Bevacizumab improves survival in patients with synchronous colorectal liver metastases provided the primary tumor is resected first

Background

Multimodal strategy including chemotherapy and hepatectomy is advocated for the management of colorectal liver metastases (CRLM). The aim of this study was to evaluate the impact of neoadjuvant Bevacizumab-based chemotherapy on survival in patients with resected stage IVA colorectal cancer and liver metastases.

Methods

Data from 120 consecutive patients who received neoadjuvant chemotherapy and underwent curative-intent hepatectomy for synchronous CRLM were retrospectively reviewed. Overall survival (OS) was stratified according to administration of Bevacizumab before liver resection and surgical strategy, i.e., classical strategy (primary tumor resection first) versus reverse strategy (liver metastases resection first).

Results

Patients who received Bevacizumab (n?=?37; 30%) had a higher number of CRLM (p?=?0.003) and underwent more often reverse strategy (p?=?0.005), as compared to those who did not (n?=?83; 70%). Bevacizumab was associated with an improved OS compared with conventional chemotherapy (p?=?0.04). After stratifying by the surgical strategy, Bevacizumab was associated with improved OS in patients who had classical strategy (p?=?0.03). In contrast, Bevacizumab had no impact on OS among patients who had liver metastases resection first (p?=?0.89).

Conclusions

Neoadjuvant Bevacizumab-based chemotherapy was associated with improved OS in patients who underwent liver resection of synchronous CRLM, especially in those who underwent primary tumor resection first.

     

D-dimer predicts postoperative recurrence and prognosis in patients with liver metastasis of colorectal cancer

Background

Colorectal cancer is common, and its incidence is increasing throughout the world. The liver is a major metastatic site, and colorectal liver metastasis (CRLM) has a poor prognosis. Although liver resection is the most effective therapy for CRLM, postoperative recurrence is common. Thus, prognostic markers for CRLM are greatly needed. D-dimer, a fibrin cleavage product, has been shown to be related to colorectal tumor progression, and is also associated with malignant progression and recurrence in various cancers. Therefore, we evaluated the value of D-dimer in predicting the prognosis in CRLM.

Methods

We retrospectively evaluated 90 cases of resected CRLM to determine the correlation between D-dimer and patient survival. The cut-off value for D-dimer levels was determined using receiver operating characteristic curve analysis.

Results

Significant differences occurred in the recurrence group with higher D-dimer levels (P?=?0.00736*), while the optimal cut-off value was 0.6 µg/mL. High D-dimer levels (≥?0.6 µg/mL) were associated with poor recurrence-free survival (RFS; P?=?0.0000841*) and cancer-specific survival (CSS; P?=?0.00615*). In the multivariate analysis, D-dimer correlated with CRLM prognosis and independently predicted RFS (P?=?0.0179*).

Conclusion

High D-dimer levels were associated with poor RFS and CSS. D-dimer was an independent prognostic factor of RFS. Therefore, D-dimer may help predict recurrence and prognosis in patients with CRLM.

     

Treatment strategies for rectal cancer with synchronous liver metastases: surgical and oncological outcomes with propensity-score analysis

Background

The optimal sequence of surgery for rectal cancer (RC) with synchronous liver metastases (SLM) is controversial.

Objectives

The primary objective was to explore differences between the rectum first (RF) and the liver first strategy (LF) to achieve the complete resection (CR) of both tumors.

Methods

Patients diagnosed of RC with resectable or potentially resectable SLM were included. Data collected prospectively were analyzed with an intention-to-treat perspective, adjusting for between-sample differences (propensity score). The complete resection rate (CRR) was the main outcome variable.

Results

During a 5-year period, 23 patients underwent the LF strategy and 24 patients the RF strategy. Median overall survival (OS) was 32 months in the LF group and 41 months in the RF group (p = 0.499), and was 51 and 17 months, respectively, for patients achieving or not achieving CR of both tumors (p < 0.001). CRR’s were 65% in liver first group and 63% in rectum first group, (p = 0.846). No between-strategy differences in morbidity or duration of treatment were observed.

Conclusions

This study supports the notion that the achievement of CR of RC and SLM should be the goal of oncological treatment. Both RF and LF strategies are feasible and safe, but no between-strategy differences have been found in the CRR.

     

Conversion Therapy for Initially Borderline/Unresectable Metastases in Colon Cancer: What Is the Best Neoadjuvant Chemotherapy?

Purpose of Review

Resection of metastatic colorectal cancer (mCRC) can dramatically improve overall survival (OS), particularly in patients with isolated colorectal liver metastases (CLMs). In this review, we summarize recent findings and studies addressing chemotherapy ± targeted therapy before and after metastatectomies in patients with CLM.

Recent Findings

For initially unresectable CLM that could become resectable after response to medical therapy, FOLFIRINOX has the highest response and conversion rates and is safely administered with bevacizumab. In RAS wild-type, left-sided tumors, chemotherapy with Epidermal Growth Factor Receptor-targeted therapy should be strongly considered given high (~ 70%) response rates. In patients who present with resectable CLM, there is no clear indication that neoadjuvant chemotherapy improves OS. While the New EPOC trial showed detrimental progression-free survival in the combination arm containing cetuximab in this setting, methodologic issues with that trial have raised questions about the strength of these data.

Summary

Through multidisciplinary management in patients with isolated CLM, the best course of action to effect an R0 resection of all known disease-coupling surgery with medical therapy can significantly improve patient outcomes.

     

Hepatectomy for oligo-recurrence of non-small cell lung cancer in the liver

Background

The prognosis of metastatic recurrent non-small cell lung cancer (NSCLC) is poor, and chemotherapy improves survival by only a few months. The concept of oligo-recurrence, defined as a small number of new lesions at a distant site theoretically curable by local therapy, has recently been proposed for several cancers. To evaluate the possible benefits of surgical resection for oligo-recurrence, we report the outcomes of seven patients who underwent hepatic resection for oligo-recurrence of NSCLC in the liver.

Methods

Among the 2038 patients who underwent resection for NSCLC between January 1997 and December 2015 at the Department of Chest Surgery, Chiba Cancer Center, 7 (0.34%) with oligo-recurrence in the liver underwent hepatectomy. Perioperative data were retrospectively reviewed, including recurrence-free and overall survival.

Results

Primary tumor histopathological types included five cases of squamous cell carcinoma, one case of adenocarcinoma, and one case of large-cell carcinoma. All patients underwent complete tumor resection without complication. The median survival duration following hepatectomy was 24.0 (range 15.2–30.2) months. Four patients were alive at the end of follow-up (23.4–30.2 months), whereas three died between 15.2 and 24.5 months. There was no evidence of second recurrence in two patients.

Conclusions

Hepatectomy may be equally effective as multidisciplinary therapy for oligo-recurrence of NSCLC in the liver.

     

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

Objective

Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery.

Materials and methods

We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008–March 2015). Data were collected prospectively and analyzed with SPSS 21.0.

Results

12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo–Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13–23) with an ECOG Performance Status of 0.

Conclusion

Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

     

The McGill Brisbane Symptom Score in relation to survival in pancreatic adenocarcinoma: a validation study

Purpose

The McGill Brisbane Symptom Score (MBSS) is a clinical score for pancreatic cancer patients upon initial presentation that takes into account four variables (weight loss, abdominal pain, jaundice, and history of smoking) to stratify them into two MBSS intensity categories. Several studies have suggested that these categories are strongly associated with eventual survival in patients with resectable (rPCa) and unresectable (uPCa) pancreatic cancer. This study aimed to validate the MBSS in a cohort of patients with pancreatic cancer from a single institution.

Methods

Survival time by resection status and MBSS intensity category were analyzed among 633 patients from our institution between 2001 and 2010. Hazard ratios for death using Cox proportional hazards models, with age as the timescale, adjustment for sex and year of diagnosis, and stratified by adjuvant chemotherapy status were estimated.

Results

Median survival time was the longest in patients with low-intensity MBSS and rPCa (817 days), whereas the shortest survival time was found among patients with uPCa regardless of MBSS status (144–147 days). After consideration of age and chemotherapy status, high-intensity MBSS was associated with poorer survival for both rPCa (HR 1.64; 95 % CI 1.07–2.52) and uPCa (HR 1.35; 95 % CI 1.06–1.72).

Conclusions

Preoperative MBSS intensity is a useful prognostic indicator of survival in resectable as well as unresectable pancreatic cancer.

     

Oncological strategies for locally advanced rectal cancer with synchronous liver metastases,interval strategy versus rectum first strategy: a comparison of short-term outcomes

Background

The goal of treatment for patients with synchronous liver metastases (SLM) from rectal cancer is to achieve a complete resection of both tumor locations. For patients with symptomatic locally advanced rectal cancer with resectable SLM at diagnosis, our usual strategy has been the rectum first approach (RF). However, since 2014, we advocate for the interval approach (IS) that involves the administration of chemo-radiotherapy followed by the resection of the SLM in the interval of time between rectal cancer radiation and rectal surgery.

Methods

From 2010 to 2016, 16 patients were treated according to this new strategy and 19 were treated according RF strategy. Data were collected prospectively and analyzed with an intention-to-treat perspective. Complete resection rate, duration of the treatment and morbi-mortality were the main outcomes.

Results

The complete resection rate in the IS was higher (100%, n = 16) compared to the RF (74%, n = 14, p = 0.049) and the duration of the strategy was shorter (6 vs. 9 months, respectively, p = 0.006). The incidence of severe complications after liver surgery was 14% (n = 2) in the RF and 0% in the IS (p = 1.000), and after rectal surgery was 24% (n = 4) and 12% (n = 2), respectively (p = 1.000).

Conclusion

The IS is a feasible and safe strategy that procures higher level of complete resection rate in a shorter period of time compared to RF strategy.

     

Phase II trial of an alternating regimen consisting of first-line mFOLFOX6 plus bevacizumab and FOLFIRI plus bevacizumab for patients with metastatic colorectal cancer: FIREFOX plus bevacizumab trial (KSCC0801)

Objectives

The purpose of this phase II study was to explore the efficacy and safety of an alternating regimen consisting of folinic acid, 5-fluorouracil (5-FU) and oxaliplatin (mFOLFOX6) plus bevacizumab, and folinic acid, 5-FU and irinotecan (FOLFIRI) plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer.

Methods

Fifty-two patients with metastatic colorectal cancer received an alternating regimen consisting of four cycles of mFOLFOX6 plus bevacizumab followed by four cycles of FOLFIRI plus bevacizumab until disease progression. The primary endpoint was progression-free survival.

Results

The median age was 60 years (range 37–75 years). Median progression-free survival was 14.2 months (95 % confidence interval [CI] 10.6–16.3) and median overall survival was 28.4 months (95 % CI 22.6–39.1). The overall response rate was 60.0 % (95 % CI 45.2–73.6). Regarding toxicity, the commonest grade 3–4 hematological adverse events were neutropenia (34.6 %) and leukopenia (7.7 %), and the commonest grade 3–4 non-hematological adverse events were anorexia (13.5 %), fatigue (9.6 %), nausea (9.6 %), and vomiting (9.6 %). Bevacizumab-related grade 3–4 adverse events included hypertension (1.9 %) and thrombosis (1.9 %).

Conclusions

An alternating regimen consisting of mFOLFOX6 plus bevacizumab and FOLFIRI plus bevacizumab is an effective and well-tolerated first-line chemotherapy combination for patients with metastatic colorectal cancer.

     

Intensified neoadjuvant multimodal approach in synchronous liver metastases from gastric cancer: a single institutional experience

Background

Synchronous liver metastases (LM) from gastric (GC) or esophagogastric junction (EGJ) adenocarcinoma are a rare events. Several trials have evaluated the role of liver surgery in this setting, but the impact of preoperative therapy remains undetermined.

Methods

Patients with synchronous LM from GC/EGJ adenocarcinoma who achieved disease control after induction chemotherapy (ICT) and were subsequently scheduled to chemoradiotherapy (CRT) to the primary tumor and surgery assessment were retrospectively analyzed. Pathological response, patterns of relapse, progression-free survival (PFS), and overall survival (OS) were calculated. From July 2002 to September 2012, 16 patients fulfilling the inclusion criteria were identified.

Results

Primary tumor site was GC (nine patients) or EGJ (seven patients). LM were considered technically unresectable in nine patients. Radiological response to the whole neoadjuvant program was achieved in 13 patients. Eight patients underwent surgical resection of the primary tumor; in five of these LM were resected. A complete pathological response in the primary or in the LM was found in four and three patients, respectively. The most frequent site of relapse/progression was systemic (eight patients). Local and liver-only relapses were observed in two patients each. After a median follow-up of 91 months, the median OS and PFS were 23.0 (95% CI 13.2–32.8) and 17.0 months (95% CI 11.7–22.3). 5-year actuarial PFS is 17.6%.

Conclusion

Our results suggest that an intensified approach using ICT followed by CRT in synchronous LM from GC/EGJ adenocarcinoma is feasible and may translate into prolonged survival times in selected patients.

     

Surgical Resection for Hepatoblastoma—Updated Survival Outcomes

Background

Hepatoblastoma is the most common liver malignancy in the pediatric age group. The management of hepatoblastoma involves multidisciplinary approach.

Methods

Patients with hepatoblastoma who underwent liver resection between 2000 and 2013 were analyzed and survival outcomes were studied.

Results

The crude incidence rate of hepatoblastoma at the Madras Metropolitan Tumor Registry (MMTR) is 0.4/1,00,000 population per year. Twelve patients underwent liver resection for hepatoblastoma during the study period; this included eight males and four females. The median age at presentation was 1.75 years (Range 5 months to 3 years). The median serum AFP in the study population was 20,000 ng/ml (Range 4.5 to 1,40,000 ng/ml). Three patients had stage I, one patient had stage II, and eight patients had stage III disease as per the PRETEXT staging system. Two patients were categorized as high risk and ten patients were categorized as standard risk. Seven of these patients received two to four cycles of neoadjuvant chemotherapy (PLADO regimen), and one patient received neoadjuvant radiation up to 84 Gy. Major liver resection was performed in nine patients. Nine patients received adjuvant chemotherapy. The most common histological subtype was embryonal type. Microscopic margin was positive in three cases. One patient recurred 7 months after surgery and the site of failure was the lung. The 5-year overall survival of the case series was 91%. The median survival was 120 months.

Conclusion

Liver resections can be safely performed in pediatric populations after neoadjuvant treatment. Patients undergoing surgery had good disease control and long-term survival.

     

Personalizing Locoregional Therapy for Patients with Metastatic Colorectal Cancer

Purpose of review

The management of metastatic colorectal liver disease has improved overall survival by multidisciplinary approach utilizing systemic treatment followed by local control of metastatic disease. There has been an evolution of local control therapy which has expanded the new armamentarium for treatment of resectable and unresectable liver disease. The review article will address the various types of locoregional therapy and various indications for its use.

Recent findings

The application of ablative therapies combined with resections has allowed single-stage resection for patients with bilobar disease with excellent safety and efficacy. In patients with unresectable colorectal metastasis to the liver, chemo- and radio-embolization have provided improved survival outcome compared to systemic chemotherapy alone.

Summary

Locoregional therapy for metastatic colorectal liver disease can improve outcome as an adjunctive role in combination with resection or as a sole therapy for patients with unresectable disease.

     

Liver Imaging for Colorectal Cancer Metastases

Purpose of Review

The prognosis of colorectal carcinoma with liver metastases (CRLM) is driven largely by the resectability of hepatic metastatic disease. An increasing number of systemic and hepatic-directed therapies are being applied in the neoadjuvant setting to downstage patients for surgical eligibility. The goal of this review is to describe the use of imaging techniques in the management of CRLM with an emphasis on staging, pretreatment planning, and response assessment.

Recent Findings

While CT has an established role in screening for hepatic metastatic disease, MRI with hepatobiliary contrast has emerged as the workhorse technique in patients with CRLM in whom surgical intervention is being considered. Multiphasic CT and/or contrast-enhanced ultrasound are useful adjunctive tools, particularly when MRI is contraindicated. PET/CT provides added value in candidates for surgical resection or hepatic-directed therapy, primarily in its ability to exclude extra-hepatic metastatic disease.

Summary

Accurate staging and detailed presurgical anatomic assessment including volumetry, guide management in patients with CRLM, particularly in selecting for resection and hepatic-directed therapies.

     

Treatment outcomes of hepatectomy for liver metastases of gastric cancer diagnosed using contrast-enhanced magnetic resonance imaging

Background

Chemotherapy is the standard treatment for liver metastases of gastric cancer (LMGC). Hepatectomy for LMGC reportedly has a 5-year survival rate of 13–37 %; however, its significance has not been established. At our hospital, hepatectomy is performed for patients with three or fewer metastases diagnosed using contrast-enhanced magnetic resonance imaging (MRI). To identify the ideal patient subpopulation for resection, we retrospectively analyzed treatment outcomes in patients with LMGC who underwent hepatectomy.

Methods

Clinicopathological factors affecting survival were explored using univariate and multivariate analyses in 28 patients who underwent hepatectomy for LMGC diagnosed using contrast-enhanced MRI between December 2004 and October 2014.

Results

The study included 23 men and 5 women with a median age of 72 years. Metastases were synchronous in 15 patients and metachronous in 13 patients. The median overall survival time was 49 months, with a 5-year survival rate of 32 %. Univariate analysis revealed that overall survival time was shorter in the presence of the following factors: age ≥70 years (p = 0.030), synchronous liver metastases (p = 0.017), and presence of postoperative complications (p = 0.042). In patients with metachronous liver metastases, the post-resection 5-year survival rate was 59 %.

Conclusions

The 5-year survival rate was 32 % in patients who underwent hepatectomy for LMGC according to our criteria, suggesting that hepatectomy is an important treatment if indications are on the basis of contrast-enhanced MRI. Therefore, active resection should be considered, particularly for patients with metachronous liver metastases.

     

The predictors and oncological outcomes of repeat surgery for recurrence after hepatectomy for colorectal liver metastases

Purpose

Although recurrence after hepatectomy for colorectal liver metastases (CRLM) is common, the optimal treatment strategy remains unclear. The aims of this study were to clarify the impact of repeat surgery and identify the predictive factors for repeat surgery.

Methods

Among the 170 patients who underwent potentially curative surgery for CRLM, 113 developed recurrence. The predictive factors for the performance of repeat surgery were identified and a predictive model was constructed.

Results

The patterns of recurrence were as follows; single site [n?=?100 (liver, n?=?61; lung, n?=?22; other, n?=?17)], multiple site (n?=?13). Repeat surgery was performed in 54 patients (47.8%) including re-hepatectomy (n?=?25), radiofrequency ablation (n?=?12), and resection of the extrahepatic recurrent disease (n?=?17), and their overall survival (OS) was significantly better than that of those who could not (5-year OS 60.7 vs 19.5%, P?<?0.0001). A multivariate analysis revealed that a primary N-negative status [relative risk (RR) 2.93, P?=?0.017], indocyanine retention rate at 15 min ≤ 10% before hepatectomy (RR 2.49, P?=?0.04), and carcinoembryonic antigen ≤ 5 ng/mL before hepatectomy (RR 2.96, P?=?0.017) independently predicted the performance of repeat surgery. For patients who did not present any factors, the probability of repeat surgery was 19.6%. The addition of each subsequent factor increased the probability to 41.9, 67.8, and 84.0% (for 1, 2, and 3 factors, respectively).

Conclusions

Repeat surgery for not only intrahepatic but also extrahepatic recurrence is crucial for prolonging the survival of CRLM patients. The proposed model may help to predict the possibility of repeat surgery and provide optimal individualized treatment.

     

Mid-term oncologic outcome of a novel approach for locally advanced colon cancer with neoadjuvant chemotherapy and surgery

Purpose

Neoadjuvant chemotherapy is being actively tested as an emerging alternative for the treatment of locally advanced colon cancer (LACC) patients, resembling its use in other gastrointestinal tumors. This study assesses the mid-term oncologic outcome of LACC patients treated with oxaliplatin and fluoropyrimidines-based preoperative chemotherapy followed by surgery.

Methods and patients

Patients with radiologically resectable LACC treated with neoadjuvant therapy between 2009 and 2014 were retrospectively analyzed. Radiological, metabolic, and pathological tumor response was assessed. Both postoperative complications, relapse-free survival (RFS), and overall survival (OS) were studied.

Results

Sixty-five LACC patients who received treatment were included. Planned treatment was completed by 93.8 % of patients. All patients underwent surgery without delay. The median time between the start of chemotherapy and surgery was 71 days (65–82). No progressive disease was observed during preoperative treatment. A statistically significant tumor volume reduction of 62.5 % was achieved by CT scan (39.8–79.8) (p < 0.001). It was also observed a median reduction of 40.5 % (24.2–63.7 %) (p < 0.005) of SUV_max (Standard Uptake Value) by PET-CT scan. Complete pathologic response was achieved in 4.6 % of patients. Postoperative complications were observed in 15.4 % of patients, with no cases of mortality. After a median follow-up of 40.1 months, (p ₂₅–p ₇₅: 27.3–57.8) 3–5 year actuarial RFS was 88.9–85.6 %, respectively. Five-year actuarial OS was 95.3 %.

Conclusion

Preoperative chemotherapy in LACC patients is safe and able to induce major tumor regression. Survival times are encouraging, and further research seems warranted.

     

BAK is a predictive and prognostic biomarker for the therapeutic effect of docetaxel treatment in patients with advanced gastric cancer

Background

Preoperative chemotherapy is a promising strategy for downstaging advanced gastric cancer before radical resection, although severe adverse events can occur and clinical outcomes are often unsatisfactory. To identify predictive biomarkers of drug sensitivity, we used a well-designed functional apoptosis assay and assessed the correlations between chemosensitivity and clinical outcomes.

Methods

Drug sensitivity to docetaxel, cisplatin, and 5-fluorouracil was examined in 11 gastric cancer cell lines. BCL2-homology domain 3 (BH3) profiling was performed and assessed for correlations with drug sensitivity. Immunohistochemical staining of clinical gastric cancer specimens was performed before preoperative chemotherapy, and correlations with histopathological responses and clinical outcomes were assessed.

Results

BIM (BCL2L11)-BH3 profiling results correlated with docetaxel sensitivity and BAK protein expression, whose knockdown caused docetaxel resistance. The BAK expression indexes of 69 gastric cancer specimens before preoperative chemotherapy (including docetaxel treatment) were determined by multiplying numerical values describing the degrees of BAK positivity and staining intensity observed. Patients whose specimens showed good chemotherapeutic histopathological responses had higher BAK indexes than those with poor responses. Patients with BAK index values ≥3 showed improved progression-free survival (HR, 2.664; 95 % CI, 1.352–5.248; P = 0.005) and overall survival (HR, 3.390; 95 % CI, 1.549–7.422; P = 0.002).

Conclusions

BH3 profiling clearly showed that BIM expression, which depends on BAK expression, correlated with docetaxel sensitivity. BAK expression in gastric cancer is thus predictive of chemotherapeutic responses to docetaxel and clinical prognosis in patients treated with preoperative chemotherapy.

     

Incidence of and risk factors for preoperative deep venous thrombosis in patients undergoing gastric cancer surgery

Background

Pulmonary thromboembolism (PE) is one of the life-threatening complications of gastric cancer surgery. D-dimer assay is a safe and rapid tool to exclude the presence of deep venous thrombosis (DVT). In July 2012, we started preoperative DVT screening of patients scheduled for gastric cancer surgery using a combination of D-dimer measurements and lower extremity venous ultrasonography to prevent PE.

Methods

Between July 2012 and August 2015, 976 consecutive patients underwent gastric cancer surgery with preoperative D-dimer screening. Lower extremity venous ultrasonography was performed in patients with a positive D-dimer assay result (greater than 1.0 μg/ml). The incidence of and risk factors for preoperative DVT and the incidence of PE were examined in patients undergoing gastric cancer surgery.

Results

Of the 976 patients, 176 (18.0%) showed positive D-dimer assay results, and in 13 (1.3%) DVT was diagnosed by lower extremity ultrasonography. Our analysis identified neoadjuvant chemotherapy as a risk factor for preoperative detection of DVT in patients undergoing gastric cancer surgery (P = 0.021). The incidence of PE was 0.1% (1/976).

Conclusion

Preoperative gastric cancer patients receiving neoadjuvant chemotherapy seem to be at higher risk for the development of DVT.

     

Role of hepatectomy in gastric cancer with multiple liver-limited metastases

Background

Several studies have demonstrated the benefit of hepatectomy for treating gastric cancer (GC) with liver-limited metastases (LLM). The survival benefit of hepatectomy compared with that of systemic chemotherapy is unknown, particularly in patients with multiple LLM. This study investigated the survival benefit of hepatectomy compared with that of systemic chemotherapy administered to patients with GC with multiple LLM.

Methods

We retrospectively reviewed the data of consecutive patients with GC with two or three LLM who underwent hepatectomy or received systemic chemotherapy as initial treatment at the Shizuoka Cancer Center between December 2004 and December 2015.

Results

Nine of 24 patients who met the inclusion criteria underwent hepatectomy, and 15 received chemotherapy. In the hepatectomy group, all patients achieved R0 resection and none died during hospitalization. Three patients received adjuvant chemotherapy. Disease recurred in eight patients (88.9%). In the chemotherapy group, three patients underwent hepatectomy following initial chemotherapy and did not experience recurrence or death during follow-up. Median follow-up was 47.9 months and median overall survival (OS) was 38.1 and 24.8 months in the chemotherapy and hepatectomy groups, respectively. Multivariate analysis of OS, including initial treatment, revealed that unilobar liver metastasis was the only independent favorable prognostic factor.

Conclusions

Although hepatectomy for patients with GC with multiple LLM is not recommended as the initial therapy, it prolonged the survival of patients with tumors controlled using systemic chemotherapy.

     

Current Management of Liver Metastasis From Colorectal Cancer

Purpose of Review

To describe the main components of modern treatment for colorectal cancer (CRC) metastatic to the liver.

Recent Findings

Liver metastasis occurs in 50–60% of patients with CRC, and surgery is the only potentially curative treatment. Surgery should be performed where a complete (R0) resection of all radiologically visible metastases is possible. The presence of extra-hepatic disease no longer precludes liver metastectomy, and combined metastectomy in the liver and the extra-hepatic site can result in acceptable long-term survival. Peri-operative chemotherapy significantly improves PFS and DFS, but not OS. Modern cytotoxic regimens can convert a significant percentage of unresectable patients to resectable status, and the addition of biologic agents can increase the rate of conversion. Several local treatment modalities serve as alternatives, or sometimes as adjuncts, to resection of CRC liver metastasis and systemic chemotherapy.

Summary

The modern approach to CRC with liver metastasis combines surgery, modern cytotoxic and biologic agents, and modern technologies in the field of ablation, radiation, and endovascular access. The result is that long-term survival, and even cure, is now possible.