Repeat Local Treatment of Recurrent Colorectal Liver Metastases, the Role of Neoadjuvant Chemotherapy: An Amsterdam Colorectal Liver Met Registry (AmCORE) Based Study.

Madelon Dijkstra,Hester J Scheffer,Birgit I Lissenberg-Witte,Jip Opperman,Martijn R Meijerink,Sanne Nieuwenhuizen,Evelien A C Schouten,Jan J J De Vries,Florentine E F Timmer,Monique Petrousjka Van Den Tol,Robbert S Puijk,Bart Geboers,Kathelijn S Versteeg

doi:10.3390/cancers13194997

Abstract

Simple SummaryFollowing curative intent local treatment for patients with colorectal liver metastases (CRLM), 64 to 85% of patients develop distant intrahepatic recurrence. Repeat local treatment, comprising partial hepatectomy and/or thermal ablation, is currently considered standard of care to treat these recurrences. This AmCORE-based study evaluated efficacy, safety and survival outcomes of neoadjuvant chemotherapy (NAC) followed by repeat local treatment compared to upfront repeat local treatment to eradicate recurrent CRLM. Adding NAC prior to repeat local treatment did not improve survival or distant and local recurrence rates, nor did it affect periprocedural morbidity or length of hospital stay. The results of this comparative assessment do not substantiate the routine use of NAC prior to repeat local treatment of CRLM. Because the exact role of NAC (in different subgroups) remains inconclusive, we are currently designing a phase III randomized controlled trial (RCT), COLLISION RELAPSE trial, directly comparing upfront repeat local treatment to neoadjuvant systemic therapy followed by repeat local treatment.This cohort study aimed to evaluate efficacy, safety, and survival outcomes of neoadjuvant chemotherapy (NAC) followed by repeat local treatment compared to upfront repeat local treatment of recurrent colorectal liver metastases (CRLM). A total of 152 patients with 267 tumors from the prospective Amsterdam Colorectal Liver Met Registry (AmCORE) met the inclusion criteria. Two cohorts of patients with recurrent CRLM were compared: patients who received chemotherapy prior to repeat local treatment (32 patients) versus upfront repeat local treatment (120 patients). Data from May 2002 to December 2020 were collected. Results on the primary endpoint overall survival (OS) and secondary endpoints local tumor progression-free survival (LTPFS) and distant progression-free survival (DPFS) were reviewed using the Kaplan–Meier method. Subsequently, uni- and multivariable Cox proportional hazard regression models, accounting for potential confounders, were estimated. Additionally, subgroup analyses, according to patient, initial and repeat local treatment characteristics, were conducted. Procedure-related complications and length of hospital stay were compared using chi-square test and Fisher’s exact test. The 1-, 3-, and 5-year OS from date of diagnosis of recurrent disease was 98.6%, 72.5%, and 47.7% for both cohorts combined. The crude survival analysis did not reveal a significant difference in OS between the two cohorts (p = 0.834), with 1-, 3-, and 5-year OS of 100.0%, 73.2%, and 57.5% for the NAC group and 98.2%, 72.3%, and 45.3% for the upfront repeat local treatment group, respectively. After adjusting for two confounders, comorbidities (p = 0.010) and primary tumor location (p = 0.023), the corrected HR in multivariable analysis was 0.839 (95% CI, 0.416–1.691; p = 0.624). No differences between the two cohorts were found with regards to LTPFS (HR = 0.662; 95% CI, 0.249–1.756; p = 0.407) and DPFS (HR = 0.798; 95% CI, 0.483–1.318; p = 0.378). No heterogeneous treatment effects were detected in subgroup analyses according to patient, disease, and treatment characteristics. No significant difference was found in periprocedural complications (p = 0.843) and median length of hospital stay (p = 0.600) between the two cohorts. Chemotherapy-related toxicity was reported in 46.7% of patients. Adding NAC prior to repeat local treatment did not improve OS, LTPFS, or DPFS, nor did it affect periprocedural morbidity or length of hospital stay. The results of this comparative assessment do not substantiate the routine use of NAC prior to repeat local treatment of CRLM. Because the exact role of NAC (in different subgroups) remains inconclusive, we are currently designing a phase III randomized controlled trial (RCT), COLLISION RELAPSE trial, directly comparing upfront repeat local treatment (control) to neoadjuvant systemic therapy followed by repeat local treatment (intervention).

Highlights

Colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-associated deaths worldwide [1]
Patients with recurrent colorectal liver metastases (CRLM) were identified from the Amsterdam Colorectal Liver Met Registry (AmCORE) database, revealing
Notwithstanding, no difference in periprocedural morbidity and length of hospital stay was detected between the neoadjuvant chemotherapy (NAC) group and upfront repeat local treatment group

Summary

Introduction

Colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-associated deaths worldwide [1]. Roughly 20% of patients with CRLM are eligible for local treatment options, such as partial hepatectomy or thermal ablation (i.e., radiofrequency ablation (RFA), microwave ablation (MWA)) [16]. Whereas partial hepatectomy was considered standard of care for resectable CRLM in the last few decades, thermal ablation for small unresectable CRLM is considered as an option resulting in cure [3,15,17,18,19,20,21,22,23,24]. Five-year OS of initially unresectable CRLM reaches, when successfully downstaged with induction chemotherapy followed by local treatment, 33% [25]

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Discussion

Conclusion