Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: A case matched study

Background

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

Methods

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

Results

Operative blood losses were: synchronous group, median 475 mL (range 150–850 mL) vs median 425 mL (range 50–1700 mL), (p > 0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p = 0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8–21] vs 20 [range 7–51], p = 0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8–13.7) versus 14 (95% CI 12.2–16.3; p = 0.487) and 21% versus 24% at 5 years (p = 0.838).

Conclusion

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.     

Socioeconomic differences in selection for liver resection in metastatic colorectal cancer and the impact on survival

Background

Socioeconomic inequalities in colorectal cancer (CRC) survival are well recognised. The aim of this study was to describe the impact of socioeconomic deprivation on survival in patients with synchronous CRC liver-limited metastases, and to investigate if any survival inequalities are explained by differences in liver resection rates.

Predictors of survival after hepatic resection among patients with colorectal liver metastasis

Studies suggest improved survival following resection of colorectal cancer liver metastases (CLMs). We investigated predictors of survival among patients with CLM who underwent hepatic resection using the SEER-Medicare database to identify patients >/=65 years diagnosed with CLM, 1991-2003, who underwent hepatectomy. Cox proportional hazards models were used to identify factors associated with survival after hepatectomy. Of 923 patients with CLM who underwent hepatectomy, 514 were stages I-III and developed CLM>6 months after diagnosis (metachronous), and 409 were stage IV with CLM at diagnosis (synchronous). From the date of hepatectomy, 5 year survival was 22%; younger age, being married, female gender, surgery in an NCI-designated cancer centre, fewer comorbidities, fewer positive lymph nodes, and lower grade were associated with improved survival. Both 5-fluorouracil (5FU)-based chemotherapy and hepatic arterial infusion (HAI) of floxuridine-based chemotherapy following hepatectomy improved survival (HR=0.62, 95% CI: 0.50-0.78; HR=0.51, 95% CI: 0.28-0.97, respectively) in the synchronous, but not metachronous, group. The HR for overall mortality was higher in hospitals with a high vs low procedure volume (0.75, 95% CI: 0.58-0.94). A substantial subgroup of patients with CLM who undergo hepatectomy experiences long-term survival. High hospital procedure volume and use of 5FU-based or HAI-based chemotherapy after resection were associated with improved prognosis.     

Racial disparities in colorectal cancer survival

BACKGROUND:

Racial/ethnic differences in colorectal cancer (CRC) survival have been documented throughout the literature. However, the reasons for these disparities are difficult to decipher. The objective of this analysis was to determine the extent to which racial/ethnic disparities in survival are explained by differences in sociodemographics, tumor characteristics, diagnosis, treatment, and hospital characteristics.

METHODS:

A cohort of 37,769 Medicare beneficiaries who were diagnosed with American Joint Committee on Cancer stages I, II, and III CRC from 1992 to 2002 and resided in 16 Surveillance, Epidemiology, and End Results (SEER) regions of the United States was identified in the SEER‐Medicare linked database. Survival was estimated using the Kaplan‐Meier method. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) of mortality and 95% confidence intervals (CIs).

RESULTS:

Black patients had worse CRC‐specific survival than white patients, but the difference was reduced after adjustment (adjusted HR [aHR], 1.24; 95% CI, 1.14‐1.35). Asian patients had better survival than white patients after adjusting for covariates (aHR, 0.80; 95% CI, 0.70‐0.92) for stages I, II, and III CRC. Relative to Asians, blacks and whites had worse survival after adjustment (blacks: aHR, 1.56; 95% CI, 1.33‐1.82; whites: aHR, 1.26; 95% CI, 1.10‐1.44). Comorbidities and socioeconomic Status were associated with a reduction in the mortality difference between blacks and whites and blacks and Asians.

CONCLUSIONS:

Comorbidities and SES appeared to be more important factors contributing to poorer survival among black patients relative to white and Asian patients. However, racial/ethnic differences in CRC survival were not fully explained by differences in several factors. Future research should further examine the role of quality of care and the benefits of treatment and post‐treatment surveillance in survival disparities. Cancer 2010. © 2010 American Cancer Society.     

Variation in quality of care among older men with localized prostate cancer

BACKGROUND:

The objective of this study was to assess the racial and ethnic disparities in outcomes and their association with process‐of‐care measures for elderly Medicare recipients with localized prostate cancer.

METHODS:

The Surveillance, Epidemiology, and End Results‐Medicare databases for the period from 1995 to 2003 were used to identify African‐American men, non‐Hispanic white men, and Hispanic men with localized prostate cancer, and data were obtained for the 1‐year period before the diagnosis of prostate cancer and up to 8 years postdiagnosis. The short‐term outcomes of interest were complications, emergency room visits, readmissions, and mortality; the long‐term outcomes of interest were prostate cancer‐specific mortality and all‐cause mortality; and process‐of‐care measures of interest were treatment and time to treatment. Cox proportional hazards regression, logistic regression, and Poisson regression were used to study the racial and ethnic disparities in outcomes and their association with process‐of‐care measures.

RESULTS:

Compared with non‐Hispanic white patients, African‐American patients (Hazard ration [HR], 1.43; 95% confidence interval [CE], 1.19‐1.86) and Hispanic patients (HR=1.39; 95% CI, 1.03‐1.84) had greater hazard of long term prostate specific mortality. African‐American patients also had greater odds of emergency room visits (odds ratio, 1.4; 95% CI, 1.2‐1.7) and greater all‐cause mortality (HR, 1.39; 95% CI, 1.3‐1.5) compared with white patients. The time to treatment was longer for African‐American patients and was indicative of a greater hazard of all‐cause, long‐term mortality. Hispanic patients who underwent surgery or received radiation had a greater hazard of long‐term prostate‐specific mortality compared with white patients who received hormone therapy.

CONCLUSIONS:

Racial and ethnic disparities in outcomes were associated with process‐of‐care measures (the type and time to treatment). The current results indicated that there is an opportunity to reduce these disparities by addressing these process‐of‐care measures. Cancer 2011. © 2010 American Cancer Society.     

The role of hepatectomy for synchronous liver metastases from pancreatic adenocarcinoma

Background

The role of hepatectomy for patients with liver metastases from ductal adenocarcinoma of the pancreas (PLM) remains controversial. Therefore, the aim of our study was to examine the postoperative morbidity, mortality, and long-term survivals after liver resection for synchronous PLM.

Cytoreductive surgery and intraperitoneal chemotherapy for colorectal peritoneal and hepatic metastases: a case-control study

Background

Concomitant treatment of colorectal peritoneal metastases (PM) and hepatic metastases (HM) remains controversial. This study compares the cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) treatment of colorectal peritoneal metastases (PM) with the CRS/IPC/hepatic resection treatment of colorectal PM and HM.

Methods

All patients from a prospective PM registry at the Uppsala institution treated concomitantly for PM/HM with CRS/IPC/hepatic resections were included in a PM/HM-group, n=11. They were matched 1^:2 with patients from the registry being treated only for PM with CRS/IPC, n=22. Overall survival (OS), disease-free survival (DFS), morbidity, mortality, and recurrences were compared.

Results

The PM/HM-group had median OS of 15 months (95% CI: 6-46 months) and the PM-group had a median OS of 34 months (95% CI: 19-37 months), P=0.2. The DFS was 10 months (95% CI: 3-14 months)
and 24 months (95% CI: 10-32 months) respectively, P=0.1. Morbidity was 27% in both groups and one postoperative death in the PM/HM-group. Currently, 1/10 (10%) patients with an R1 resection are
disease-free in the PM/HM group while 9/20 (45%) are disease-free in the PM group (P=0.05).

Conclusions

Concomitant treatment of PM and HM with CRS/IPC/hepatic resections is feasible with no significant increase in morbidity compared to CRS/IPC. The risk of recurrences is higher in the PM/HM group with a tendency towards worse DFS.Key Words: Colorectal cancer, peritoneal carcinomatosis, peritoneal metastases, hepatic metastases, cytoreductive surgery, intraperitoneal chemotherapy     

Racial disparities in receipt and comparative effectiveness of oxaliplatin for stage III colon cancer in older adults

BACKGROUND:

African Americans in the United States have higher rates of colon cancer mortality than other races. This study examines the use of oxaliplatin, a novel chemotherapeutic agent approved in 2004, among African American and Caucasian American patients with stage III colon cancer to determine whether differential receipt or differential effectiveness of the drug may explain the racial disparity in colon cancer mortality.

METHODS:

The authors conducted a population‐based retrospective cohort study of stage III colon cancer patients aged 65 years and older treated from 2004 through 2006 who initiated chemotherapy within 90 days of surgical resection (N = 1162) using Surveillance, Epidemiology and End Results‐Medicare data. Patients receiving oxaliplatin (n = 477) were compared with those receiving 5‐fluorouracil without oxaliplatin (n = 685). The authors estimated prevalence ratios and hazard ratios (HRs) using multivariate binomial regression and Cox models to evaluate racial differences in oxaliplatin receipt and survival.

RESULTS:

African Americans were as likely as Caucasian Americans to receive oxaliplatin (40.5 vs 41.1%; prevalence ratio, 0.90; 95% confidence interval [CI], 0.71‐1.13). Oxaliplatin was associated with lower mortality compared with 5‐fluorouracil (HR, 0.76; 95% CI, 0.58‐1.00). This benefit appeared stronger among African Americans (HR, 0.31; 95% CI, 0.09‐1.05) than Caucasian Americans (HR, 0.80; 95% CI, 0.60‐1.06).

CONCLUSIONS:

In Medicare‐insured patients receiving chemotherapy, the authors observed no meaningful racial disparities in receipt of oxaliplatin and, among those receiving it, potentially better survival among African Americans. Differential receipt and effectiveness of oxaliplatin‐containing regimens does not appear to contribute to the previously documented racial disparities in colon cancer survival. Understanding reasons for potentially enhanced effectiveness among African Americans may inform efforts to resolve racial disparities in colon cancer outcomes. Cancer 2011. © 2011 American Cancer Society.     

Prediagnostic smoking history, alcohol consumption, and colorectal cancer survival: the Seattle Colon Cancer Family Registry

BACKGROUND:

Smoking and alcohol consumption are associated with an increased risk of developing colorectal cancer. However, it is unclear whether these exposures are associated with survival after colorectal cancer diagnosis.

METHODS:

Men and women diagnosed with incident colorectal cancer between 1998 and 2007 in 13 counties in western Washington State were identified by using the Surveillance, Epidemiology, and End Results cancer registry. Information on smoking history and alcohol consumption was collected by telephone interview. Follow‐up for mortality was completed through linkage to the National Death Index. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations among smoking, alcohol consumption, and mortality after colorectal cancer diagnosis. Stratified analyses were conducted by sex, age at diagnosis (<50 years, ≥50 years), tumor site (proximal, distal, rectal), stage (I‐II, III‐IV), and microsatellite instability status (stable/low, high).

RESULTS:

Disease‐specific and all‐cause mortality were significantly higher for smokers (HR, 1.30; 95% CI, 1.09‐1.74) compared with never‐smokers (HR, 1.51; 95% CI, 1.24‐1.83). However, this association was most prominent in those with tumors exhibiting high microsatellite instability (HR, 3.83; 95% CI, 1.32‐11.11) and did not extend to those with rectal cancer (HR, 1.08; 95% CI, 0.72‐1.61) or those diagnosed before age 50 years (HR, 0.99; 95% CI, 0.67‐1.48). Alcohol consumption was not associated with disease‐specific or all‐cause mortality, regardless of patient or tumor characteristics.

CONCLUSIONS:

In addition to an association with disease risk, smoking is associated with increased mortality after colorectal cancer diagnosis. This association is especially pronounced for colorectal cancer with high microsatellite instability. Cancer 2011;. © 2011 American Cancer Society.     

Family history and survival after colorectal cancer diagnosis

BACKGROUND

A history of colorectal cancer in a first‐degree relative is a recognized risk factor for developing this malignancy. The influence of a family history of colorectal cancer on survival after a diagnosis of colorectal cancer was examined in a large cohort of women.

METHODS

We analyzed data from 1001 women diagnosed with colorectal cancer while participating in a prospective cohort study. Data on family history were obtained before cancer diagnosis. We computed Cox proportional hazards for cancer‐specific and overall mortality according to a family history of colorectal cancer, adjusting for other predictors for survival.

RESULTS

Before diagnosis, 16% of colorectal patients reported a history of colorectal cancer in a first‐degree relative. Patients with a history of colorectal cancer in 1 or more first‐degree relatives experienced an adjusted hazard ratio (HR) for overall mortality of 1.32 (95% confidence interval [CI], 1.01–1.72) and colorectal cancer‐specific mortality of 1.38 (95% CI, 1.02–1.86) when compared with those without a family history. Moreover, patients with 2 or more affected relatives had an HR for overall mortality of 2.07 (95% CI, 1.14–3.76) and cancer‐specific mortality of 2.19 (95% CI, 1.10–4.38). The significant deleterious effect of family history was limited to patients with advanced disease at presentation and cancers originating in the colon.

CONCLUSIONS

Among women with colorectal cancer, a history of colorectal cancer in a first‐degree relative was associated with a significant decrease in survival. Additional study is needed to validate these findings and determine whether specific germline polymorphisms correlate with clinical outcomes. Cancer 2008. © 2008 American Cancer Society.     

Esophageal tumor length is independently associated with long‐term survival

BACKGROUND:

Esophageal cancer staging uses tumor depth as the sole criterion for assessment of the primary tumor (pT). To the authors' knowledge the impact of esophageal tumor length on long‐term outcome and the esophageal cancer staging system has not been fully evaluated in the current era.

METHODS:

All esophageal cancer patients (n = 209) undergoing surgery from 1995 to 2005 who did not receive preoperative chemotherapy or radiotherapy were reviewed. Maximum esophageal tumor length along a craniocaudal axis was determined pathologically after surgical resection. Univariate and multivariate analyses were used to assess the impact of esophageal tumor length (≤3 cm vs >3 cm) on long‐term survival.

RESULTS:

Esophageal tumor length was closely associated with long‐term survival (hazards ratio [HR] of 6.14 [95% confidence interval (95% CI), 4.1‐9.25]; 5‐year survival: ≤3 cm = 68%, >3 cm = 10% [P < .001]). Multivariate Cox regression analyses demonstrated tumor length (HR of 2.13 [95% CI, 1.26‐3.63]) was found to be a significant independent predictor of long‐term survival even when controlled for sex, age, tumor location, histology, margin positivity, surgical procedure, and current pTNM criteria. The incorporation of tumor length in pTNM staging significantly improves the ability to predict the long‐term survival of patients (5‐year survival for patients with tumors ≤3 cm and stages I, IIA, IIB, and III disease = 86%, 62%, 49%, and 22%, respectively; survival for patients with tumors measuring >3 cm and stages I, IIA, IIB, and III disease = 27%, 22%, 0%, and 8%, respectively [P < .1]).

CONCLUSIONS:

Esophageal tumor length is an independent predictor of long‐term survival in the current era and should be considered for incorporation into the current esophageal cancer staging system to better predict long‐term survival and identify high‐risk patients for postoperative therapy. Cancer 2009. © 2008 American Cancer Society.     

Comparison of the prognostic value of selected markers of the systemic inflammatory response in patients with colorectal cancer

There is increasing evidence that the presence of a systemic inflammatory response plays an important role in predicting survival in patients with colorectal cancer. However, it is not clear what components of the systemic inflammatory response best predict survival. The aim of the present study was to compare the prognostic value of an inflammation-based prognostic score (modified Glasgow Prognostic Score (Mgps) 0=C-reactive protein <10 mg l(-1), 1=C-reactive protein >10 mg l(-1), and 2=C-reactive protein >10 mg l(-1) and albumin<35 g l(-1)) with that of components of the white cell count (neutrophils, lymphocytes, monocytes and platelets using standard thresholds) in patients with colorectal cancer. Two patient groups were studied: 149 patients who underwent potentially curative resection for colorectal cancer and 84 patients who had synchronous unresectable liver metastases. In those patients who underwent potentially curative resection the minimum follow-up was 36 months and 20 patients died of their cancer. On multivariate survival analysis only TNM stage (HR 3.75, 95% CI 1.54-9.17, P=0.004), monocyte count (HR 3.79, 95% CI 1.29-11.12, P=0.015) and mGPS (HR 2.21, 95% CI 1.11-4.41, P=0.024) were independently associated with cancer-specific survival. In patients with synchronous unresectable liver metastases the minimum follow-up was 6 months and 71 patients died of their cancer. On multivariate survival analysis only single liver metastasis >5 cm (HR 1.78, 95% CI 0.99-3.21, P=0.054), extra-hepatic disease (HR 2.09, 95% CI 1.05-4.17, P=0.036), chemotherapy treatment (HR 2.40, 95% CI 1.82-3.17, P<0.001) and mGPS (HR 1.44, 95% CI 1.01-2.04, P=0.043) were independently associated with cancer-specific survival. In summary, markers of the systemic inflammatory response are associated with poor outcome in patients with either primary operable or synchronous unresectable colorectal cancer. An acute-phase protein-based prognostic score, the mGPS, appears to be a superior predictor of survival compared with the cellular components of the systemic inflammatory response.     

Hepatic resection for metastatic gastrointestinal stromal tumors in the tyrosine kinase inhibitor era

BACKGROUND:

Before the advent of tyrosine kinase inhibitors (TKIs), surgical resection was the primary treatment for hepatic gastrointestinal stromal tumor (GIST) metastases. Although TKIs have improved survival in the metastatic setting, outcomes after multimodal therapy comprised of hepatectomy and TKIs for GIST are unknown. The objective of this study was to determine whether combination therapy for hepatic GIST metastases is associated with improved overall survival compared with reported outcomes from surgery or TKI therapy alone.

METHODS:

Demographics, clinicopathologic tumor characteristics, treatments, and outcomes of patients who underwent hepatic resection at 3 high‐volume centers from 1995 to 2010 were reviewed.

RESULTS:

In total, 39 patients underwent hepatectomy for metastatic GISTs, and 27 patients received postoperative TKI therapy. At a median follow‐up of 39.7 months, 23 patients (59%) experienced recurrence at a median of 18 months. The 1‐year, 2‐year, and 3‐year overall survival rates were 96.7%, 76.8%, and 67.9%, respectively. Median survival was not reached at 5 years. The rates of severe complication and mortality were 10.2% (4 patients) and 2.5% (1 patient), respectively. When controlling for confounders, postoperative TKI therapy was associated with improved survival (hazard ratio, 0.04; 95% confidence interval, 0.01‐0.50; P = .006), and extrahepatic disease was associated with worse survival (hazard ratio, 9.51; 95% confidence interval, 1.63‐55.7; P = .012).

CONCLUSIONS:

Overall survival after combination therapy exceeded previous reports for the treatment of metastatic GIST with hepatic resection or TKI therapy alone and was significantly enhanced by postoperative TKI therapy. The results from this study support findings that combination therapy for GIST liver metastases comprised of surgical resection and TKI therapy is more effective than surgery or TKI therapy alone. Cancer 2012;3571–3578. © 2011 American Cancer Society.     

Lifestyle factors associated with survival after colorectal cancer diagnosis

Background:

Aside from tumour stage and treatment, little is known about potential factors that may influence survival in colorectal cancer patients. The aim of this study was to investigate the associations between physical activity, obesity and smoking and disease-specific and overall mortality after a colorectal cancer diagnosis.

Methods:

A cohort of 879 colorectal cancer patients, diagnosed in Western Australia between 2005 and 2007, were followed up to 30 June 2012. Cox''s regression models were used to estimate the hazard ratios (HR) for colorectal cancer-specific and overall mortality associated with self-reported pre-diagnosis physical activity, body mass index (BMI) and smoking.

Results:

Significantly lower overall and colorectal cancer-specific mortality was seen in females who reported any level of recent physical activity than in females reporting no activity. The colorectal cancer-specific mortality HR for increasing levels of physical activity in females were 0.34 (95% CI=0.15, 0.75), 0.37 (95% CI=0.17, 0.81) and 0.41 (95% CI=0.18, 0.90). Overweight and obese women had almost twice the risk of dying from any cause or colorectal cancer compared with women of normal weight. Females who were current smokers had worse overall and colorectal cancer-specific mortality than never smokers (overall HR=2.64, 95% CI=1.18, 5.93; colorectal cancer-specific HR=2.70, 95% CI=1.16, 6.29). No significant associations were found in males.

Conclusion:

Physical activity, BMI and smoking may influence survival after a diagnosis of colorectal cancer, with more pronounced results found for females than for males.     

The primary tumor location impacts survival outcome of colorectal liver metastases after hepatic resection: A systematic review and meta-analysis

ObjectiveLocation of the primary tumor side has become an increasingly prognostic factor for colorectal liver metastasis. The present study was to perform a meta-analysis to investigate if primary right-sided tumor impacted on long-term survival outcome of colorectal liver metastases following local treatment.MethodEligible trials were identified from the Embase, PubMed, Web of Science and the Cochrane database that were published before October in 2018. English language trials that compared long-term survival outcome of primary left-sided tumor with right-sided tumor colorectal liver metastases following local treatment were included. Hepatic resection for colorectal liver metastases was investigated. The main study outcomes included overall survival and disease free survival of primary right-sided colorectal liver metastases following local treatment. The risk factors of largest tumor size, primary node metastases, multiple tumor and RAS mutation were also analyzed. A systematic review and meta-analysis was done using a fixed-effects model. Hazard ratio with a 95% confidence interval was used to measure the pooled effect.ResultsA total of twelve studies with 6387 patients were included. For primary right-sided colorectal liver metastases patients following hepatic resection, the overall pooled HR for 5-year overall survival rate was 1.354 (95% CI: 1.238–1.482; p = 0.000; I² = 33.7%, p = 0.138). The pooled HR for 5-year disease free survival rate of primary right-sided CRLM in the included studies calculated using the fix-effects model was 1.104 (95% CI: 0.987–1.235; p = 0.084; I² = 0%, p = 0.477).ConclusionIt demonstrated that primary right-sided for colorectal liver metastases location was a significantly worse prognostic factor in terms of overall survival.     

Survival after complete surgical resection of multiple metastases from renal cell carcinoma

BACKGROUND:

Although a role for resection of solitary metastases from renal cell carcinoma (RCC) has been described, the utility of surgery in patients with multiple sites of disease has been less well defined. The authors report the survival of patients who underwent complete metastasectomy for multiple RCC metastases.

METHODS:

The authors identified 887 patients who underwent nephrectomy for RCC between 1976 and 2006 who developed multiple metastatic lesions. The impact of complete metastasectomy on survival was evaluated controlling for the timing, location, and number of metastases and for patient performance status.

RESULTS:

Of 887 patients, 125 (14%) underwent complete surgical resection of all metastases. Complete metastasectomy was associated with a significant prolongation of median cancer‐specific survival (CSS) (4.8 years vs 1.3 years; P < .001). Patients who had lung‐only metastases had a 5‐year CSS rate of 73.6% with complete resection versus 19% without complete resection (P < .001). A survival advantage from complete metastasectomy also was observed among patients with multiple, nonlung‐only metastases, who had a 5‐year CSS rate of 32.5% with complete resection versus 12.4% without complete resection (P < .001). Complete resection remained predictive of improved CSS for patients who had ≥3 metastatic lesions (P < .001) and for patients who had synchronous (P < .001) and asynchronous (P = .002) multiple metastases. Moreover, on multivariate analysis, the absence of complete metastasectomy was associated significantly with an increased risk of death from RCC (hazard ratio, 2.91; 95% confidence interval, 2.17‐3.90; P < .001).

CONCLUSIONS:

The current results indicated that complete resection of multiple RCC metastases may be associated with long‐term survival and should be considered when technically feasible in appropriate surgical candidates. Cancer 2011. © 2011 American Cancer Society.     

Sarcopenia and primary tumor location influence patients outcome after liver resection for colorectal liver metastases

IntroductionRight-sided and left-sided colorectal cancer (CRC) is known to differ in their molecular carcinogenic pathways. The prevalence of sarcopenia is known to worsen the outcome after hepatic resection. We sought to investigate the prevalence of sarcopenia and its prognostic application according to the primary CRC tumor site.Methods355 patients (62% male) who underwent liver resection in our center were identified. Clinicopathologic characteristics and long-term outcomes were stratified by sarcopenia and primary tumor location (right-sided vs. left-sided). Tumors in the coecum, right sided and transverse colon were defined as right-sided, tumors in the left colon and rectum were defined as left-sided. Sarcopenia was assessed using the skeletal muscle index (SMI) with a measurement of the skeletal muscle area at the level L3.ResultsPatients who underwent right sided colectomy (n = 233, 65%) showed a higher prevalence of sarcopenia (35.2% vs. 23.9%, p = 0.03). These patients also had higher chances for postoperative complications with Clavien Dindo >3 (OR 1.21 CI95% 0.9–1.81, p = 0.05) and higher odds for mortality related to CRC (HR 1.2 CI95% 0.8–1.8, p = 0.03).On multivariable analysis prevalence of sarcopenia remained independently associated with worse overall survival and disease free survival (overall survival: HR 1.47 CI 95% 1.03–2.46, p = 0.03; HR 1.74 CI95% 1.09–3.4, p = 0.05 respectively).ConclusionSarcopenia is known to have a worse prognosis in patients with CRLM and CRC. Depending on the primary location sarcopenia has a variable effect on the outcome after liver resection.     

Nonsteroidal anti‐inflammatory drugs

BACKGROUND:

Nonsteroidal anti‐inflammatory drug (NSAID) use has been associated with a decreased colorectal cancer (CRC) risk. However, to the best of the authors' knowledge, the effects of NSAID on clinical outcomes after CRC diagnosis are not well defined. The authors investigated the association between prediagnosis NSAID use and mortality after CRC diagnosis among women in the California Teachers Study cohort.

METHODS:

Women aged <85 years participating in the California Teachers Study, without a prior CRC diagnosis at baseline (1995‐1996), and who were diagnosed with CRC during follow‐up through December 2005, were eligible for analysis of the association between prediagnosis NSAID use and mortality. NSAID use (including aspirin and ibuprofen) was collected through a self‐administered questionnaire. Cancer occurrence was identified through California Cancer Registry linkage. Multivariate Cox proportional hazards regression models were used to estimate hazards ratios (HR) for death and 95% confidence intervals (95% CIs).

RESULTS:

Among 621 CRC patients who were identified, 64% reported no prediagnosis regular NSAID use, 17% reported use of 1 to 6 days/week, and 20% reported daily use. A duration of NSAID use <5 years was reported by 17% of patients and a use of ≥5 years was reported by 18%. Regular prediagnosis NSAID use (1‐3 days/week, 4‐6 days/week, and daily) versus none was associated with improved overall survival (OS) (HR, 0.71; 95% CI, 0.53‐0.95) and CRC‐specific survival (HR, 0.58; 95% CI 0.40‐0.84) after adjustment for clinically relevant factors. Prediagnosis NSAID use ≥5 years (vs none) was found to be associated with improved OS (HR, 0.55; 95% CI, 0.37‐0.84) and CRC‐specific survival (HR, 0.40; 95% CI, 0.23‐0.71) in adjusted analyses.

CONCLUSIONS:

When used regularly or over a prolonged duration before CRC diagnosis, NSAIDs are associated with decreased mortality among female CRC patients. Cancer 2009. © 2009 American Cancer Society.     

The impact of caudate lobe involvement after hepatic resection for colorectal metastases

Background

Hepatic resections involving the caudate lobe are technically challenging with results from some centers indicating inferior outcomes. We assessed outcomes following hepatic resection for colorectal metastases involving the caudate lobe in a tertiary care center.

Methods

Operative and oncological data from a prospectively maintained database were analyzed on 687 patients undergoing hepatic resection for colorectal metastases between 1993 and 2006. Patients were analyzed as those with caudate lobe metastases (CLM) and compared with those without caudate lobe involvement (NCLM).

Results

Fifty-two of 687 patients had metastases involving the caudate lobe (8%). Patients with caudate lobe involvement were more likely to require an extended hepatic resection (75% vs 27%, P = 0.001), perioperative blood transfusion (29% vs 14%, P = 0.002), have a positive resection margin (57% vs 32%, P = 0.001) and stay longer in hospital (12 vs 8 days, P = 0.001). There was no difference in the complication rates (37% vs 29%) or 30-day mortality between the two groups (2% vs 1%). The median disease free (20 months vs 21 months), and cancer specific survival (42 months vs 59 months) were also similar in the CLM and NCLM groups.

Conclusions

Although caudate lobe involvement adds to the technical complexity of hepatic resection, these patients can be offered long term survival, similar to other patients with hepatic metastases from colorectal cancer.     

Synchronous resection of colorectal primary and hepatic metastasis

Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.Key Words: Colorectal cancer, colorectal liver metastases, synchronous resection