Comparative analysis of radiofrequency ablation and resection for resectable colorectal liver metastases

AIM:To evaluate the therapeutic efficacy of radiofrequency ablation(RFA)for resectable colorectal liver metastases(CRLM)compared with that of resection.METHODS:Between June 2004 and June 2009,we retrospectively analyzed 29 patients with resectable CRLMs;17 patients underwent RFA,and 12 underwent hepatic resection.All of the patients were informed about the treatment modalities and were allowed to choose either of them.RFA including an intraoperative approach was performed by a radiologist;otherwise,hepatic resection was performed by a surgeon.Comparative analysis of the two groups was performed,including comparisons of gender,age,and clinical outcomes,such as primary tumor stage and survival rates.RESULTS:The mean tumor size was significantly larger in the resection group(3.59 cm vs 2.02 cm,P<0.01),and the 5-year overall survival(OS)rate for all patients was 44.7%.There was no difference in the 5-year OS rates between the RFA and resection groups(37.8%vs66.7%).Univariate analysis indicated significantly lower5-year OS rates for patients with a tumor size>3cm.The 5-year disease-free survival(DFS)rates were17.6%and 22.2%in the RFA and resection groups,respectively(P=0.119).Univariate analysis revealed that in cases of male gender,age>65 years,T stage<Ⅳ,absence of lymphatic metastasis,and tumor size>3 cm,RFA resulted in significantly inferior 5-year DFS rates compared with surgical resection.CONCLUSION:Surgical resection revealed superior outcomes in the treatment of resectable CRLMs,particularly in cases with a hepatic tumor size>3 cm.     

Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection

Surgical resection of colorectal liver metastases(CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin(R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.     

Liver resection or cryotherapy for colorectal liver metastases

Background and aims While there is promising survival data for cryosurgery of colorectal liver metastases, local recurrence following cryoablation remains a problem. We aimed to compare morbidity and mortality, as well as the recurrence pattern and survival after liver resection and cryotherapy (alone or in combination with resection) for liver metastases.Patients and methods Between 1996 and 2002, 168 patients underwent liver resection alone and 55 patients had cryotherapy (25 in combination with liver resection) for colorectal liver metastases. The patient, tumour and operative details were recorded prospectively and the two patient groups were compared regarding morbidity, survival and recurrence.Results More patients had a prior liver resection, liver metastases were smaller and less frequently synchronous, morbidity was significantly lower and hepatic recurrence was significantly more frequent in the cryotherapy group. Five-year survival rates following resection and cryotherapy were comparable (23 and 26% respectively), while overall and hepatic recurrence-free survival was inferior following cryotherapy.Conclusion Cryotherapy is a valuable treatment option for some patients with non-resectable colorectal liver metastases. While survival is comparable to that after resection, higher hepatic recurrence rates following cryotherapy should caution against the use of cryotherapy for resectable disease until the results of randomized controlled trials are available.     

Hepatectomy vs radiofrequency ablation for colorectal liver metastasis:A propensity score analysis

AIM:To compare outcomes from radiofrequency ablation(RFA) and hepatectomy for treatment of colorectal liver metastasis(CRLM).METHODS:From January 2000 to December 2009,408 patients underwent curative intent treatment for CRLM.We excluded patients using the criteria:size of CRLM 3 cm,number of CRLM ≥ 5,percutaneous RFA,follow-up period 12 mo,double primary cancer,or treatment with both RFA and hepatectomy.We matched 51 patients who underwent RFA with 102 patients who underwent hepatectomy by propensity scores.RESULTS:The median follow-up period was 45 mo(range,12 mo to 158 mo).Hepatic recurrence was more frequent in the RFA than the hepatectomy group(P = 0.021) although extrahepatic recurrence curves were similar(P = 0.716).Survival curves of hepatectomy group were better than that of RFA for multiple,large( 2 cm) CRLM(P = 0.034).However,survival curves were similar for single or small(≤ 2 cm) CRLM(P = 0.714,P = 0.740).CONCLUSION:Hepatectomy is better than RFA for the treatment of CRLM.However,RFA might be suitable for selected patients with single,small(≤ 2 cm) CRLM.     

Role of surgery in colorectal cancer liver metastases

Colorectal carcinoma (CRC) is the third most common cancer, and approximately 35%-55% of patients with CRC will develop hepatic metastases during the course of their disease. Surgical resection represents the only chance of long-term survival. The goal of surgery should be to resect all metastases with negative histological margins while preserving sufficient functional hepatic parenchyma. Although resection remains the only chance of long-term survival, management strategies should be tailored for each case. For patients with extensive metastatic disease who would otherwise be unresectable, the combination of advances in medical therapy, such as systemic chemotherapy (CTX), and the improvement in surgical techniques for metastatic disease, have enhanced prognosis with prolongation of the median survival rate and cure. The use of portal vein embolization and preoperative CTX may also increase the number of patients suitable for surgical treatment. Despite current treatment options, many patients still experience a recurrence after hepatic resection. More active systemic CTX agents are being used increasingly as adjuvant therapy either before or after surgery. Local tumor ablative therapies, such as microwave coagulation therapy and radiofrequency ablation therapy, should be considered as an adjunct to hepatic resection, in which resection cannot deal with all of the tumor lesions. Formulation of an individualized plan, which combines surgery with systemic CTX, is a necessary task of the multidisciplinary team. The aim of this paper is to discuss different approaches for patients that are treated due to CRC liver metastasis.     

Aggressive liver resection including major-vessel resection for colorectal liver metastases

AIM: To clarify short- and long-term outcomes of combined resection of liver with major vessels in treating colorectal liver metastases.METHODS: Clinicopathologic data were evaluated for 312 patients who underwent 371 liver resections for metastases from colorectal cancer. Twenty-five patients who underwent resection and reconstruction of retrohepatic vena cava, major hepatic veins, or hepatic venous confluence during hepatectomies were compared with other patients, who underwent conventional liver resections.RESULTS: Morbidity was 20% (75/371) and mortality was 0.3% (1/312) in all patients after hepatectomy. Hepatic resection combined with major-vessel resection/reconstruction could be performed with acceptable morbidity (16%) and no mortality. By multivariate analysis, repeat liver resection (relative risk or RR, 5.690; P = 0.0008) was independently associated with resection/reconstruction of major vessels during hepatectomy, as were tumor size exceeding 30 mm (RR, 3.338; P = 0.0292) and prehepatectomy chemotherapy (RR, 3.485; P = 0.0083). When 312 patients who underwent a first liver resection for initial liver metastases were divided into those with conventional resection (n = 296) and those with combined resection of liver and major vessels (n = 16), overall survival and disease-free rates were significantly poorer in the combined resection group than in the conventional resection group (P = 0.02 and P < 0.01, respectively). A similar tendency concerning overall survival was observed for conventional resection (n = 37) vs major-vessel resection combined with liver resection (n = 7) performed as a second resection following liver recurrences (P = 0.09). Combined major-vessel resection at first hepatectomy (not performed; 0.512; P = 0.0394) and histologic major-vessel invasion at a second hepatectomy (negative; 0.057; P = 0.0005) were identified as independent factors affecting survival by multivariate analysis.CONCLUSION: Hepatic resection including major-vessel resection/reconstruction for colorectal liver metastases can be performed with acceptable operative risk. However, such aggressive approaches are beneficial mainly in patients responding to effective prehepatectomy chemotherapy.     

结直肠癌肝转移影像诊断策略

超声、CT、MRI、PET/CT及PET/MR在结直肠癌肝转移诊治中广泛应用,NCCN指南提出结直肠癌肝转移影像学诊断首选增强MR,但对于每个结直肠癌肝转移患者如何选择合适的影像学检查,充分合理地应用有限的资源是临床关注的重点。结合国内外文献及笔者多年的MDT经验,对于结直肠癌肝转移患者,在参照指南的基础上更要结合患者自身病情,由多学科专家讨论做出合理的影像诊断。     

Referral patterns of patients with liver metastases due to colorectal cancer for resection

Introduction  Colorectal carcinoma accounts for 10% of cancer deaths in the Western World, with the liver being the most common site of distant metastases. Resection of liver metastases is the treatment of choice, with a 5-year survival rate of 35%. However, only 5–10% of patients are suitable for resection at presentation. Aims  To examine the referral pattern of patients with liver metastases to a specialist hepatic unit for resection. Methodology  Retrospective review of patient’s charts diagnosed with colorectal liver metastases over a 10-year period. Results  One hundred nine (38 women, 71 men) patients with liver metastases were included, mean age 61 years; 79 and 30 patients had synchronous and metachronus metastases, respectively. Ten criteria for referral were identified; the referral rate was 8.25%, with a resection rate of 0.9%. Forty two percent of the patients had palliative chemotherapy; 42% had symptomatic treatment. Conclusion  This study highlights the advanced stage of colorectal cancer at presentation; in light of modern evidence-based, centre-oriented therapy of liver metastasis, we conclude that criteria of referral for resection should be based on the availability of treatment modalities.     

手术切除联合射频消融治疗结肠癌肝转移疗效分析

目的 探讨手术联合射频消融治疗结肠癌肝转移患者的治疗效果。方法 对2008年1月至2014年3月我科诊治的结肠癌肝转移接受结肠癌根治术和肝内肿瘤灶切除治疗的17例和结肠癌根治术后对肝内肿瘤行射频消融（RFA）治疗的12例患者的临床资料进行回顾性分析。绘制Kaplan-Meier生存曲线,进行生存分析。结果 单纯手术治疗的17例患者均于术后20个月内死亡,平均生存时间为（13.412±0.912）月,而手术联合射频消融治疗的12例患者随访6~28个月,平均生存时间为（18.496±2.139）月（P<0.05）;RFA治疗后患者均出现不同程度的恶心、呕吐、胸闷、右上腹痛、发热,血清ALT和AST轻度升高。结论 手术联合射频消融治疗结肠癌肝转移是一种可行的、安全的、有效的方法,可以明显延长患者的生存期。     

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

Objective: A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).Methods: A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.Results: Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.Conclusion: A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.     

Pulmonary resection for metastases from colorectal cancer: prognostic factors and survival

Backgrounds Pulmonary metastases occur in up to 10% of all patients who undergo curative resection. Surgical resection is an important part in the treatment of pulmonary metastasis from colorectal cancer. We analyzed the treatment outcome and prognostic factors affecting survival in this subset of patients. Materials and methods Between October 1994 and December 2004, 59 patients underwent curative resection for pulmonary metastases of colorectal cancer. Uncontrollable synchronous liver and lung metastasis or synchronous colorectal cancer with isolated lung metastasis were excluded from this study. A retrospective review of patient characteristics and factors influencing survival was performed. Survival was analyzed by the Kaplan–Meier method. Comparison between groups were performed by a log-rank analysis and the Cox proportional hazard model. Results The 5-year overall survival rate of all patients who received pulmonary resection was 50.3%. The number of pulmonary metastases was significantly related with survival in univariate analysis, but not in multivariate analysis (p = 0.032). Prethoracotomy carcinoembryonic antigen (CEA) level exceeding 5 ng/ml was related with poor survival (p = 0.001). A disease-free interval of greater than 2 years did not correlate with survival after thoracotomy (p = 0.3). Conclusion The prethoracotomy CEA level and the number of metastases were independent prognostic factors. Resection of pulmonary metastasis from colorectal cancer may result in improved survival or even healing in selected patients. Pulmonary resection of colorectal cancer is regarded as a safe and effective treatment with low morbidity and mortality rates.     

Concurrent vs. staged colectomy and hepatectomy for primary colorectal cancer with synchronous hepatic metastases

PURPOSE: Resection of hepatic metastases is the preferred treatment for selected patients after resection of primary colorectal carcinoma, but timing is controversial. This study was designed to compare outcomes of patients receiving concurrent resection of hepatic metastases and the primary colorectal tumor with those of patients receiving staged resection (within 6 months).METHODS: We retrospectively analyzed medical records (1986–1999) of 96 consecutive patients with synchronously recognized primary carcinoma and hepatic metastases who underwent concurrent (64 patients) or staged (32 patients) colonic and hepatic resections performed at our institution.RESULTS: Concurrent and staged groups were similar in demographics, tumor grade, stage, preoperative comorbidity (cardiac and respiratory), characteristics of hepatic metastases, and single vs. multiple lesions. No significant differences were observed between groups (concurrent vs. staged) in type of colon resection (P = 0.45) or hepatic resection (P = 0.09), overall operative duration (mean, 430 vs. 427 minutes; P = 0.39), blood loss (mean, 890 vs. 889 ml; P = 0.87), volume of blood products transfused (mean, 326 vs. 185 ml; P = 0.08), perioperative morbidity (53 vs. 41 percent; P = 0.25), disease-free survival from date of hepatectomy (median, 13 vs. 13 months; P = 0.53), or overall survival from date of hepatectomy (median, 27 vs. 34 months; P = 0.52). There was no operative mortality. Overall duration of hospitalization was significantly shorter for concurrent than for staged resection (mean, 11 vs. 22 days; P 0.001).CONCLUSIONS: Concurrent colectomy and hepatectomy is safe and more efficient than staged resection and should be the procedure of choice for selected patients in medical centers with appropriate capacity and experience.Poster presentation at the Digestive Disease Week meeting, San Diego, California, May 16 to 19, 1999.     

趋化因子受体CXCR4/CXCL12信号转导通路在结直肠癌肝转移中的作用

目的:探讨CXCR4／CXCL12在结直肠癌肝转移中的作用．方法:应用Western blot检测160例结直肠癌患者标本中肿瘤组织、邻近正常黏膜以及肝转移组织中CXCR4／CXCL12通路成员的表达情况,免疫组织化学法检测CXCR4／CXCL12在细胞水平的分布．结果:与正常组织相比,结直肠癌组织中 CXCR4／CXCL12表达水平明显增高(P<0．05); 与原发肿瘤相比,10例肝转移组织中CXCR4／ CXCL12表达增高(CXCR4:3．9±0．5 vs 2．2± 0．3,P<0．05:CXCL12:3．6±0．5 vs 2．4±0．3, P<0．05):TNMⅢ、Ⅳ分期CXCR4／CXCL12表达水平比Ⅰ、Ⅱ分期显著增加有关(CXCR4: 3．4±0．6 vs 1．8±0．3．P<0．05;CXCL12:3．6± 0．5 vs 1．8±0．4．P<0．05)．结论:趋化因子受体CXCR4／CXCL12在原发结直肠癌与肝转移组织中呈高表达,CXCR4／ CXCL12信号转导通路可能在结直肠癌肝转移过程中起一定作用．     

结直肠癌肝转移的危险因素分析138例

目的:探讨影响结直肠癌肝转移的危险因素.方法:采用Kaplan-Meier和多因素回归分析方法,分析138例有完整随访资料的结直肠癌肝转移患者的生存情况及影响预后的相关因素.结果:138例患者的中位生存时间为18.3mo.单因素分析显示,患者年龄(P=0.460)、原发肿瘤部位(P=0.568)、原发肿瘤最大直径(P=0.250)、原发肿瘤组织学分级(P=0.589)与患者的总生存时间无关,而性别(P=0.048)、治疗前血清CEA水平(P=0.023)、肝转移灶数目(P=0.000)、肝转移灶最大直径(P=0.001)、区域淋巴结转移情况(P=0.001)、肝转移灶手术与否(P=0.002)与患者的预后有关.多因素回归分析显示,治疗前血清CEA水平(P=0.028)、肝转移灶数目(P=0.001)、肝转移灶最大直径(P=0.001)、区域淋巴结转移情况(P=0.049)、肝转移灶手术与否(P=0.003)是影响结直肠癌肝转移患者预后的主要因素.结论:治疗前血清CEA水平、肝转移灶数目、肝转移灶最大直径、区域淋巴结转移情况、肝转移灶手术与否是结直肠癌肝转移患者预后的影响因素;治疗前血清CEA水平越低、肝转移灶数目越少、肝转移灶最大直径越小、无区域淋巴结转移、肝转移灶通过手术治疗的患者预后越好.     

结直肠癌同时性肝转移患者原发灶切除的预后分析

目的 原发灶切除能否使结直肠癌肝转移患者生存获益,目前仍有争议.本研究探讨接受原发灶切除结直肠癌肝转移患者的生存状况及预后的影响因素.方法 回顾性分析2010年1月～2018年2月在国家癌症中心/中国医学科学院肿瘤医院治疗的371例结直肠癌同时性肝转移患者的病例资料.根据治疗方式分为单纯化疗组和原发灶切除组,分析两组患...     

Comparison of surgical outcomes in patients with colorectal liver metastases versus non‐colorectal liver metastases: A Chinese experience

Aim: To compare the surgical treatment outcomes between patients with colorectal liver metastases (CLM) and non‐colorectal liver metastases (NCLM). Methods: The study population consisted of 132 patients undergoing hepatectomy at Tianjin Medical University Cancer Hospital between January 1996 and December 2008. Survival analyses were used to assess the differences in prognosis and survival between groups. Results: The primary tumor site was colorectal in 60 (45.5%), breast in 16 (12.1%), lung in 14 (10.6%), non‐colorectal gastrointestinal in 12 (9.1%), genitourinary in 10 (7.6%), pancreatobiliary tumor (n = 8, 6.1%) and others in 12 (9.1%). A curative liver resection was performed in all patients by pathological findings. After a median follow‐up of 32 months, the overall 3‐ and 5‐year survival rate was 44.7 and 29.5% in all patients, respectively. The 3‐ and 5‐year survival rates were 53.3 and 36.7% for liver metastases from colorectal tumors, 62.5 and 43.8% from breast, 60.0 and 40.0% from genitourinary neoplasm, 41.7 and 25.0% from non‐colorectal gastrointestinal cancer, 28.5 and 15.0% from lung, 12.5 and 0% from pancreatobiliary malignancies, and 41.7 and 8.3% from other sites, respectively. Conclusions: Hepatic resection is an effective and safe treatment for liver metastases mainly depending on primary tumor sites. Hepatic metastases from non‐colorectal gastrointestinal cancer, pulmonary and pancreatobiliary malignancies have the worst prognosis; those from breast and genitourinary neoplasm show the best prognosis.     

In vitro detection of occult bone marrow metastases in patients with colorectal cancer hepatic metastases

PURPOSE: The purpose of this study was to assess the immunocytochemical status of bone marrow aspirates from patients with clinically isolated hepatic metastases to test the hypothesis that such findings would allow improved patient selection for liver-directed treatment. METHODS: All patients had biopsy-proven or presumed colorectal cancer metastatic to the liver and were scheduled for an operative procedure for hepatic resection or for hepatic artery catheter and chemotherapy pump implant. Immunocytochemical analysis of bone marrow aspirate smears was performed with a panel of monoclonal antibodies directed toward cytokeratins, Lewis Y antigen and A-33 colorectal epitopes. RESULTS: Data from 80 patients indicated that bone marrow reactivity was present in 9.5 percent of those with resectable hepatic metastases and in 34 percent of those not resected (P=0.03). No single monoclonal antibody or combination produced better discrimination. CONCLUSIONS: Presence or absence of presumed occult colorectal cancer cells in the bone marrow of patients with isolated hepatic metastases is biologically interesting, but not useful in selecting or altering patient management.Supported in part by the Ludwig Institute.     

Intensive or not surveillance of patients with colorectal cancer after curative resection

It is common practice to follow patients with colorectal cancer for some years after resection and/or adjuvant treatment.Data are lacking about how often patients should be seen,what tests should be performed,and what surveillance strategy has a signifi cant impact on patient outcome.Seven randomized trials have addressed this issue,but none had sufficient statistical power.Four published meta-analyses have established that overall survival is significantly improved for patients in the more intensive progra...