R1 margin and TRG were independently associated with DFS. Patients with response to neoadjuvant chemotherapy had better survival than those with stable or progressive disease (radiological response 5-y OS: 65% vs. 50%; 5-y DFS: 20% vs. 10%; pathological response 5-y OS: 75% vs. 56%; 5-y DFS: 45% vs. 11%). CONCLUSIONS LFA is an oncologically safe strategy. Selection is a critical point, and the best results in terms of OS and DFS are observed in patients having radiological and pathological response to neoadjuvant chemotherapy.
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Affiliation(s)
- Giammauro Berardi
- Dept. of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Marc De Man
- Dept. of Oncology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Stéphanie Laurent
- Dept. of Oncology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Peter Smeets
- Dept. of Radiology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Federico Tomassini
- Dept. of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Riccardo Ariotti
- Dept. of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Anne Hoorens
- Dept. of Pathology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Jo van Dorpe
- Dept. of Pathology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Oswald Varin
- Dept. of Gastroenterology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Karen Geboes
- Dept. of Oncology, Ghent University Hospital and Medical School, Ghent, Belgium
| | - Roberto I Troisi
- Dept. of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, C. Heymanslaan 10, Ghent 9000, Belgium; Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.
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Valderrama-Treviño AI, Barrera-Mera B, Ceballos-Villalva JC, Montalvo-Javé EE. Hepatic Metastasis from Colorectal Cancer. Euroasian J Hepatogastroenterol 2017; 7:166-175. [PMID: 29201802 PMCID: PMC5670263 DOI: 10.5005/jp-journals-10018-1241] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022] Open
Abstract
The liver is the most common site of metastasis in patients with colorectal cancer due to
its anatomical situation regarding its portal circulation. About 14 to 18% of patients
with colorectal cancer present metastasis at the first medical consultation, and 10 to 25%
at the time of the resection of the primary colorectal cancer. The incidence is higher
(35%) when a computed tomography (CT) scan is used. In the last decades, a significant increase in the life expectancy of patients with
colorectal cancer has been achieved with different diagnostic and treatment programs.
Despite these improvements, the presence of metastasis, disease recurrence, and advanced
local tumors continue to remain poor prognostic factors. Median survival without treatment is <8 months from the moment of its presentation,
and a survival rate at 5 years of 11% is the best prognosis for those who present with
local metastasis. Even in patients with limited metastatic disease, 5-year survival is
exceptional. Patients with hepatic metastasis of colorectal cancer have a median survival
of 5 to 20 months with no treatment. Approximately 20 to 30% of patients with colorectal
metastasis have disease confined to the liver, and this can be managed with surgery.
Modern surgical strategies at the main hepatobiliary centers have proved that hepatectomy
of 70% of the liver can be performed, with a mortality rate of <5%. It is very important to have knowledge of predisposing factors, diagnostic methods, and
treatment of hepatic metastasis. However, the establishment of newer, efficient,
preventive screening programs for early diagnosis and adequate treatment is vital. How to cite this article: Valderrama-Treviño AI, Barrera-Mera B,
Ceballos-Villalva JC, Montalvo-Javé EE. Hepatic Metastasis from Colorectal Cancer.
Euroasian J Hepato-Gastroenterol 2017;7(2):166-175.
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Affiliation(s)
| | - Baltazar Barrera-Mera
- Department of Physiology, Universidad Nacional Autonoma de México, Ciudad de México, México
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