Colorectal liver metastases: Current management and future perspectives

Patterns of care in patients with asymptomatic stage IV colon cancer: A population-based analysis

BACKGROUND

Currents guidelines recommend chemotherapy with or without biologic agents for asymptomatic stage IV colon cancer treatment, whereas primary tumor resection is reserved for symptomatic tumors or resectable metastases. However, US treatment patterns are understudied. Our study aims to identify real-world treatment patterns for asymptomatic metastatic colon cancer.

METHODS

Adults with asymptomatic metastatic colon cancer were identified in the 2014 Surveillance, Epidemiology, and End Results Patterns of Care database and categorized into 6 groups: chemotherapy with or without biologic agents, chemotherapy with or without biologic agents with primary tumor resection and metastasectomy, chemotherapy with or without biologic agents and primary tumor resection alone, primary tumor resection only, no treatment, or other treatments. Multinomial logistic regression was used to examine factors associated with receiving each treatment modality. Cox proportional hazard models were used to assess the relationships between treatments and survival.

RESULTS

Among 1,717 weighted patient cases, 28% received chemotherapy with or without biologic agents, 23% chemotherapy with or without biologic agents with primary tumor resection, 12% chemotherapy with or without biologic agents with primary tumor resection and metastasectomy, 12% primary tumor resection only, 23% no treatment, and 2% other treatment. Younger patients were more likely to receive chemotherapy with or without biologic agents with primary tumor resection and metastasectomy than chemotherapy with or without biologic agents alone (odds ratio, 3.32; 95% confidence interval, 1.3-8.6) and less likely to undergo no treatment (odds ratio, 0.05; 95% confidence interval, 0.02-0.17). Patients treated by chemotherapy with or without biologic agents with primary tumor resection and metastasectomy had the greatest median survival of 61 months, whereas those with no treatment had a 1-month median survival.

CONCLUSION

Almost one quarter of patients with asymptomatic stage IV colon cancer received no treatment. Meanwhile, 12% of patients underwent curative systemic and surgical treatment, which was associated with a median survival of 5 years, validating reported outcomes of this approach by institutional studies. These data provide an important benchmark for future interventions pertaining to asymptomatic patients with stage IV colon cancer.

Effects of Hepatic or Renal Impairment on Pharmacokinetics of Fruquintinib

Fruquintinib (FRUZAQLATM) is a highly selective tyrosine kinase inhibitor of all three vascular endothelial growth factor receptors (-1, -2, and -3). Two Phase 1, open-label, single-dose studies investigated the impact of hepatic or renal impairment on the pharmacokinetics and tolerability of fruquintinib. Participants with moderate renal impairment (creatinine clearance [CrCl] 30-59 mL/min; eight participants) and matched healthy controls (eight participants for each study) received fruquintinib 5 mg. Participants with moderate hepatic impairment (Child-Pugh B; eight participants) and severe renal impairment (CrCl 15-29 mL/min; eight participants) received fruquintinib 2 mg. Pharmacokinetic samples were collected over 240 h. Fruquintinib pharmacokinetics were similar between participants with moderate hepatic impairment and healthy controls; geometric mean ratios (GMRs) and 90% confidence intervals (CIs) for maximum plasma concentration (Cmax), area under the plasma concentration-time curve from 0 to time of last measurable concentration (AUC0-t), and AUC from 0 to infinity (AUC0-inf) were 1.04 (0.87-1.24), 0.89 (0.64-1.23), and 0.91 (0.66-1.26), respectively. Fruquintinib pharmacokinetics were similar between participants with severe or moderate renal impairment and healthy controls. Compared with healthy controls, the respective GMRs (90% CIs) for Cmax, AUC0-t, and AUC0-inf for participants with severe renal impairment were 0.89 (0.78-1.03), 0.97 (0.83-1.14), and 1.01 (0.85-1.19), and for participants with moderate renal impairment were 0.95 (0.78-1.15), 1.06 (0.89-1.26), and 1.07 (0.89-1.28). Fruquintinib was generally well tolerated. These results support fruquintinib use without dose adjustment (5 mg daily, 3 weeks on, and 1 week off) in patients with moderate hepatic impairment or moderate to severe renal impairment.

Automatic future remnant segmentation in liver resection planning

PURPOSE

Liver resection is a complex procedure requiring precise removal of tumors while preserving viable tissue. This study proposes a novel approach for automated liver resection planning, using segmentations of the liver, vessels, and tumors from CT scans to predict the future liver remnant (FLR), aiming to improve pre-operative planning accuracy and patient outcomes.

METHODS

This study evaluates deep convolutional and Transformer-based networks under various computational setups. Using different combinations of anatomical and pathological delineation masks, we assess the contribution of each structure. The method is initially tested with ground-truth masks for feasibility and later validated with predicted masks from a deep learning model.

RESULTS

The experimental results highlight the crucial importance of incorporating anatomical and pathological masks for accurate FLR delineation. Among the tested configurations, the best performing model achieves an average Dice score of approximately 0.86, aligning closely with the inter-observer variability reported in the literature. Additionally, the model achieves an average symmetric surface distance of 0.95 mm, demonstrating its precision in capturing fine-grained structural details critical for pre-operative planning.

CONCLUSION

This study highlights the potential for fully-automated FLR segmentation pipelines in liver pre-operative planning. Our approach holds promise for developing a solution to reduce the time and variability associated with manual delineation. Such method can provide better decision-making in liver resection planning by providing accurate and consistent segmentation results. Future studies should explore its seamless integration into clinical workflows.

Reprogramming liver metastasis-associated macrophages toward an anti-tumoral phenotype through enforced miR-342 expression

Upon metastatic seeding in the liver, liver macrophages, including Kupffer cells, acquire a transcriptional profile typical of tumor-associated macrophages (TAMs), which support tumor progression. MicroRNAs (miRNAs) fine-tune TAM pro-tumoral functions, making their modulation a promising strategy for macrophage reprogramming into an anti-tumoral phenotype. Here, we analyze the transcriptomic profiles of liver and splenic macrophages, identifying miR-342-3p as a key regulator of liver macrophage function. miR-342-3p is highly active in healthy liver macrophages but significantly downregulated in colorectal cancer liver metastases (CRLMs). Lentiviral vector-engineered liver macrophages enforcing miR-342-3p expression acquire a pro-inflammatory phenotype and reduce CRLM growth. We identify Slc7a11, a cysteine-glutamate antiporter linked to pro-tumoral activity, as a direct miR-342-3p target, which may be at least partially responsible for TAM phenotypic reprogramming. Our findings highlight the potential of in vivo miRNA modulation as a therapeutic strategy for TAM reprogramming, offering an approach to enhance cancer immunotherapy.

Enhancing outcome prediction in patients with colorectal liver metastases undergoing hepatectomy: the synergistic impact of FIB-4 index and tumor burden score across KRAS profiles

BACKGROUND

The prognostic value of Fibrosis-4 (FIB-4) index, concerning KRAS status (wild-type [wtKRAS] vs. mutated [mutKRAS]) remains unclear in post-hepatectomy colorectal liver metastases (CRLM). We evaluated the combined impact of FIB-4 and Tumor Burden Score (TBS) on overall survival (OS)/recurrence-free survival (RFS), stratified by KRAS status.

METHODS

CRLM patients undergoing hepatectomy (2000-2020) were analyzed, grouped by TBS/FIB-4.

RESULTS

Among 828 patients, 196 had high FIB-4. High TBS had worse 5-year OS (P < 0.001). In wtKRAS, high TBS correlated with worse OS (P < 0.001), but not in mutKRAS. High FIB-4 correlated with worse OS (P = 0.01). Sub-stratification showed no OS difference by FIB-4 in wtKRAS, but a difference in mutKRAS (P = 0.03). Multivariable analysis identified mutKRAS (HR: 1.90), high TBS (HR: 1.62), and FIB-4 (HR: 1.15) as mortality risk factors. The TBS-FIB-4-KRAS index had highest predictive accuracy. For RFS, TBS and FIB-4 independently stratified outcomes. High TBS was associated with worse RFS in wtKRAS (P < 0.001) but not in mutKRAS. High FIB-4 decreased RFS in mutKRAS (P = 0.001) but not in wtKRAS. FIB-4 was associated with a 10% increased recurrence risk.

CONCLUSION

TBS and FIB-4, alongside KRAS status, should be considered to improve outcome predictions.

METACHRONOUS COLORECTAL LIVER METASTASIS

Deaths related to colorectal cancer are generally associated with its metastases that affect the liver (50%) through the hematogenous route. Approximately 20-25% of these patients already have synchronous metastases in the liver at the time of primary tumor diagnosis. In others, liver metastases will occur during the course of the disease and are called metachronous. Metachronous metastases are believed to have a better prognosis; however, 20-25% of metastatic cases can be resected during the course of the disease. There is a lack of consensus on the diagnostic time interval for metastases to be considered metachronous in the consulted literature. Surgical treatment of metastases and lymph nodes is indicated, and extrahepatic neoplastic disease must be carefully evaluated. Liver transplantation can benefit the patient, should be evaluated, and is indicated in some special situations.

Computed Tomography-Based Habitat Analysis for Prognostic Stratification in Colorectal Liver Metastases

Background

Colorectal liver metastasis (CRLM) has a poor prognosis, and traditional prognostic models have certain limitations in clinical application. This study aims to evaluate the prognostic value of CT-based habitat analysis in CRLM patients and compare it with existing traditional prognostic models to provide more evidence for individualized treatment of CRLM patients.

Methods

This retrospective study included 197 patients with CRLM whose preoperative contrast-enhanced CT images and corresponding DICOM Segmentation Objects (DSOs) were obtained from The Cancer Imaging Archive (TCIA). Tumor regions were segmented, and habitat features representing distinct subregions were extracted. An unsupervised K-means clustering algorithm classified the tumors into two clusters based on their habitat characteristics. Kaplan-Meier analysis was used to evaluate overall survival (OS), disease-free survival (DFS), and liver-specific DFS. The habitat model's predictive performance was compared with the Clinical Risk Score (CRS) and Tumor Burden Score (TBS) using the concordance index (C-index), Integrated Brier Score (IBS), and time-dependent area under the curve (AUC).

Results

The habitat model identified two distinct patient clusters with significant differences in OS, DFS, and liver-specific DFS (p < 0.01). Compared with CRS and TBS, the habitat model demonstrated superior predictive accuracy, particularly for DFS and liver-specific DFS, with higher time-dependent AUC values and improved model calibration (lower IBS).

Conclusions

CT-based habitat analysis captures spatial tumor heterogeneity and provides enhanced prognostic stratification in CRLM. The method outperforms conventional models and offers potential for more personalized treatment planning.

Combined peritoneal and liver metastases in colorectal cancer: A Dutch nationwide population-based analysis of incidence, treatment and survival

INTRODUCTION

The aim of this study was to determine the incidence, treatment patterns, survival and factors associated with curative treatment in colorectal cancer patients with combined liver and peritoneal metastases using Dutch population-based data.

MATERIALS AND METHODS

Data from the Netherlands Cancer Registry were used. All patients diagnosed with synchronous isolated peritoneal and liver metastasized colorectal adenocarcinoma between January 1, 2015 and December 31, 2021 were included. Multivariable regression analyses were performed to identify factors associated with receiving curative treatment. Survival rates were calculated for patients undergoing palliative and curative treatment separately.

RESULTS

Of 14627 patients with colorectal adenocarcinoma in the study period, 927 patients (6.3 %) had isolated liver and peritoneal metastases and were evaluated in this study. Mean age was 66.9 years, non-mucinous and non-signet-ring cell adenocarcinomas were most prevalent (89.0 %) and tumors were mostly located in the colon (92.1 %). Patients were treated with best supportive care (n = 254, 27,4 %), palliative treatment (n = 618, 66,7 %) or curative treatment (n = 55, 5,9 %). Median OS was 1.5 months, 11.3 months, and 32.6 months, respectively. Multivariable analysis showed that younger age (OR 0.95, p < 0.001) and up to 3 liver metastases (OR 0.13, p < 0.001) are positively associated with receiving curative treatment.

CONCLUSION

This population-based study provides a comprehensive overview of the incidence and treatment of patients with synchronous colorectal liver and peritoneal metastases. It shows that in a highly selected group of patients, curative treatment is associated with better overall survival.

Evolving Transplant Oncology: Evolving Criteria for Better Decision-Making

Transplant oncology integrates a wide variety of fields, such as surgery, oncology, and transplant medicine, intending to increase the range of studies and treatments for hepatobiliary cancers and other liver-related malignant lesions. Liver transplantation (LT) has proven to be an effective treatment for hepatocellular carcinoma. While the Milan criteria are still the gold standard, several new, more inclusive criteria have been proposed, and hepatocellular carcinoma has become a major indication for liver transplantation. The continuous evolution of diagnostic technologies supported this with higher image quality and more accurate staging. This review describes the current applications of transplant oncology in hepatocellular carcinoma, cholangiocarcinoma, neuroendocrine tumors, and liver metastatic disease from colorectal cancer and discusses the path that led to the development of transplant oncology as an organized approach to managing gastrointestinal malignancies through transplantation. More importantly, the significance of a multidisciplinary approach and criteria in the selection of suitable candidates are discussed. In addition, newer aspects of transplant oncology, such as immunotherapy, circulating tumor DNA (ctDNA), novel surgical techniques, and the utilization of artificial intelligence, are presented. Finally, the opportunities and challenges involved in the field's future, as well as the evolution of the criteria used over the years and insightful thoughts for the future of the criteria, are discussed.

Ultrasound-guided intraoperative liver ablation - retrospective review of indications and outcomes

AIM

To define the indications and outcomes of intraoperative ablation of hepatic malignancies.

MATERIALS AND METHODS

This retrospective study comprises 27 patients (male/female: 19/8; mean age: 56 ± 13) undergoing intraoperative ablation (IOA) of liver tumours between July 2001 and August 2021 for 42 tumours, including colorectal liver metastasis (CRLM) (n = 27), hepatocellular carcinoma (HCC)(n = 14), and ovarian cancer metastasis (n = 1). The mean tumour diameter was 2.1 cm ± 1.3 (range, 0.6-5.6 cm). The median imaging follow-up was 26.3 months ± 25.6 (range: 0.13-161.6). Technical success (TS), local tumour progression (LTP), and local progression-free survival (LPFS) were calculated leveraging the Kaplan-Meier method. Adverse events (AE) were categorised according to SIR guidelines.

RESULTS

Indications for IOA include concurrent partial hepatectomy (n = 9), intraoperative detection of a new tumour (n = 4), lack of a safe percutaneous trajectory (n = 3) or clamp of hilum (n = 1). In 7 patients, surgeons made independent decisions for IOA not based on established criteria. Of 32 ablated tumours among 25 patients with available follow-up, TS was achieved for 31 tumours (97%). LTP was detected in 32% of cases at a median of 13.7 months. LPFS at 1,2,3,5 years were 82%, 60%, 51%, 51%. AE rate was 55.5% addressed with minimal or no interventions in 80% of cases. One patient with HCC died of liver failure.

CONCLUSION

The indications for IOA are concurrent partial hepatectomy, intraoperative detection of a new tumour, and suboptimal percutaneous ablation. IOA is effective with high TS. LTP is high. AE rate is relatively high; however, no significant treatment is required in most cases.

Pulsed field ablation in medicine: irreversible electroporation and electropermeabilization theory and applications

BACKGROUND

Focal ablation techniques are integral in the surgical intervention of diseased tissue, where it is necessary to minimize damage to the surrounding parenchyma and critical structures. Irreversible electroporation (IRE) and high-frequency IRE (H-FIRE), colloquially called pulsed-field ablation (PFA), utilize high-amplitude, low-energy pulsed electric fields (PEFs) to nonthermally ablate soft tissue. PEFs induce cell death through permeabilization of the cellular membrane, leading to loss of homeostasis. The unique nonthermal nature of PFA allows for selective cell death while minimally affecting surrounding proteinaceous structures, permitting treatment near sensitive anatomy where thermal ablation or surgical resection is contraindicated. Further, PFA is being used to treat tissue when tumor margins are not expected after surgical resection, termed margin accentuation. This review explores both the theoretical foundations of PFA, detailing how PEFs induce cell membrane destabilization and selective tissue ablation, the outcomes following treatment, and its clinical implications across oncology and cardiology.

CONCLUSIONS

Clinical experience is still progressing, but reports have demonstrated that PFA reduces complications often seen with thermal ablation techniques. Mounting oncology data also support that PFA produces a robust immune response that may prevent local recurrences and attenuate metastatic disease. Despite promising outcomes, challenges such as optimizing field delivery and addressing variations in tissue response require further investigation. Future directions include refining PFA protocols and expanding its application to other therapeutic areas like benign tissue hyperplasia and chronic bronchitis.

Hepatic Stellate Cells Functional Heterogeneity in Liver Cancer

Hepatic stellate cells (HSCs) are the liver's pericytes, and play key roles in liver homeostasis, regeneration, fibrosis, and cancer. Upon injury, HSCs activate and are the main origin of myofibroblasts and cancer-associated fibroblasts (CAFs) in liver fibrosis and cancer. Primary liver cancer has a grim prognosis, ranking as the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) being the predominant type, followed by intrahepatic cholangiocarcinoma (iCCA). Moreover, the liver hosts 35% of all metastatic lesions. The distinct spatial distribution and functional roles of HSCs across these malignancies represent a significant challenge for universal therapeutic strategies, requiring a nuanced and tailored understanding of their contributions. This review examines the heterogeneous roles of HSCs in liver cancer, focusing on their spatial localization, dynamic interactions within the tumor microenvironment (TME), and emerging therapeutic opportunities, including strategies to modulate their activity, and harness their potential as targets for antifibrotic and antitumor interventions.

Initial Assessment of Resectability of Colorectal Cancer Liver Metastases Versus Clinical Outcome

BACKGROUND

Surgery improves long-term survival for resectable, liver-only metastatic colorectal cancer (mCRC). With no consensus definition of "resectable" disease, decisions regarding resectability are reliant on the expertise and judgement of the treating clinician working in consultation with a multidisciplinary team (MDT). This study examines the clinical outcome versus initial assessment of resectability in an Australian population with mCRC.

PATIENTS AND METHODS

Patients with liver-only mCRC diagnosed January 2009 to December 2022 were identified from the Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry. Patients were classified based on prospectively documented treatment assessment as "resectable," "potentially resectable," or "unresectable." The correlation between initial assessment of resectability and clinical outcome, and any impact of clinicopathologic factors were examined. Kaplan-Meier analysis assessed overall survival based on initial resectability assessment and resection status.

RESULTS

Of 4437 patients with mCRC identified through TRACC, 1250 (28%) had liver-only disease at presentation, with 497 (43%), 277 (24%), and 374 (33%) classified as "unresectable," "potentially resectable," and "resectable," respectively. In total, 516 (41%) ultimately underwent surgical resection, including 30 (6%) of the "initially unresectable," 148 (53%) of the "potentially resectable," and 338 (90%) of the "resectable" at a median of 9.5, 5.9, and 2.4 months from the diagnosis of liver metastases, respectively. Resection in the "unresectable" patient population was associated with younger age (mean age 63 vs. 69, P = .0006), better performance status (ECOG 0-1 100% vs. 74%, P = .0017), and fewer comorbidities (Charlson index 0-3 in 73% vs. 53%, P = .0296) compared with no resection. Median overall survival was longer for resected versus nonresected patients across all categories: "unresectable" (59.2 vs. 17.6 months, P < .0001), "potentially resectable" (57.2 vs. 22.8 months, P < .0001), and "resectable" (108 vs. 55 months, P < .0001).

CONCLUSIONS

This real-world study demonstrates the potential for "initially unresectable" patients to become surgical candidates following systemic therapy, more likely in younger and fitter patients, with overall excellent survival outcomes in resected patients. This highlights the value of routine, repeated MDT assessments for patients with liver-only disease who are continuing to respond to systemic therapy, even for those initially considered never to be surgical candidates.

Expanding Indications in Transplant Oncology

Liver transplantation is aptly described as the only curative treatment for cirrhosis and cirrhosis with co-morbid hepatocellular carcinoma (HCC). Its utility in the management of various other primary and secondary liver cancers is gaining traction rapidly, with more thorough assessments on broader populations continuing to emerge. Most prominently, this includes colorectal cancer liver metastasis (CRLM), cholangiocarcinoma (CCA), neuroendocrine tumors (NETs), and more. Furthermore, despite being a well described treatment for HCC for many years, growing evidence supports a change in oncological strategy for HCC, with broadened selection criteria and more advanced systemic and locoregional therapies available. Our review aims to describe the evidence supporting the expansion of indications and selection criteria for liver transplantation in various oncologic indications of primary and secondary liver tumors.

Inflammation and Immunity in Liver Neoplasms: Implications for Future Therapeutic Strategies

Over the past two decades, the "hallmarks of cancer" have revolutionized cancer research and highlighted the crucial roles of inflammation and immunity. Protumorigenic inflammation promotes cancer development along with inhibition of antitumor immunity, shaping the tumor microenvironment (TME) toward a tumor-permissive state and further enhancing the malignant potential of cancer cells. This immunosuppressive TME allows tumors to evade immunosurveillance. Thus, understanding the complex interplay between tumors and the immune system within the TME has become pivotal, especially with the advent of immunotherapy. Although immunotherapy has achieved notable success in many malignancies, primary liver cancer, particularly hepatocellular carcinoma, presents unique challenges. The hepatic immunosuppressive environment poses obstacles to the effectiveness of immunotherapy, along with high mortality rates and limited treatment options for patients with liver cancer. In this review, we discuss current understanding of the complex immune-mediated mechanisms underlying liver neoplasms, focusing on hepatocellular carcinoma and liver metastases. We describe the molecular and cellular heterogeneity within the TME, highlighting how this presents unique challenges and opportunities for immunotherapy in liver cancers. By unraveling the immune landscape of liver neoplasms, this review aims to contribute to the development of more effective therapeutic interventions, ultimately improving clinical outcomes for patients with liver cancer.

Evaluation of the Ki-67 labeling index on immediate pre-ablation biopsies as a predictive biomarker of local recurrence of colorectal cancer liver metastases

The aim of this study was to evaluate if the Ki-67 labeling index (LI) on immediate pre-ablation biopsies of colorectal liver metastases (CLM) is associated with the presence of viable tumor cells in subsequent ablation zone biopsies and/or local tumor progression-free survival (LTPFS). Biopsies of CLM were performed before and after microwave ablation (MWA), as part of a prospective clinical trial between October 2013 and May 2019. Pre-ablation biopsy slides were examined for the Ki-67 LI using light microscopy. Ablation zone biopsy specimens were evaluated for the presence of viable tumor using hematoxylin-eosin and immunohistochemistry. Differences in CLM Ki-67 LI between positive and negative for viable tumor ablation zone biopsies were assessed using the Mann-Whitney U test. Biopsy, tumor and margin data were evaluated as predictors of LTPFS using Kaplan-Meier/Cox methods. Thirty-four patients with 48 CLM underwent biopsy before and after MWA. Sufficient tissue for Ki-67 labeling was obtained in 43/48 (89.6%) CLM. Viable tumor cells were detected in 11 ablation zones (22.9%). There was no significant difference in the CLM Ki-67 LI between the positive and negative for viable tumor ablation zones (mean: 69.2% vs. 64.3% respectively, p = 0.4). Adequate ablation zone margins (> 5 mm; p = 0.029) and negative ablation zone biopsies (p = 0.009) were significant predictors of longer LTPFS. KRAS status, tumor size and Ki-67 LI were not significant predictors of LTPFS. Complete tumor ablation (with adequate margins and negative ablation zone biopsies) is the most important factor in achieving local control of CLM, even for tumors exhibiting aggressive tumor biology.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

Liver transplantation for colorectal cancer with liver metastases

Over the last decade, multiple clinical trials have demonstrated a survival benefit for liver transplantation in colorectal cancer with liver metastases. Additionally, advances in donor organ preservation have expanded organ availability affording the opportunity to expand indications for liver transplantation, such as colorectal cancer with unresectable liver metastases. Current data support comparable overall survival (OS) for liver transplantation for colorectal cancer with liver metastases compared with general liver transplantation recipients. Supported by this data, in the United States, allocation policy is changing to include deceased donor livers for patients with unresectable colorectal cancer liver metastases. Available studies to date demonstrate improved outcomes with primary tumor R0 resection, 6-12 months of pretransplantation chemotherapy, and careful radiologic restaging (including positron emission tomography/computed tomography) to confirm lack of extrahepatic disease. A response to pretransplantation chemotherapy is a key predictor of long-term outcomes and progression during chemotherapy appears to be a contraindication to proceeding to transplant. A carcinoembryonic antigen level ≤80 µg/L and largest liver tumor dimension <5.5 cm are both associated with improved progression-free and OS in the available literature. Liver transplantation for colorectal cancer with unresectable liver metastases is associated with longer progression-free and OS compared with chemotherapy alone. Patient selection based on imaging, laboratory, and clinical findings is critical to identify patients most likely to benefit. Liver transplantation should be considered at all centers with an active transplant program to improve outcomes for patients with advanced colorectal cancer.

Multiparameter magnetic resonance imaging-based radiomics model for the prediction of rectal cancer metachronous liver metastasis

BACKGROUND

The liver, as the main target organ for hematogenous metastasis of colorectal cancer, early and accurate prediction of liver metastasis is crucial for the diagnosis and treatment of patients. Herein, this study aims to investigate the application value of a combined machine learning (ML) based model based on the multiparameter magnetic resonance imaging for prediction of rectal metachronous liver metastasis (MLM).

AIM

To investigate the efficacy of radiomics based on multiparametric magnetic resonance imaging images of preoperative first diagnosed rectal cancer in predicting MLM from rectal cancer.

METHODS

We retrospectively analyzed 301 patients with rectal cancer confirmed by surgical pathology at Jingzhou Central Hospital from January 2017 to December 2023. All participants were randomly assigned to the training or validation queue in a 7:3 ratio. We first apply generalized linear regression model (GLRM) and random forest model (RFM) algorithm to construct an MLM prediction model in the training queue, and evaluate the discriminative power of the MLM prediction model using area under curve (AUC) and decision curve analysis (DCA). Then, the robustness and generalizability of the MLM prediction model were evaluated based on the internal validation set between the validation queue groups.

RESULTS

Among the 301 patients included in the study, 16.28% were ultimately diagnosed with MLM through pathological examination. Multivariate analysis showed that carcinoembryonic antigen, and magnetic resonance imaging radiomics were independent predictors of MLM. Then, the GLRM prediction model was developed with a comprehensive nomogram to achieve satisfactory differentiation. The prediction performance of GLRM in the training and validation queue was 0.765 [95% confidence interval (CI): 0.710-0.820] and 0.767 (95%CI: 0.712-0.822), respectively. Compared with GLRM, RFM achieved superior performance with AUC of 0.919 (95%CI: 0.868-0.970) and 0.901 (95%CI: 0.850-0.952) in the training and validation queue, respectively. The DCA indicated that the predictive ability and net profit of clinical RFM were improved.

CONCLUSION

By combining multiparameter magnetic resonance imaging with the effectiveness and robustness of ML-based predictive models, the proposed clinical RFM can serve as an insight tool for preoperative assessment of MLM risk stratification and provide important information for individual diagnosis and treatment of rectal cancer patients.

Orosomucoid 2 upregulation mediates liver injury-induced colorectal cancer liver metastasis by promoting EMT and cell migration

The relationship between drug-induced liver injury and liver metastasis of colorectal cancer and the underlying mechanisms are not well understood. In this study, we used carbon tetrachloride to construct a classic mouse liver injury model and injected CT26 colorectal cancer cells into the mouse spleen to simulate the natural route of colorectal cancer liver metastasis. Liver injury significantly increased the number of colorectal cancer liver metastases. Transcriptome sequencing and data-independent acquisition protein quantification identified proteins that were significantly differentially expressed in injured livers, and orosomucoid (ORM) 2 was identified as a target protein for tumor liver metastasis. In vitro experiments showed that exogenous ORM2 protein increased the expression of EMT markers such as Twist, Zeb1, Vim, Snail1 and Snail2 and chemokine ligands to promote CT26 cell migration. In addition, liver-specific overexpression of the ORM2 protein in the mouse model significantly promoted tumor cell liver metastasis without inducing liver injury. Our results indicate that drug-induced liver injury can promote colorectal cancer liver metastasis and that ORM2 can promote cell migration by inducing EMT in tumor cells.

KRAS inhibitors may prevent colorectal cancer metachronous metastasis by suppressing TGF‑β mediated epithelial‑mesenchymal transition

In colorectal cancer (CRC), KRAS mutations enhance metachronous metastasis, a condition without prognostic biomarkers or preventive measures. The present study demonstrated that KRAS mutation may be a risk factor for CRC metachronous metastasis through meta‑analysis of public databases. A risk scoring model was constructed using machine learning for predicting metachronous metastasis in KRAS‑mutant CRC. Wound healing and Transwell assay indicated that KRAS inhibitors strongly suppress migration and invasion capabilities of high‑risk CRC cells and these findings were validated through ex vivo organoid and a mouse model of splenic‑liver metastasis. Mechanistically, RNA sequencing, reverse transcription‑quantitative PCR and western blot analyses revealed that KRAS inhibitors suppressed epithelial‑mesenchymal transition (EMT) and transforming growth factor β (TGF‑β) signaling. Notably, addition of TGF‑β1 protein partially reversed the inhibitory effects of KRAS inhibitors on CRC. These results suggested that KRAS inhibitors may prevent CRC metachronous metastasis by downregulating TGF‑β‑mediated EMT, suggesting they can be used prophylactically in high‑risk KRAS‑mutant CRC.

snRNA-seq of long-preserved FFPE samples from colorectal liver metastasis lesions with diverse prognoses

Differences in prognostic outcomes are prevalent in patients with colorectal cancer liver metastases. Comparative analysis of tissue samples, particularly applying single-cell transcriptome sequencing technology, can provide a deeper understanding of potential impacting factors. However, long-term monitoring for prognosis determination necessitates extended preservation of tissue samples using formalin-fixed and paraffin-embedded (FFPE) treatments, which can cause substantial RNA degradation, presenting challenges to single-cell or single-nucleus sequencing. In this study, employing snRandom-seq, a single-nucleus RNA sequencing (snRNA-seq) technology specifically for FFPE samples, we tested multiple lesion samples from 18 distinctive colorectal cancer liver metastasis cases with diverse prognostic outcomes that have been preserved for at least three years (mostly over five years). The process yielded expression data from 82,285 cells. The high-quality snRNA-seq data demonstrate the feasibility of single-nucleus sequencing in long-term preserved FFPE samples, offering potential insights into the heterogeneity between different prognoses of colorectal cancer liver metastases, and the relationship between the heterogeneity within different lesions of the same patient and prognosis.

Assessing the performance of AI-assisted technicians in liver segmentation, Couinaud division, and lesion detection: a pilot study

BACKGROUND

In patients with primary and secondary liver cancer, the number and sizes of lesions, their locations within the Couinaud segments, and the volume and health status of the future liver remnant are key for informing treatment planning. Currently this is performed manually, generally by trained radiologists, who are seeing an inexorable growth in their workload. Integrating artificial intelligence (AI) and non-radiologist personnel into the workflow potentially addresses the increasing workload without sacrificing accuracy. This study evaluated the accuracy of non-radiologist technicians in liver cancer imaging compared with radiologists, both assisted by AI.

METHODS

Non-contrast T1-weighted MRI data from 18 colorectal liver metastasis patients were analyzed using an AI-enabled decision support tool that enables non-radiology trained technicians to perform key liver measurements. Three non-radiologist, experienced operators and three radiologists performed whole liver segmentation, Couinaud segment segmentation, and the detection and measurements of lesions aided by AI-generated delineations. Agreement between radiologists and non-radiologists was assessed using the intraclass correlation coefficient (ICC). Two additional radiologists adjudicated any lesion detection discrepancies.

RESULTS

Whole liver volume showed high levels of agreement between the non-radiologist and radiologist groups (ICC = 0.99). The Couinaud segment volumetry ICC range was 0.77-0.96. Both groups identified the same 41 lesions. As well, the non-radiologist group identified seven more structures which were also confirmed as lesions by the adjudicators. Lesion diameter categorization agreement was 90%, Couinaud localization 91.9%. Within-group variability was comparable for lesion measurements.

CONCLUSION

With AI assistance, non-radiologist experienced operators showed good agreement with radiologists for quantifying whole liver volume, Couinaud segment volume, and the detection and measurement of lesions in patients with known liver cancer. This AI-assisted non-radiologist approach has potential to reduce the stress on radiologists without compromising accuracy.

DNA methylation biomarker panels for differentiating various liver adenocarcinomas, including hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastases and pancreatic adenocarcinoma liver metastases

BACKGROUND

DNA methylation biomarkers are one of the most promising tools for the diagnosis and differentiation of adenocarcinomas of the liver, which are among the most common malignancies worldwide. Their differentiation is important because of the different prognoses and treatment options. This study aimed to validate previously identified DNA methylation biomarkers that successfully differentiate between liver adenocarcinomas, including the two most common primary liver cancers, hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), as well as two common metastatic liver cancers, colorectal liver metastases (CRLM) and pancreatic ductal adenocarcinoma liver metastases (PCLM), and translate them to the methylation-sensitive high-resolution melting (MS-HRM) and digital PCR (dPCR) platforms.

METHODS

Our study included a cohort of 149 formalin-fixed, paraffin-embedded tissue samples, including 19 CRLMs, 10 PCLMs, 15 HCCs, 15 CCAs, 15 colorectal adenocarcinomas (CRCs), 15 pancreatic ductal adenocarcinomas (PDACs) and their paired normal tissue samples. The methylation status of the samples was experimentally determined by MS-HRM and methylation-specific dPCR. Previously determined methylation threshold were adjusted according to dPCR data and applied to the same DNA methylation array datasets (provided by The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO)) used to originally identify the biomarkers for the included cancer types and additional CRLM projects. The sensitivities, specificities and diagnostic accuracies of the panels for individual cancer types were calculated.

RESULTS

In the dPCR experiment, the DNA methylation panels identified HCC, CCA, CRC, PDAC, CRLM and PCLM with sensitivities of 100%, 66.7%, 100%, 86.7%, 94.7% and 80%, respectively. The panels differentiate between HCC, CCA, CRLM, PCLM and healthy liver tissue with specificities of 100%, 100%, 97.1% and 94.9% and with diagnostic accuracies of 100%, 94%, 97% and 93%, respectively. Reevaluation of the same bioinformatic data with new additional CRLM projects demonstrated that the lower dPCR methylation threshold still effectively differentiates between the included cancer types. The bioinformatic data achieved sensitivities for HCC, CCA, CRC, PDAC, CRLM and PCLM of 88%, 64%, 97.4%, 75.5%, 80% and 84.6%, respectively. Specificities between HCC, CCA, CRLM, PCLM and healthy liver tissue were 98%, 93%, 86.6% and 98.2% and the diagnostic accuracies were 94%, 91%, 86% and 98%, respectively. Moreover, we confirmed that the methylation of the investigated promoters is preserved from primary CRC and PDAC to their liver metastases.

CONCLUSIONS

The cancer-specific methylation biomarker panels exhibit high sensitivities, specificities and diagnostic accuracies and enable differentiation between primary and metastatic adenocarcinomas of the liver using methylation-specific dPCR. High concordance was achieved between MS-HRM, dPCR and bioinformatic data, demonstrating the successful translation of bioinformatically identified methylation biomarkers from the Illumina Infinium HumanMethylation450 BeadChip (HM450) and lllumina MethylationEPIC BeadChip (EPIC) platforms to the simpler MS-HRM and dPCR platforms.

Epidemiological and anatomopathological profile of colorectal cancer in Northern Morocco between 2017 and 2019

BACKGROUND AND STUDY AIMS

Colorectal cancer (CRC) is the third most common type of cancer worldwide and the second leading cause of cancer-related death. CRC represents a major public health problem in many countries, and its incidence is increasing worldwide. In Morocco, CRC is the third most common cancer. However, epidemiological data on CRC in Morocco, especially in the north, are very limited. This study aimed to describe the epidemiological and clinicopathological characteristics of CRC in northern Morocco.

PATIENTS AND METHODS

This retrospective study was conducted at the Ahmed Ben Zayed Al Nahyan Regional Oncology Center of Tangier between April 2017 and December 2019. Data were collected from the medical records of confirmed CRC patients and analyzed using SPSS computer software version 23.

RESULTS

CRC was detected in 142 patients, accounting for 13.0 % of all cancers identified during the study period in the center. The sex ratio (male/female) of all patients was 1.1. The mean age was 58 years, and the most affected group was 60-69 years old (29.0 %). The rectum was the most common anatomical site (44.0 %) compared to the left and right colon. Histologically, adenocarcinomas were the most common type (91.3 %), half of the tumors were moderately differentiated, and only 4.9 % of the patients presented with poorly differentiated tumors. At diagnosis, 83.0 % of patients were already in advanced stages (stage III, or IV), including 40.3 % presenting with metastatic disease. The liver (64.8 %) was the most affected site by metastasis in our series. Relapse was observed in 11.9 % of patients.

CONCLUSION

Our results showed a younger age at diagnosis and a higher incidence of cancer at the rectal site compared to the Western literature, as well as a high frequency of patients who presented with late-stage disease and other characteristics. However, larger multicenter studies are still needed to confirm our results.

A review on the functional characteristics of the c-Myeloproliferative Leukaemia (c-MPL) gene and its isoforms

The c-MPL-TPO axis regulates hematopoiesis by activating various signalling cascades, including JAK/STAT, MAPK/ERK, and PIK3/AKT. Here, we have summarized how TPO is regulated by c-MPL and, how mutations in the c-MPL regulate hematopoiesis. We also focus on its non-hematological regulatory role in diseases like Unstable Angina and pathways like DNA damage repair, skeletal homeostasis, & apoptotic regulation of neurons/HSCs at the embryonic state. We discuss the therapeutic efficiency of c-MPL and, its potential to be developed as a bio-marker for detecting metastasis and development of chemo-resistance in various cancers, justifying the multifaceted nature of c-MPL. We have also highlighted the importance of c-MPL isoforms and their stoichiometry in controlling the HSC quiescent and proliferative state. The regulation of the ratio of different isoforms through gene-therapy can open future therapeutic avenues. A systematic understanding of c-MPL-isoforms would undoubtedly take one step closer to facilitating c-MPL from basic-research towards translational medicine.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

Impact of Positive Lymph Nodes after Systematic Perihilar Lymphadenectomy in Colorectal Liver Metastases

Background: 25 to 50% of patients suffering from colorectal cancer develop liver metastases. The incidence of regional lymph node (LN) metastases within the liver is up to 14%. The need for perihilar lymph node dissection (LND) is still a controversial topic in patients with colorectal liver metastases (CRLM). This study investigates the role of perihilar LND in patients with CRLM. Methods: For this retrospective study, patients undergoing surgery for CRLM at the University Hospital Basel between May 2009 and December 2021 were included. In patients with perihilar LND, LN were stained for CK22 and examined for single tumour cells (<0.2 mm), micro- (0.2-2 mm), and macro-metastases (>2 mm). Results: 112 patients undergoing surgery for CRLM were included. 54 patients underwent LND, 58/112 underwent liver resection only (LR). 3/54 (5.6%) showed perihilar LN metastases in preoperative imaging, and in 10/54 (18.5%), micro-metastases could be proven after CK22 staining. Overall complications were similar in both groups (LND: 46, 85.2%; LR: 48, 79.3%; p = 0.800). The rate of major complications was higher in the LND group (LND: 22, 40.7%; LR: 18, 31%, p = 0.002). Median recurrence-free survival (RFS) (LND: 10 months; LR: 15 months, p = 0.076) and overall survival (OS) were similar (LND: 49 months; LR: 60 months, p = 0.959). Conclusion: Preoperative imaging is not sensitive enough to detect perihilar LN metastases. Perihilar LND enables precise tumour staging by detecting more lymph node metastases, especially through CK22 staining. However, perihilar LND does not influence oncologic outcomes in patients with CRLM.

ZLN005, a PGC-1α Activator, Protects the Liver against Ischemia-Reperfusion Injury and the Progression of Hepatic Metastases

BACKGROUND

Exercise can promote sustainable protection against cold and warm liver ischemia-reperfusion injury (IRI) and tumor metastases. We have shown that this protection is by the induction of hepatic mitochondrial biogenesis pathway. In this study, we hypothesize that ZLN005, a PGC-1α activator, can be utilized as an alternative therapeutic strategy.

METHODS

Eight-week-old mice were pretreated with ZLN005 and subjected to liver warm IRI. To establish a liver metastatic model, MC38 cancer cells (1 × 106) were injected into the spleen, followed by splenectomy and liver IRI.

RESULTS

ZLN005-pretreated mice showed a significant decrease in IRI-induced tissue injury as measured by serum ALT/AST/LDH levels and tissue necrosis. ZLN005 pretreatment decreased ROS generation and cell apoptosis at the site of injury, with a significant decrease in serum pro-inflammatory cytokines, innate immune cells infiltration, and intrahepatic neutrophil extracellular trap (NET) formation. Moreover, mitochondrial mass was significantly upregulated in hepatocytes and maintained after IRI. This was confirmed in murine and human hepatocytes treated with ZLN005 in vitro under normoxic and hypoxic conditions. Additionally, ZLN005 preconditioning significantly attenuated tumor burden and increased the percentage of intratumoral cytotoxic T cells.

CONCLUSIONS

Our study highlights the effective protection of ZLN005 pretreatment as a therapeutic alternative in terms of acute liver injury and tumor metastases.

Neoadjuvant Statistical Algorithm to Predict Individual Risk of Relapse in Patients with Resected Liver Metastases from Colorectal Cancer

(1) Background: Liver metastases (LM) are the leading cause of death in colorectal cancer (CRC) patients. Despite advancements, relapse rates remain high and current prognostic nomograms lack accuracy. Our objective is to develop an interpretable neoadjuvant algorithm based on mathematical models to accurately predict individual risk, ensuring mathematical transparency and auditability. (2) Methods: We retrospectively evaluated 86 CRC patients with LM treated with neoadjuvant systemic therapy followed by complete surgical resection. A comprehensive analysis of 155 individual patient variables was performed. Logistic regression (LR) was utilized to develop the predictive model for relapse risk through significance testing and ANOVA analysis. Due to data limitations, gradient boosting machine (GBM) and synthetic data were also used. (3) Results: The model was based on data from 74 patients (12 were excluded). After a median follow-up of 58 months, 5-year relapse-free survival (RFS) rate was 33% and 5-year overall survival (OS) rate was 60.7%. Fifteen key variables were used to train the GBM model, which showed promising accuracy (0.82), sensitivity (0.59), and specificity (0.96) in predicting relapse. Similar results were obtained when external validation was performed as well. (4) Conclusions: This model offers an alternative for predicting individual relapse risk, aiding in personalized adjuvant therapy and follow-up strategies.

Obesity-Associated Colorectal Cancer

Colorectal cancer (CRC) affects approximately 2 million people worldwide. Obesity is the major risk factor for CRC. In addition, obesity contributes to a chronic inflammatory stage that enhances tumor progression through the secretion of proinflammatory cytokines. In addition to an increased inflammatory response, obesity-associated cancer presents accrued molecular factors related to cancer characteristics, such as genome instability, sustained cell proliferation, telomere dysfunctions, angiogenesis, and microbial alteration, among others. Despite the evidence accumulated over the last few years, the treatments for obesity-associated CRC do not differ from the CRC treatments in normal-weight individuals. In this review, we summarize the current knowledge on obesity-associated cancer, including its epidemiology, risk factors, molecular factors, and current treatments. Finally, we enumerate possible new therapeutic targets that may improve the conditions of obese CRC patients. Obesity is key for the development of CRC, and treatments resulting in the reversal of obesity should be considered as a strategy for improving antineoplastic CRC therapies.

Transarterial (chemo)embolisation versus systemic chemotherapy for colorectal cancer liver metastases

BACKGROUND

The liver is affected by two groups of malignant tumours: primary liver cancers and liver metastases. Liver metastases are significantly more common than primary liver cancer, and five-year survival after radical surgical treatment of liver metastases ranges from 28% to 50%, depending on primary cancer site. However, R0 resection (resection for cure) is not feasible in most people; therefore, other treatments have to be considered in the case of non-resectability. One possible option is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Transarterial chemoembolisation (TACE) of the peripheral branches of the hepatic artery can be achieved by administering a chemotherapeutic drug followed by vascular occlusive agents and can lead to selective necrosis of the cancer tissue while leaving normal liver parenchyma virtually unaffected. The entire procedure can be performed without infusion of chemotherapy and is then called bland transarterial embolisation (TAE). These procedures are usually applied over a few sessions. Another possible treatment option is systemic chemotherapy which, in the case of colorectal cancer metastases, is most commonly performed using FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) and FOLFIRI (folinic acid, 5-fluorouracil, and irinotecan) regimens applied in multiple sessions over a long period of time. These therapies disrupt the cell cycle, leading to death of rapidly dividing malignant cells. Current guidelines determine the role of TAE and TACE as non-curative treatment options applicable in people with liver-only or liver-dominant metastatic disease that is unresectable or non-ablatable, and in people who have failed systemic chemotherapy. Regarding the treatment modalities in people with colorectal cancer liver metastases, we found no systematic reviews comparing the efficacy of TAE or TACE versus systemic chemotherapy.

OBJECTIVES

To evaluate the beneficial and harmful effects of transarterial embolisation (TAE) or transarterial chemoembolisation (TACE) compared with systemic chemotherapy in people with liver-dominant unresectable colorectal cancer liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three additional databases up to 4 April 2024. We also searched two trials registers and the European Medicines Agency database and checked reference lists of retrieved publications.

SELECTION CRITERIA

We included randomised clinical trials assessing beneficial and harmful effects of TAE or TACE versus systemic chemotherapy in adults (aged 18 years or older) with colorectal cancer liver metastases.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality; overall survival (time to mortality); and any adverse events or complications. Our secondary outcomes were cancer mortality; health-related quality of life; progression-free survival; proportion of participants dying or surviving with progression of the disease; time to progression of liver metastases; recurrence of liver metastases; and tumour response measures (complete response, partial response, stable disease, and progressive disease). For the purpose of the review and to perform necessary analyses, whenever possible, we converted survival rates to mortality rates, as this was our primary outcome. For the analysis of dichotomous outcomes, we used the risk ratio (RR); for continuous outcomes, we used the mean difference; and for time to event outcomes, we calculated hazard ratios (HRs), all with 95% confidence intervals (CI). We used the standardised mean difference with 95% CIs when the trials used different instruments. We used GRADE to assess the certainty of evidence for each outcome. We based our conclusions on outcomes analysed at the longest follow-up.

MAIN RESULTS

We included three trials with 118 participants randomised to TACE versus 120 participants to systemic chemotherapy. Four participants were excluded; one due to disease progression prior to treatment and three due to decline in health. The trials reported data on one or more outcomes. Two trials were performed in China and one in Italy. The trials differed in terms of embolisation techniques and chemotherapeutic agents. Follow-up ranged from 12 months to 50 months. TACE may reduce mortality at longest follow-up (RR 0.86, 95% CI 0.79 to 0.94; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. TACE may have little to no effect on overall survival (time to mortality) (HR 0.61, 95% CI 0.37 to 1.01; 1 trial, 70 participants; very low-certainty evidence), any adverse events or complications (3 trials, 234 participants; very low-certainty evidence), health-related quality of life (2 trials, 154 participants; very low-certainty evidence), progression-free survival (1 trial, 70 participants; very low-certainty evidence), and tumour response measures (presented as the overall response rate) (RR 1.81, 95% CI 1.11 to 2.96; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. No trials reported cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases. We found no trials comparing the effects of TAE versus systemic chemotherapy in people with colorectal cancer liver metastases.

AUTHORS' CONCLUSIONS

The evidence regarding effectiveness of TACE versus systemic chemotherapy in people with colorectal cancer liver metastases is of very low certainty and is based on three trials. Our confidence in the results is limited due to the risk of bias, inconsistency, indirectness, and imprecision. It is very uncertain whether TACE confers benefits with regard to reduction in mortality, overall survival (time to mortality), reduction in adverse events or complications, improvement in health-related quality of life, improvement in progression-free survival, and tumour response measures (presented as the overall response rate). Data on cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases are lacking. We found no trials assessing TAE versus systemic chemotherapy. More randomised clinical trials are needed to strengthen the body of evidence and provide insight into the benefits and harms of TACE or TAE in comparison with systemic chemotherapy in people with liver metastases from colorectal cancer.

Testosterone, β-estradiol, and hepatocellular carcinoma: stimulation or inhibition? A comparative effect analysis on cell cycle, apoptosis, and Wnt signaling of HepG2 cells

Unlike breast and prostate cancers, which are specifically affected by estrogens or androgens, hepatocellular carcinoma has been reported to be influenced by both sex hormones. Given the coincidental differences of hepatocellular carcinoma in men and women, we investigated the effects of β-estradiol and testosterone on the cell cycle, apoptosis, and Wnt signaling in a model of hepatocellular carcinoma to understand the sex hormone-related etiology. To determine the effective concentration of both hormones, an MTT assay was performed. The effects of β-estradiol and testosterone on cell proliferation and death were evaluated by specific staining and flow cytometry. In addition, gene expression levels of estimated factors involved in GPC3-Wnt survival signaling were analyzed using quantitative real-time polymerase chain reaction. Both hormones inhibited hepatic cell proliferation through arresting the cell cycle at S/G2 and increased the apoptosis rate in HepG2 cells. Both hormones dose-dependently decreased GPC3, Wnt, and DVL expression levels as activators of the Wnt-signaling pathway. In the case of Wnt-signaling inhibitors, the effects of both hormones on WIF were negligible, but they increased DKK1 levels in a dose-dependent manner. In each of the effects mentioned above, β-estradiol was notably more potent than testosterone. In contrast to the primary hypothesis of the project, in which testosterone was considered a stimulating carcinogenic factor in HCC pathogenesis, testosterone inhibited the occurrence of HCC similarly to β-estradiol. However, this inhibitory effect was weaker than that of β-estradiol and requires further study.

Evolution and current trends in the management of colorectal cancer liver metastasis

Metastatic colorectal cancer (mCRC) is a major cause of cancer-related death, with a 5-year relative overall survival of up to 20%. The liver is the most common site of distant metastasis in colorectal cancer (CRC), with about 50% of CRC patients metastasizing to their liver over the course of their disease. Complete liver resection is the primary modality of treatment for resectable colorectal cancer liver metastasis (CRLM), with an overall 5-year survival rate of up to 58%. However, only 15% to 20% of patients with CRLM are deemed suitable for resection at presentation. For unresectable diseases, the median survival of patients remains low even with the best chemotherapy. In recent decades, the management of CRLM has continued to evolve with the expansion of resection criteria, novel targeted systemic therapies, and improved locoregional therapies. However, due to the heterogeneity of the CRC patient population, the optimal evaluation of treatment options for CRLM remains complex. Therefore, effective management requires a multidisciplinary team to help define resectability and devise a personalized treatment approach, from the initial diagnosis to the final treatment.

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

Simulated deep CT characterization of liver metastases with high-resolution filtered back projection reconstruction

Early diagnosis and accurate prognosis of colorectal cancer is critical for determining optimal treatment plans and maximizing patient outcomes, especially as the disease progresses into liver metastases. Computed tomography (CT) is a frontline tool for this task; however, the preservation of predictive radiomic features is highly dependent on the scanning protocol and reconstruction algorithm. We hypothesized that image reconstruction with a high-frequency kernel could result in a better characterization of liver metastases features via deep neural networks. This kernel produces images that appear noisier but preserve more sinogram information. A simulation pipeline was developed to study the effects of imaging parameters on the ability to characterize the features of liver metastases. This pipeline utilizes a fractal approach to generate a diverse population of shapes representing virtual metastases, and then it superimposes them on a realistic CT liver region to perform a virtual CT scan using CatSim. Datasets of 10,000 liver metastases were generated, scanned, and reconstructed using either standard or high-frequency kernels. These data were used to train and validate deep neural networks to recover crafted metastases characteristics, such as internal heterogeneity, edge sharpness, and edge fractal dimension. In the absence of noise, models scored, on average, 12.2% ( α = 0.012 ) and 7.5% ( α = 0.049 ) lower squared error for characterizing edge sharpness and fractal dimension, respectively, when using high-frequency reconstructions compared to standard. However, the differences in performance were statistically insignificant when a typical level of CT noise was simulated in the clinical scan. Our results suggest that high-frequency reconstruction kernels can better preserve information for downstream artificial intelligence-based radiomic characterization, provided that noise is limited. Future work should investigate the information-preserving kernels in datasets with clinical labels.

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Studies on the mechanism of local and extra-intestinal tissue manifestations in AOM-DSS-induced carcinogenesis in BALB/c mice: role of PARP-1, NLRP3, and autophagy

Colitis-associated colorectal cancer (CACC) is one of the devastating complications of long-term inflammatory bowel disease and is associated with substantial morbidity and mortality. Combination of azoxymethane (AOM) and dextran sulfate sodium (DSS) has been extensively used for inflammation-mediated colon tumor development due to its reproducibility, potency, histological and molecular changes, and resemblance to human CACC. In the tumor microenvironment and extra-intestinal tissues, PARP-1, NLRP3 inflammasome, and autophagy's biological functions are complicated and encompass intricate interactions between these molecular components. The focus of the present investigation is to determine the colonic and extra-intestinal tissue damage induced by AOM-DSS and related molecular mechanisms. Azoxymethane (10 mg/kg, i.p.; single injection) followed by DSS (3 cycles, 7 days per cycle) over a period of 10 weeks induced colitis-associated colon cancer in male BALB/c mice. By initiating carcinogenesis with a single injection of azoxymethane (AOM) and then establishing inflammation with dextran sulfate sodium (DSS), a two-stage murine model for CACC was developed. Biochemical parameters, ELISA, histopathological and immunohistochemical analysis, and western blotting have been performed to evaluate the colonic, hepatic, testicular and pancreatic damage. In addition, the AOM/DSS-induced damage has been assessed by analyzing the expression of a variety of molecular targets, including proliferating cell nuclear antigen (PCNA), interleukin-10 (IL-10), AMP-activated protein kinase (AMPK), poly (ADP-ribose) polymerase-1 (PARP-1), cysteine-associated protein kinase-1 (caspase-1), NLR family pyrin domain containing 3 (NLRP3), beclin-1, and interleukin-1β (IL-1β). Present findings revealed that AOM/DSS developed tumors in colon tissue followed by extra-intestinal hepatic, testicular, and pancreatic damages.

Colorectal cancer: a comprehensive review of carcinogenesis, diagnosis, and novel strategies for classified treatments

Colorectal cancer is the third most common and the second deadliest cancer worldwide. To date, colorectal cancer becomes one of the most important challenges of the health system in many countries. Since the clinical symptoms of this cancer appear in the final stages of the disease and there is a significant golden time between the formation of polyps and the onset of cancer, early diagnosis can play a significant role in reducing mortality. Today, in addition to colonoscopy, minimally invasive methods such as liquid biopsy have received much attention. The treatment of this complex disease has been mostly based on traditional treatments including surgery, radiotherapy, and chemotherapy; the high mortality rate indicates a lack of success for current treatment methods. Moreover, disease recurrence is another problem of traditional treatments. Recently, new approaches such as targeted therapy, immunotherapy, and nanomedicine have opened new doors for cancer treatment, some of which have already entered the market, and many methods have shown promising results in clinical trials. The success of immunotherapy in the treatment of refractory disease, the introduction of these methods into neoadjuvant therapy, and the successful results in tumor shrinkage without surgery have made immunotherapy a tough competitor for conventional treatments. It seems that the combination of those methods with such targeted therapies will go through promising changes in the future of colorectal cancer treatment.

Propensity-score matched outcomes of resection of stage IV primary colon cancer with and without simultaneous resection of liver metastases

There is controversy in the best management of colorectal cancer liver metastasis (CLM). This study aimed to compare short-term and survival outcomes of simultaneous resection of CLM and primary colon cancer compared to resection of only colon cancer. This retrospective matched cohort study included patients from the National Cancer Database (2015-2019) with stage IV colon adenocarcinoma and synchronous liver metastases who underwent colectomy. Patients were divided into two groups: colectomy-only (resection of primary colon cancer only) and colectomy-plus (simultaneous resection of primary colon cancer and liver metastases). The groups were matched using the propensity score method. The primary outcome was short-term mortality and readmission. Secondary outcomes were conversion, hospital stay, surgical margins, and overall survival. 4082 (37.6%) of 10,862 patients underwent simultaneous resection of primary colon cancer and liver metastases. After matching, 2038 patients were included in each group. There were no significant differences between the groups in 30-days mortality (3.1% vs 3.8%, p = 0.301), 90-days (6.6% vs 7.7%, p = 0.205) mortality, 30-days unplanned readmission (7.2% vs 5.3%, p = 0.020), or conversion to open surgery (15.5% vs. 13.8%, p = 0.298). Patients in the colectomy plus group had a higher rate of lower incidence of positive surgical margins (13.2% vs. 17.2%, p = 0.001) and longer overall survival (median: 41.5 vs 28.4 months, p < 0.001). Synchronous resection of CLM did not increase the rates of short-term mortality, readmission, conversion from minimally invasive to open surgery, or hospital stay and was associated with a lower incidence of positive surgical margins.

Gut-liver axis: Potential mechanisms of action of food-derived extracellular vesicles

Food-derived extracellular vesicles (FEVs) are nanoscale membrane vesicles obtained from dietary materials such as breast milk, plants and probiotics. Distinct from other EVs, FEVs can survive the harsh degrading conditions in the gastrointestinal tract and reach the intestines. This unique feature allows FEVs to be promising prebiotics in health and oral nanomedicine for gut disorders, such as inflammatory bowel disease. Interestingly, therapeutic effects of FEVs have recently also been observed in non-gastrointestinal diseases. However, the mechanisms remain unclear or even mysterious. It is speculated that orally administered FEVs could enter the bloodstream, reach remote organs, and thus exert therapeutic effects therein. However, emerging evidence suggests that the amount of FEVs reaching organs beyond the gastrointestinal tract is marginal and may be insufficient to account for the significant therapeutic effects achieved regarding diseases involving remote organs such as the liver. Thus, we herein propose that FEVs primarily act locally in the intestine by modulating intestinal microenvironments such as barrier integrity and microbiota, thereby eliciting therapeutic impact remotely on the liver in non-gastrointestinal diseases via the gut-liver axis. Likewise, drugs delivered to the gastrointestinal system through FEVs may act via the gut-liver axis. As the liver is the main metabolic hub, the intestinal microenvironment may be implicated in other metabolic diseases. In fact, many patients with non-alcoholic fatty liver disease, obesity, diabetes and cardiovascular disease suffer from a leaky gut and dysbiosis. In this review, we provide an overview of the recent progress in FEVs and discuss their biomedical applications as therapeutic agents and drug delivery systems, highlighting the pivotal role of the gut-liver axis in the mechanisms of action of FEVs for the treatment of gut disorders and metabolic diseases.

Prognostic factors for overall survival and safety of trans-arterial chemoembolization (TACE) with irinotecan-loaded drug-eluting beads (DEBIRI) in patients with colorectal liver metastases

BACKGROUND

Transarterial chemoembolisation with irinotecan-loaded drug-eluting beads (DEBIRI TACE) can be considered in patients with unresectable colorectal cancer liver metastases (CRLM) who progress after all approved standard therapies or in patients unsuitable for systemic therapy.

PATIENTS AND METHODS

Between September 2010 and March 2020, thirty patients (22 men and 8 women; mean age 66.8 ± 13.2) were included in this retrospective study. DEBIRI TACE was conducted in 43% of patients unsuitable for systemic therapy as a first-line treatment and 57% as salvage therapy after the progression of systemic therapy. All the patients had liver-limited disease. In the case of unilobar disease, two treatments were performed at four-week intervals, and in the case of bilobar disease, four treatments were performed at two-week intervals. All patients were premedicated and monitored after the procedure. Adverse events were graded according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system for complications.

RESULTS

The median overall survival (OS) from the beginning of DEBIRI TACE in the salvage group was 17.4 months; in the group without prior systemic therapy, it was 21.6 months. The median overall survival of all patients was 17.4 months (95% confidence interval [CI]: 10.0-24.7 months), and progression-free survival (PFS) was 4.2 months (95% CI: 0.9-7.4 months). The one-year survival rate after the procedure was 61%, and the two-year rate was 25%. Univariate analysis showed better survival of patients with four or fewer liver metastases (p = 0.002). There were no treatment-related deaths or grade 4 and 5 adverse events. Nonserious adverse events (Grades 1 and 2) were present in 53% of patients, and Grade 3 adverse events were present in 6% of the patients.

CONCLUSIONS

DEBIRI TACE is a well-tolerated treatment option for patients with liver metastases of colorectal cancer. Patients with four or fewer liver metastases correlated with better survival.

Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts

BACKGROUND

In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time.

METHODS

Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC.

RESULTS

Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013).

CONCLUSION

Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.

Safety and feasibility of establishing an adjuvant hepatic artery infusion program

BACKGROUND

Hepatic artery infusion (HAI) is less frequently used in the adjuvant setting for resectable colorectal liver metastasis (CRLM) due to concerns regarding toxicity. Our objective was to evaluate the safety and feasibility of establishing an adjuvant HAI program.

METHODS

Patients who underwent HAI pump placement between January 2019 and February 2023 for CRLM were identified. Complications and HAI delivery were compared between patients who received HAI in the unresectable and adjuvant settings.

RESULTS

Of 51 patients, 23 received HAI for unresectable CRLM and 28 in the adjuvant setting. Patients with unresectable CRLM more commonly had bilobar disease (n = 23/23 vs n = 18/28, p < 0.01) and more preoperative liver metastases (median 10 [IQR 6-15] vs 4 [IQR 3-7], p < 0.01). Biliary sclerosis was the most common complication (n = 2/23 vs n = 4/28); however, there were no differences in postoperative or HAI-specific complications. In the most recent two years, 0 patients in the unresectable group vs 2 patients in the adjuvant group developed biliary sclerosis. All patients were initiated on HAI with no difference in treatment times or dose reductions.

CONCLUSION

Adjuvant HAI is safe and feasible for patients with resectable CRLM. HAI programs can carefully consider including patients with resectable CRLM if managed by an experienced multidisciplinary team with quality assurance controls in place.

Fusobacteria alterations are associated with colorectal cancer liver metastasis and a poor prognosis

Liver metastasis is a major cause of mortality in patients with advanced stages of colorectal cancer (CRC). The gut microbiota has been demonstrated to influence the progression of liver diseases, potentially providing novel perspectives for diagnosis, treatment and research. However, the gut microbial characteristics in CRC with liver metastasis (LM) and with no liver metastasis (NLM) have not yet been fully established. In the present study, high-throughput 16S RNA sequencing technology was employed, in order to examine the gut microbial richness and composition in patients with CRC with LM or NLM. A discovery cohort (cohort 2; LM=18; NLM=36) and a validation cohort (cohort 3; LM=13; NLM=41) were established using fresh feces. In addition, primary carcinoma tissue samples were also analyzed (LM=8 and NLM=10) as a supplementary discovery cohort (cohort 1). The findings of the present study indicated that the intestinal microbiota richness and diversity were increased in the LM group as compared to the NLM group. A significant difference was observed in species composition between the LM and NLM group. In the two discovery cohorts with two different samples, the dominant phyla were consistent, but varied at lower taxonomic levels. Phylum Fusobacteria presented consistent and significant enrichment in LM group in both discovery cohorts. Furthermore, with the application of a random forest model and receiver operator characteristic curve analysis, Fusobacteria was identified as a potential biomarker for LM. Moreover, Fusobacteria was also a poor prognosis factor for survival. Importantly, the findings were reconfirmed in the validation cohort. On the whole, the findings of the present study demonstrated that CRC with LM and NLM exhibit distinct gut microbiota characteristics. Fusobacteria detection thus has potential for use in predicting LM and a poor prognosis of patients with CRC.

Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center

INTRODUCTION

Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLM) and its indication and results have varied in the last 30 years.

METHODS

All patients operated on for CRLM in our centre from 1990 to 2021 were prospectively collected, establishing 3 subgroups based on the year of the first surgery: group A 1990-1999, group B 2000-2010, group C 2011-2021. Clinical characteristics and the results of survival, recurrence and prognostic factors were compared.

RESULTS

1736 hepatectomies were included (Group A n = 208; Group B n = 770; Group C n = 758). Patients in group C had better survival at 5 and 10 years (A 40.5%/28.2%; B 45.9%/32.2%; C 51.6%/33.1%, p = 0.013), although there were no differences between groups in overall recurrence at 5 and 10 years (A 73%/75.7%; B 67.6%/69.2%, and C 63.9%/66%, p = 0.524), nor in liver recurrence (A 46.4%/48.2%; B 45.8%/48.2%; and C 44.4%/48.4%, p = 0.899). An improvement was observed in median survival after recurrence, being 19 months, 23 months, and 31 months (groups A, B and C respectively). Prognostic factors of long-term survival changed over the 3 study periods. The only ones that remained relevant in the last decade were the presence of >4 liver metastasis, extrahepatic disease at the time of hepatectomy, and intraoperative blood transfusion.

CONCLUSIONS

Survival after surgery for CRLM has improved significantly, although this cannot be explained by a reduction in overall and hepatic recurrence, but rather by an improvement in post-recurrence survival. Involvement of the resection margin has lost prognostic value in the last decade.

Liver Transplantation for Nonresectable Colorectal Liver Metastases (CRLM)

Transplantation represents the most radical locoregional therapy through removal of the liver, associated vasculature and locoregional lymph nodes, and replacing it with an allograft. Recent evidence has demonstrated that transplantation for unresectable CRLM is feasible with acceptable post-transplant outcomes in a highly selected cohort of patients. Controversy exists regarding whether transplantation is an appropriate treatment for such patients, due to concerns regarding disease recurrence in the transplanted graft in an immunosuppressed recipient along with utilising a donor liver which are in short supply. Expanding the indications for liver transplantation may also limit access for other patients with end-stage liver disease having ethical implications due to the effect of increasing the waiting list. In this review, we summarise the current evidence for liver transplantation in patients with nonresectable CRLM and highlight unresolved controversies and future directions for this type of treatment.

The Importance of Digital Rectal Examination in Identifying Early-Onset Rectal Malignancies

Colorectal cancer (CRC) is the second most diagnosed cancer and the second leading cause of cancer-related deaths in the United States. Rectal cancers, specifically, are the second most common cancer of the large intestine. Although once perceived as a disease of the elderly, the incidence of early-onset CRC (EO-CRC), classified as occurring in individuals less than 50 years old, has been paradoxically increasing. Although the incidence of rectal cancers has increased, the digital rectal exam (DRE) continues to be an underutilized physical exam maneuver when a patient presents with red-flag symptoms. Here, we present a case of a 38-year-old male from West Virginia who was referred to general surgery for complaints of rectal bleeding attributed to internal hemorrhoids. After undergoing a colonoscopy, the patient was found to have a rectal mass consistent with adenocarcinoma. We describe the importance of identifying red-flag signs to keep colorectal malignancy in the differential diagnosis in a young patient and highlight the importance of performing rectal exams to identify rectal cancers early to expedite treatment.