Colorectal hepatic metastasis: Evolving therapies

Advanced image analytics predicting clinical outcomes in patients with colorectal liver metastases: A systematic review of the literature

BACKGROUND

To better select patients with colorectal liver metastases (CRLM) for an optimal selection of treatment strategy (i.e. local, systemic or combined treatment) new prognostic models are warranted. In the last decade, radiomics has emerged as a field to create predictive models based on imaging features. This systematic review aims to investigate the current state and potential of radiomics to predict clinical outcomes in patients with CRLM.

METHODS

A comprehensive literature search was conducted in the electronic databases of PubMed, Embase, and Cochrane Library, according to PRISMA guidelines. Original studies reporting on radiomics predicting clinical outcome in patients diagnosed with CRLM were included. Clinical outcomes were defined as response to systemic treatment, recurrence of disease, and survival (overall, progression-free, disease-free). Primary outcome was the predictive performance of radiomics. A narrative synthesis of the results was made. Methodological quality was assessed using the radiomics quality score.

RESULTS

In 11 out of 14 included studies, radiomics was predictive for response to treatment, recurrence of disease, survival, or a combination of outcomes. Combining clinical parameters and radiomic features in multivariate modelling often improved the predictive performance. Different types of individual features were found prognostic. Noticeable were the contrary levels of heterogeneous and homogeneous features in patients with good response. The methodological quality as assessed by the radiomics quality score varied considerably between studies.

CONCLUSION

Radiomics appears a promising non-invasive method to predict clinical outcome and improve personalized decision-making in patients with CRLM. However, results were contradictory and difficult to compare. Standardized prospective studies are warranted to establish the added value of radiomics in patients with CRLM.

Minimally invasive robotic-assisted combined colorectal and liver excision surgery: feasibility, safety and surgical technique in a pilot series

Different strategies may be adopted in patients with synchronous colorectal liver metastases (LM). The role of laparoscopy has been investigated to define the benefits of minimally invasive surgery in a single-stage operation. In our study, we report our experience of 28 Minimally Invasive Robotic-Assisted combined Colorectal and Liver Excision Surgery (MIRACLES). From October 2012 to December 2019, 135 Robotic liver resections and 218 Robotic Colorectal resections were performed in our center. Twenty-eight patients underwent MIRACLES resection with 37 nodules removed. Fifty-two lesions in 28 patients were resected in minimally invasive robot-assisted surgery. Eighteen lesions were located in postero-superior liver segments (eight in segment VII, two in segment VIII, eight in segment IVa). Nine right colectomies, seven left colectomies, ten anterior rectal resections, one Hartmann and one MILES procedures were performed. The median surgical time of MIRACLES procedures was 332 min. Two conversions to open approach were necessary. Four major complications (> III) were observed. No postoperative mortality was recorded. The median hospital stay was 8 days. The median overall survival was 27.5 months. The MIRACLES approach is feasible and safe for colorectal resection and hepatic nodules located in all segments, with a low rate of postoperative complications. Surgical technique is demanding and should be reserved, presently, to tertiary centers.

Assessment of hepatic sinusoidal obstruction syndrome with intravoxel incoherent motion diffusion-weighted imaging: An experimental study in a rat model

BACKGROUND

Intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) parameters may reflect perfusion and diffusion changes in hepatic sinusoidal obstruction syndrome (SOS).

PURPOSE

To investigate the feasibility of IVIM-DWI in the noninvasive assessment of hepatic SOS in an experimental rat model.

STUDY TYPE

Animal study.

POPULATION/SUBJECTS

Forty-four rats were administered different doses (90 or 160 mg/kg) of monocrotaline by gavage either 48 or 72 hours before MRI to induce different degrees of hepatic SOS, and another 10 rats served as controls.

FIELD STRENGTH/SEQUENCE

3T scanner, IVIM-DWI using nine b values (0-800 sec/mm² ).

ASSESSMENT

Histologically, rats were classified as having none (n = 10), mild (n = 8), moderate (n = 19), or severe SOS (n = 17). The apparent diffusion coefficient (ADC) and IVIM-derived parameters (D: true diffusion coefficient, D*: pseudo-diffusion coefficient, and f: perfusion fraction) of the liver parenchyma were measured.

STATISTICAL TESTS

IVIM-DWI parameters were compared according to histologic grades of SOS (none, mild, moderate, and severe), and receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic accuracy.

RESULTS

ADC, D, and f of the liver parenchyma were significantly different according to SOS severity groups (Ps < 0.01) and significantly decreased as SOS severity increased (rho = -0.323, -0.313, and -0.700; P = 0.017, 0.021, and <0.001, respectively). Means of f in none, mild, moderate, and severe SOS were 17.2%, 13.3%, 12.3%, and 11.1%, respectively. Among ADC and IVIM-derived parameters, f provided the highest area under the ROC curves for detecting ≥mild, ≥moderate, and severe SOS (0.991, 0.890, and 0.803, respectively).

DATA CONCLUSION

IVIM-DWI may be useful in the diagnosis and severity assessment of hepatic SOS.

LEVEL OF EVIDENCE

2 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020;51:81-89.

Respiratory motion during 90Yttrium PET contributes to underestimation of tumor dose and overestimation of normal liver tissue dose

Background Yttrium-90 dosimetry after radioembolization is reliant on accurate quantitative imaging of the microsphere deposition. Previous studies have focused on the correction of geometrical resolution effects. Purpose To uncover additional effects of respiratory motion. Material and Methods Mathematical models describing spherical tumors were formed and two blurring effects, limited geometrical resolution and respiratory motion, were simulated. The virtual images were used as basis for dose volume histogram estimations by convolving the radioactivity representations with a dose point kernel. Results For respiratory motion only, the largest errors were found for the smallest tumors and/or tumors with heterogeneous distribution of yttrium-90 microspheres. The deviations in max dose and dose to 25% and 50% of the tumor volume were estimated at 20-40%, 10-30%, and 0-30%, respectively. Additional blurring from geometrical resolution increased the errors to 55-75%, 50-60%, and 25-60%, respectively. Conclusion Respiratory motion contributes to underestimation of tumor dose and overestimation of normal tissue dose.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

A reductionist metastasis-on-a-chip platform for in vitro tumor progression modeling and drug screening

Current animal and 2-D cell culture models employed in metastasis research and drug discovery remain poor mimics of human cancer physiology. Here we describe a "metastasis-on-a-chip" system allowing real time tracking of fluorescent colon cancer cells migrating from hydrogel-fabricated gut constructs to downstream liver constructs within a circulatory fluidic device system that responds to environmental manipulation and drug treatment. Devices consist of two chambers in which gut and liver constructs are housed independently, but are connected in series via circulating fluid flow. Constructs were biofabricated with a hyaluronic acid-based hydrogel system, capable of a variety of customizations, inside of which representative host tissue cells were suspended and metastatic colon carcinoma tumor foci were created. The host tissue of the constructs expressed normal epithelial markers, which the tumor foci failed to express. Instead, tumor regions lost membrane-bound adhesion markers, and expressed mesenchymal and proliferative markers, suggesting a metastatic phenotype. Metastatic tumor foci grew in size, eventually disseminating from the intestine construct and entering circulation, subsequently reaching in the liver construct, thus mimicking some of the migratory events observed during metastasis. Lastly, we demonstrated the ability to manipulate the system, including chemically modulating the hydrogel system mechanical properties and administering chemotherapeutic agents, and evaluated the effects of these parameters on invasive tumor migration. These results describe the capability of this early stage metastasis-on-a-chip system to model several important characteristics of human metastasis, thereby demonstrating the potential of the platform for making meaningful advances in cancer investigation and drug discovery. Biotechnol. Bioeng. 2016;113: 2020-2032. © 2016 Wiley Periodicals, Inc.

Liver metastases from non-gastrointestinal non-neuroendocrine tumours: review of the literature

Liver resection is integrated in the oncological surgical management of metastatic gastrointestinal and neuroendocrine tumours. However, the good prognosis reached in these cases has not been obtained for metastatic tumours of other histological types. In this review, we analysed the published case reports and series of hepatectomies in patients with metastatic breast cancer, melanoma, sarcoma, genitourinary tumours, pulmonary and adrenocortical tumours. From the reported data the surgical resection of oligometastases yields good results in terms of improved survival, in particular when the disease-free time period is longer than 1 year. Hepatic resection can be a valid surgical strategy to obtain a survival benefit in patients with liver metastases from non-gastrointestinal, non-neuroendocrine tumours. However, a careful patient selection is needed in order to obtain a real survival benefit; patients with a good performance status, with a disease-free period longer than 1 year and with oligometastases may obtain the best advantage from this approach.

Liver-Tumor Hybrid Organoids for Modeling Tumor Growth and Drug Response In Vitro

Current in vitro models for tumor growth and metastasis are poor facsimiles of in vivo cancer physiology and thus, are not optimal for anti-cancer drug development. Three dimensional (3D) tissue organoid systems, which utilize human cells in a tailored microenvironment, have the potential to recapitulate in vivo conditions and address the drawbacks of current tissue culture dish 2D models. In this study, we created liver-based cell organoids in a rotating wall vessel bioreactor. The organoids were further inoculated with colon carcinoma cells in order to create liver-tumor organoids for in vitro modeling of liver metastasis. Immunofluorescent staining revealed notable phenotypic differences between tumor cells in 2D and inside the organoids. In 2D they displayed an epithelial phenotype, and only after transition to the organoids did the cells present with a mesenchymal phenotype. The cell surface marker expression results suggested that WNT pathway might be involved in the phenotypic changes observed between cells in 2D and organoid conditions, and may lead to changes in cell proliferation. Manipulating the WNT pathway with an agonist and antagonist showed significant changes in sensitivity to the anti-proliferative drug 5-fluoruracil. Collectively, the results show the potential of in vitro 3D liver-tumor organoids to serve as a model for metastasis growth and for testing the response of tumor cells to current and newly discovered drugs.

Predictors of recurrence after a first hepatectomy for colorectal cancer liver metastases: a retrospective analysis

Background

Surgical resection is considered the standard therapy in the treatment of liver metastases from colorectal cancer (CRCLM); however, most patients experience tumor recurrence after curative hepatic resection. The objective was to determine potential prognostic factors for tumor recurrence after an initial hepatectomy for CRCLM.

Methods

A study population of 101 patients who had undergone a first curative hepatectomy for CRCLM was retrospectively analyzed. Selected biological tumor markers, and clinical and pathological features were then tested by Cox regression.

Results

Synchronous liver metastases occurred in 38 patients (37.6%) and 63 patients (62.3%) presented with metachronous liver metastases. In a median follow-up time of 68 months, recurrence was observed in 64 patients (63.3%). The 5-year cumulative risk of recurrence was 56.7%. The median survival after recurrence was 24.5 months (range 1 to 41 months) and 5-year cumulative overall survival was 31.8%. Of all variables tested by Cox regression, intra- and extrahepatic resectable disease, CEA levels ≥50 ng/mL and bilobar liver disease remained significant as predictors of recurrence in the multivariate analysis.

Conclusions

Independent risk factors for recurrence after an initial hepatectomy for CRCLM, such as intra- and extrahepatic resectable disease, CEA levels ≥50 ng/mL and bilobar liver disease, can eventually help in making decisions in this very complex scenario.