Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM: Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS: Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS: In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION: By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.     

微波消融与手术治疗结直肠癌肝转移临床疗效的meta分析

【摘要】 目的 比较MWA和肝切除术（HR）治疗结直肠癌肝转移（CRLM）患者的临床疗效。方法 利用计算机辅以人工检索维普、万方、中国知网、Embase、Cochrane library、Pubmed等有关数据库中关于MWA与HR治疗CRLM患者疗效的临床对照研究,检索日期为2000年1月1日至2020年9月5日。由2名评估人员独立的筛选文献,提取资料并进行质量评价,利用RevMan 5.3软件做出meta分析。结果 最终纳入13篇文献,其中回顾性队列研究8篇,病例对照研究3篇,随机对照研究2篇。共计1 470例患者包括MWA组662例,HR组808例。meta分析表明,MWA组与HR组的1年（OR=1.09,95%CI=0.69～1.73）、2年（OR=1.04,95%CI=0.72～1.52）、3年（OR=1.07,95%CI=0.83～1.38）、5年（OR=0.78,95%CI=0.57～1.05）生存率及1年（OR=0.66,95%CI=0.41～1.07）、3年（OR=0.87,95%CI=0.61～1.25）、5年（OR=0.77,95%CI=0.47～1.26）无瘤生存率比较,差异无统计学意义（均P＞0.05）;与HR组患者相比,MWA组患者的住院治疗时间短且治疗费用低,严重临床并发症发生率低,两组差异有统计学意义（均P≤0.05）。结论 MWA与HR治疗CRLM患者疗效相仿,且MWA可缩短住院时间、降低治疗费用、减少严重并发症的出现,但未来仍需大规模、前瞻性、多中心试验进一步证实。     

肝动脉化疗栓塞治疗原发病灶切除的胰腺神经内分泌肿瘤肝转移疗效分析

【摘要】 目的 探讨TACE对于已经切除原发病灶的胰腺神经内分泌肿瘤肝转移（neuroendocrine neoplasm liver metastasis, NELM）的疗效。方法 回顾分析2014年6月至2018年6月诊治的21例胰腺NELM患者入组进行研究,所有病例均行原发病灶切除后针对肝脏病灶进行65例次TACE治疗。分析临床疗效,安全性和有效性;根据影像学检查后实体瘤反应评价标准评价病灶疗效;并随访无疾病生存期（PFS）和总生存期（OS）情况。 结果 所有患者均顺利完成TACE治疗,有效率为81.0%（17/21）;影像学评价中17例达到部分缓解,3例病情稳定,1例出现疾病进展;PFS为（16.6±6.5）个月,OS为（28.0±11.8）个月,所有手术均未出现严重并发症。 结论 TACE治疗原发病灶切除后的胰腺NELM安全有效,其可能因降低肿瘤负荷、阻断分泌功能提高总生存率而获得更多获益。     

Standardized added metabolic activity (SAM) IN 18F-FDG PET assessment of treatment response in colorectal liver metastases

Purpose

Standardized added metabolic activity (SAM) is a PET parameter for assessing the total metabolic load of malignant processes, avoiding partial volume effects and lesion segmentation. The potential role of this parameter in the assessment of response to chemotherapy and bevacizumab was tested in patients with metastatic colorectal cancer with potentially resectable liver metastases (mCRC).

Methods

¹⁸F-FDG PET/CT was performed in 18 mCRC patients with liver metastases before treatment and after five cycles of FOLFOX/FOLFIRI and bevacizumab. Of the 18 patients, 16 subsequently underwent resection of liver metastases. Baseline and follow-up SUV_max, and SAM as well as reduction in SUV_max (?SUV_max) and SAM (?SAM) of all liver metastases were correlated with morphological response, and progression-free and overall survival (PFS and OS).

Results

A significant reduction in metabolic activity of the liver metastases was seen after chemotherapy with a median ?SUV_max of 25.3 % and ?SAM of 94.5 % (p?=?0.033 and 0.003). Median baseline SUV_max and SAM values were significantly different between morphological responders and nonresponders (3.8 vs. 7.2, p?=?0.021; and 34 vs. 211, p?=?0.002, respectively), but neither baseline PET parameters nor morphological response was correlated with PFS or OS. Follow-up SUV_max and SAM as well as ?SAM were found to be prognostic factors. The median PFS and OS in the patient group with a high follow-up SUV_max were 10.4 months and 32 months, compared to a median PFS of 14.7 months and a median OS which had not been reached in the group with a low follow-up SUV_max (p?=?0.01 and 0.003, respectively). The patient group with a high follow-up SAM and a low ?SAM had a median PFS and OS of 9.4 months and 32 months, whereas the other group had a median PFS of 14.7 months and a median OS which had not been reached (p?=?0.002 for both PFS and OS).

Conclusion

¹⁸F-FDG PET imaging is a useful tool to assess treatment response and predict clinical outcome in patients with mCRC who undergo chemotherapy before liver metastasectomy. Follow-up SUV_max, follow-up SAM and ?SAM were found to be significant prognostic factors for PFS and OS.     

Does resection of small liver metastases from colorectal cancer improve survival of patients?

Because the size of metastases greatly affects their detection, we retrospectively investigated the influence of the size of liver metastases on survival after hepatic surgery. The subject group study consisted of 77 patients who underwent liver surgery for metastases from colorectal cancer. The survival rate after hepatic surgery was analysed using multivariate Cox's proportional hazards model with the following variables: (1) size of dominant metastases (Small: < 3 cm; Medium: > or = 3 cm and < 6 cm; Large: > or = 6 cm); (2) synchronous versus metachronous resection; (3) solitary versus multiple metastases. The size of dominant metastases (p = 0.035) and synchronous versus metachronous resection (p = 0.0009) were independently associated with survival after liver resection. No association was found, however, for solitary versus multiple metastases. The survival of the Large group was much poorer than that of the Small group (p = 0.0168) and that of the Medium group (p = 0.0205), with statistically significant differences. No statistically significant difference was seen between the Small and the Medium groups (p = 0.7963). This study showed that long-term survival following resection of metastases was much poorer when metastases were 6 cm or greater in diameter. With regard to metastases less than 6 cm in diameter, resection of the smallest of these (less than 3 cm) did not appear to improve survival.     

18F-FDG PET scanning correlates with tissue markers of poor prognosis and predicts mortality for patients after liver resection for colorectal metastases.

(18)F-FDG PET has proven invaluable in the staging of patients with metastatic colorectal cancer. The aim of the current study was to determine whether this biologic scan would correlate with other cellular characteristics and the clinical behavior of tumors. METHODS: Ninety patients with resectable colorectal cancer metastatic to the liver underwent (18)F-FDG PET before hepatectomy. At surgery, tumors were harvested and prepared for assessment by histology and immunohistochemistry. Expression of Ki67 (a marker for cell proliferation), GLUT1 and GLUT3 (markers for glucose transportation), p53 and p27 (markers for cell cycle control), and BCL-2 (a marker for apoptosis) was assessed by a pathologist who was unaware of the PET results and the clinical outcome. Patients were followed to determine outcome. Survival analysis was performed comparing patient outcome in groups segregated according to standardized uptake values (SUVs) greater or less than 5, 7, or 10. RESULTS: Maximum SUV correlated with GLUT1 (P=0.03), Ki67 (P=0.026), and p53 (P=0.024) but did not correlate with p27, BCL-2, or GLUT3. Survival was significantly longer for patients with a low SUV than for patients with a high SUV, with P values of 0.014, 0.025, and 0.0095 for SUV cutoffs of 5, 7, and 10, respectively. CONCLUSION: (18)F-FDG PET is a biologic scan that predicts prognosis in patients with metastatic colorectal cancer. It is uncertain if this ability is due to cellular glucose metabolism or to a correlation with other cellular characteristics of aggressive tumors.     

Local tumor progression after radiofrequency ablation of colorectal liver metastases: evaluation of ablative margin and three-dimensional volumetric analysis

PURPOSE: Detection of local tumor progression (LTP) after radiofrequency (RF) ablation of colorectal cancer liver metastases may facilitate repeat intervention with potential benefits for patient survival. Ablative margins 1 month after RF ablation may predict LTP, and repeated three-dimensional (3D) volumetric analysis of coagulation volume after ablation may provide earlier detection of LTP versus conventional morphologic criteria. MATERIALS AND METHODS: Seven patients with LTP and four patients without LTP after a follow-up of at least 24 months were identified. Multidetector computed tomography (CT) was performed at 1 and 3 months after RF ablation and then at 3-month intervals until 24 months. Ablative margins were determined from preablation tumor diameter and the corresponding coagulation diameter 1 month after ablation. Postablation coagulation volume was measured from 81 follow-up multidetector CT images using a seeding-based semiautomatic 3D method. RESULTS: LTP was detected at a median of 9 months (range, 6-21 months) after RF ablation. A coagulation diameter smaller than the preoperative tumor diameter was associated with LTP. Increase in coagulation volume was found in six of seven patients at the time of diagnosis of LTP by conventional morphologic criteria. CONCLUSION: Three-dimensional volumetric analysis of postablation coagulation volume is feasible for detection of LTP after RF ablation of colorectal cancer liver metastases. No advantage in early detection of LTP was found for 3D volumetric analysis compared with conventional morphologic criteria in this preliminary study. These findings may reflect a type II error caused by the limited sample size.     

Non-invasive diagnostic imaging of colorectal liver metastases

Colorectal cancer is one of the few malignant tumors in which synchronous or metachronous liver metastases [colorectal liver metastases (CRLMs)] may be treated with surgery. It has been demonstrated that resection of CRLMs improves the long-term prognosis. On the other hand, patients with un-resectable CRLMs may benefit from chemotherapy alone or in addition to liver-directed therapies. The choice of the most appropriate therapeutic management of CRLMs depends mostly on the diagnostic imaging. Nowadays, multiple non-invasive imaging modalities are available and those have a pivotal role in the workup of patients with CRLMs. Although extensive research has been performed with regards to the diagnostic performance of ultrasonography, computed tomography, positron emission tomography and magnetic resonance for the detection of CRLMs, the optimal imaging strategies for staging and follow up are still to be established. This largely due to the progressive technological and pharmacological advances which are constantly improving the accuracy of each imaging modality. This review describes the non-invasive imaging approaches of CRLMs reporting the technical features, the clinical indications, the advantages and the potential limitations of each modality, as well as including some information on the development of new imaging modalities, the role of new contrast media and the feasibility of using parametric image analysis as diagnostic marker of presence of CRLMs.     

Radiofrequency ablation therapy of remnant colorectal liver metastases after a course of hepatic arterial infusion chemotherapy

The present study evaluated the feasibility of combined therapy employing repeated hepatic arterial infusion chemotherapy (HAIC) via a port-catheter system and radiofrequency (RF) ablation for unresectable metastatic liver cancer from the colo-rectum. RF ablation was performed for six patients with liver malignancies that had been well controlled and had decreased in number and size with repeated HAIC. After RF ablation subsequent to repeated HAIC, all six patients had stable disease or complete or partial remission as documented by follow-up contrast-enhanced computed tomographic (CT) imaging. Fluorodeoxyglucose positron emission tomography (18F) showed complete response in all ablated lesions. In conclusion, RF ablation after a course of HAIC achieved complete necrosis in residual lesions after HAIC therapy.     

^131I—抗CEA单抗防治大肠癌根治术后肝转移的实验研究

目的 探讨＾１３１Ｉ－抗癌胚抗原－（ＣＥＡ）单抗防治裸鼠体内人结肠癌细胞肝转移的效果。方法 裸鼠脾内注入人结肠癌细胞后、脾切除后第４或第８ｄ腹腔注射＾１３１Ｉ－抗ＣＥＡ单抗,观察术后生存时间,并对肝脏进行组织学检查。结果 术后第４或第８ｄ腹腔注射＾１３１Ｉ－抗ＣＥＡ单抗,观察术后生存时间,;术后第４ｄ注射可使肝转移率减少３３．３％,第８ｄ注射不能使肝转移率减少。结论 术后早期行放射免疫治疗可取得较     

Angiography as diagnostic, prognostic and therapeutic tool in liver metastases from a colo-rectal primary tumor

Angiograms from 60 patients with liver metastases from colo-rectal carcinoma were reviewed in retrospect to find prognostic parameters. All patients were treated with intraarterial cytostatic drugs. Patients with a small tumor mass in the liver survived significantly longer than those with a huge tumor burden. A longer survival was seen also in patients who developed occlusion of the hepatic arterial tree. When the tumor showed reduction in size or was stationary at the follow-up angiographic examinations after institution of therapy survival was markedly improved. When compared with the findings at laparotomy, angiography adequately demonstrated tumor growth in the right lobe of the liver but repeatedly failed to do so in the left lobe. In 14 patients computed tomography was also performed. Tumor localization by CT corresponded well with the findings at laparotomy and was thus more accurate than the results by angiography. Information about tumor volume and number of tumor nodules was approximately the same with the two methods.     

Adjuvant therapy after resection of brain metastases

Background

Tumor bed stereotactic radiosurgery (SRS) after resection of brain metastases is a new strategy to delay or avoid whole-brain irradiation (WBRT) and its associated toxicities. This retrospective study analyzes results of frameless image-guided linear accelerator (LINAC)-based SRS and stereotactic hypofractionated radiotherapy (SHRT) as adjuvant treatment without WBRT.

Materials and methods

Between March 2009 and February 2012, 44 resection cavities in 42 patients were treated with SRS (23 cavities) or SHRT (21 cavities). All treatments were delivered using a stereotactic LINAC. All cavities were expanded by ≥?2 mm in all directions to create the clinical target volume (CTV).

Results

The median planning target volume (PTV) for SRS was 11.1 cm³. The median dose prescribed to the PTV margin for SRS was 17 Gy. Median PTV for SHRT was 22.3 cm³. The fractionation schemes applied were: 4 fractions of 6 Gy (5 patients), 6 fractions of 4 Gy (6 patients) and 10 fractions of 4 Gy (10 patients). Median follow-up was 9.6 months. Local control (LC) rates after 6 and 12 months were 91 and 77?%, respectively. No statistically significant differences in LC rates between SRS and SHRT treatments were observed. Distant brain control (DBC) rates at 6 and 12 months were 61 and 33?%, respectively. Overall survival (OS) at 6 and 12 months was 87 and 63.5?%, respectively, with a median OS of 15.9 months. One patient treated by SRS showed symptoms of radionecrosis, which was confirmed histologically.

Conclusion

Frameless image-guided LINAC-based adjuvant SRS and SHRT are effective and well tolerated local treatment strategies after resection of brain metastases in patients with oligometastatic disease.     

Percutaneous stereotactic radiofrequency ablation of colorectal liver metastases

Objectives  

To evaluate the outcome of patients with colorectal liver metastasis (CRLM) treated with stereotactic radiofrequency ablation (SRFA).     

结直肠肝转移瘤的经皮立体定向射频消融术

目的评价立体定向射频消融(SRFA)治疗结直肠肝转移瘤(CRLM)的疗效。方法经伦理委员会批准,回顾性评估连续的63例病人189个CRLM的98次射频消融治疗过程。分析局部复发率(LR)、总体生存期(OS)和无病生存期(DFS)。结果LR见于16%(31/189)的肿瘤,瘤体直径为<3cm     

Portal vein embolisation prior to hepatic resection for colorectal liver metastases and the effects of periprocedure chemotherapy

Portal vein embolisation (PVE) is an effective method of increasing future liver remnant (FLR) but may stimulate tumour growth. The effect of periprocedure chemotherapy has not been established. 15 consecutive patients underwent PVE prior to hepatic resection for colorectal liver metastases with a FLR <30% of tumour-free liver (TFL). Liver and tumour volumes pre-PVE and 6 weeks post-PVE were calculated by CT or MRI volumetry and correlated with the periprocedure chemotherapy regimen. PVE increased the FLR from 18+/-5% of TFL to 27+/-8% post-PVE (p<0.01). Post-PVE chemotherapy did not prevent hypertrophy of the FLR but the volume increase with chemotherapy (median 89 ml, range 7-149 ml) was significantly reduced (median 135 ml, range 110-254 ml without chemotherapy) (p = 0.016). Tumour volume (TV) decreased in those receiving post-PVE chemotherapy (median TV decrease 8 ml, range -77 ml to +450 ml) and increased without chemotherapy (median TV increase 39 ml, range -58 ml to +239 ml). Of the 15 patients, eight underwent resection; four were not resected due to disease progression and three due to insufficient hypertrophy of the FLR. PVE increased the FLR by an average of 9% allowing resection in 50% of patients. Periprocedure chemotherapy did not prevent but did reduce hypertrophy. A trend towards tumour regression was observed.     

Intra-arterial treatment of liver metastases from colorectal carcinoma

Colorectal carcinoma is a major public health concern with its yearly mondial incidence of about one million cases and yearly mortality of 500,000 cases. The liver is the organ most frequently affected by metastases with a frequency of 40 to 60% (contemporaneous in 25% of cases). While surgical resection is the only curative therapy, many patients are not such candidates due to the infiltrative nature of the liver metastases. Systemic chemotherapy and biotherapy regimens are the conventional treatment options for patients with multiple liver metastases. Under such circumstances, intra-arterial therapy may play a major role. We will review the main types of endovascular therapies for liver metastases from colorectal carcinoma including indications, results and potential complications.