Development Of Liver Metastases Research Articles

Lymph Node Ratio and Liver Metachronous Metastases in Colorectal Cancer

The authors seek to assess whether the lymph node ratio (the ratio of positive nodes divided by the total number of retrieved nodes) could predict the risk of metachronous liver metastases. A homogeneous group of 280 patients, followed-up for at least 5 years, was evaluated. In order to highlight the groups with the highest risk of metachronous liver metastases, patients were divided into four quartiles groups in relation to the LNR. The number of lymph nodes sampled in group "stage I" was significantly lower. Even if statistical significance between the global LNR and the development of liver metastases has not been reached, the subdivision into quartiles has made it possible to highlight that in the more advanced ratio groups, a higher incidence of metachronous liver metastases (p <0.028) was registered and was a different distribution of patients with or without liver metastasis in function of quartiles (P =0.01). The LNR has enabled us to prognosticate patients who are at greater risk of developing metachronous liver metastases. The lower lymph node sampling in the patients with less advanced staging (I) and in patients with nodenegative cancer (I+II) who developed liver metastases, leads us to believe that some patients have been understaged. We believe that the LNR, especially in cases of adequate lymph node sampling, is a useful gauge to better sub-stratify "node-positive" patients. Colorectal cancer, Liver metastases, Lymph node ratio.

Liver resection of metastases for colorectal cancer, gastric cancer and breast cancer: two hospital experiences

Background: Surgical resection of liver metastases from colorectal cancer (CRC) is considered to have the curative potential in selected patients. In the field of gastric cancer (GC) and breast cancer (BC), opinion differs from one another. Methods: We analyzed the outcomes for patients who underwent liver resection for CRC liver metastases (CRLM), gastric cancer liver metastases (GLM) and breast cancer liver metastases (BLM) in two hospitals to identify the survival and prognostic factors. Results: From January 2002 to January 2015, a total of 181 patients were enrolled in the study. Primary tumor sites included 122 CRC, 38 GC and 21 BC. The overall 5-year survival rate was 39.2% in all the 181 patients, and that was 42.5%, 25.1%, 52.4% in CRLM, GLM and BLM patients, respectively. The 5-year survival rate was 45.7% and 33.9% (P=0.03) in patients with disease-free survival (DFS) ≥18 and <18 months, respectively (DFS referred to the interval between the primary tumor operation and the development of liver metastases). The median time to recurrence after liver resection was 17 months (range, 2–82 months). There were 99 patients (54.7%) and 112 recurrence occurred during the study. Conclusions: Liver resection for metastases was associated with long-term survival for selected patients. Longer disease free interval between primary tumor resection and occurrence of liver metastases indicated longer overall survival after the operation of liver metastases.

D38 - Prediction of tumor response after neoadjuvant chemoradiotherapy in rectal cancer using 18fluorine-2-deoxy-d-glucose positron emission tomography-computed tomography: a prospective study

Background: treatment of locally advanced rectal cancer (RC) includes pre-operative radiation therapy with chemotherapy (CRT) followed by radical surgery. The aim of this study was evaluate the role of 18fluorine-2-deoxy-D-glucose POSITRON EMISSION THOMOGRAPHY/COMPUTED TOMOGRAFY ( (18/F-FDG PET/CT) in the prediction of pathologic complete response (pCR) after CRT for rectal cancer. Material and methods: thirty-six patients (pts) ( 21 males and 15 females, age 33-84) with cT2-4 N0-2 rectal adenocarcinoma were included. This patients underwent integrated 18/F-FDG PET/CT, followed by neoadjuvant chemo-radiotherapy, PET/CT and surgery. The PET/CT results were compared with histopathological data ( Mandar's Tumor Regression Grade: TRG1 vs TRG5 as well as ypT0 N0 vs ypT1-4 N0-2. The patients were stratified according to the percentage decrease of standardized uptake values (SUV) of PET/TC: < 50% decrease, > 50% decrease and no metabolic activity. Results: All of 36 patients with PET/TC imaging before and after adjuvant chemoradiation was available. In 38 % of pts the post -CRT SUV was negative: 6 pts with pCR and TRG 1; 1 pt refused surgery; 1 pt developed liver metastasis. In 28 % of pts the post -CRT SUV decrease was > 50%: 2 pts with pCR and TRG 1, 1 pt developed lung metastasis. In 34 % of pts the post -CRT SUV decrease was < 50%: 2 pts with pCR and TRG 1, 2 pt developed lung metastasis, 1 pt developed liver metastasis and 1 pt developed brain metastasis. Conclusions: In rectal cancer PET/CT is a promising imaging marker to predict pRC to neoadjuvant theraphy.

Abstract 502: Gene expression signatures in circulating tumor cells are prognostic for metastatic lesions in breast cancer patients and correlate with response to therapy

Abstract Background: Circulating tumor cells (CTC) are discussed to be an ideal surrogate marker to monitor disease progression in metastatic breast cancer (MBC). Besides CTC characterization for targeted therapies, it would also be desirable to know where these cells derive from or to which organ site they are going to. Here we investigated whether it is possible to predict the origin of metastatic lesion based on the expression of 46 genes in CTC of MBC patients (pts). Materials and Methods: 2×5 ml blood of 45 MBC pts and 20 healthy controls was collected at the time of disease progression (T0) and at two consecutive clinical staging (T1 and T2) for the detection of CTC applying immunomagnetic enrichment using the AdnaTest EMT-2/Stem Cell Select (QIAGEN Hannover GmbH, Germany). Pts were grouped a) into overall responders (OR) and overall non-responders (ONR), thus responding or not responding at T1 and T2 and b) according to sites of metastasis. PCR assays, targeting 46 transcripts and reference markers were used for a workflow based on pre-amplification and high throughput profiling (each samples in duplicates) with the full set of markers including also ValidPrime to correct for genomic background and InterPlate Calibrator to even out variations between runs. Data were analyzed using GenEx (MultiD, Sweden) and SAS. qPCR as well as technical reads were normalized using several normalization strategies. Results: The multidrug resistant protein gene MRP1 was significantly differently expressed if OR and ONR groups were compared. In the following order of significance, VEGFR1, Keratin (KRT) 19, EGFR, MET1, ALDH, progesterone receptor (PR), UPA, Cathepsin D, KIT1 and Ki67 were differentially expressed in CTC of pts who had already developed liver metastasis as compared to pts without liver metastasis. Interestingly, a small group of pts, developing liver metastases in the course of disease, showed the estrogen receptor (ER), PR, HER2, mammaglobin, KRT19 on a significantly lower level as compared to the other pts. Similarly, once CTC were ER and PR positive, the probability of bone metastasis development decreased. Conclusion: Our preliminary results indicate that the development of metastatic lesions is associated with site-specific CTC. Thus, besides using CTC as a monitoring tool to guide therapy, they might also indicate the site of metastasis which will allow a more precise decision concerning treatment strategy. Citation Format: Maren Bredemeier, Philippos Edimiris, Pawel Mach, Mikael Kubista, Robert Sjoback, Marie Jindrichova, Eva Rohlova, Vendula Novosadova, Katarina Kolostova, Siegfried Hauch, Bahriye Aktas, Mitra Tewes, Rainer Kimmig, Sabine Kasimir-Bauer. Gene expression signatures in circulating tumor cells are prognostic for metastatic lesions in breast cancer patients and correlate with response to therapy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 502.

Abstract 4220: Tumor-targeting Salmonella typhimurium A1-R efficacy on colon cancer liver metastasis alone and in combination with fluorescence-guided surgery

Abstract Liver metastasis is the most frequent cause of death from colon and other cancers. Surgical treatment of liver metastasis has had limited success. The aim of this study is to determine the efficacy of tumor-targeting Salmonella typhimurium A1-R alone and in combination with fluorescence-guided surgery on liver metastasis in orthotopic mouse models. HT-29 human colon cancer cells expressing red fluorescent protein (RFP) developed liver metastasis after orthotopic implantation. In the orthotopic nude-mouse models, S. typhimurium A1-R targeted liver metastases and significantly reduced their growth (p &amp;lt; 0.01) after i.v. administration. Adjuvant treatment with S. typhimurium A1-R was highly effective to increase overall survival (p = 0.01) and disease-free survival (p &amp;lt; 0.01) after bright-light surgery (BLS) of liver metastasis. The results of this study demonstrate the future clinical potential of S. typhimurium A1-R treatment of liver metastasis. Citation Format: Takashi Murakami, Yukihiko Hiroshima, Yong Zhang, Ming Zhao, Ryusei Matsuyama, Takashi Chishima, Kuniya Tanaka, MIchael Bouvet, Itaru Endo, Robert M. Hoffman. Tumor-targeting Salmonella typhimurium A1-R efficacy on colon cancer liver metastasis alone and in combination with fluorescence-guided surgery. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4220.

Abstract 478: A mouse model for highly metastatic, nonfunctioning pancreatic neuroendocrine tumors

Abstract Pancreatic neuroendocrine tumors are generally classified as functioning or nonfunctioning. Patients with functioning tumors can have severe hypoglycemia because their tumors express high amounts of insulin as well as chromogranin A; fortunately, these tumors are seldom metastatic. Patients with nonfunctioning tumors express high amounts of chromogranin A but little insulin; unfortunately these tumors are highly metastatic to the liver. Nonfunctioning tumors are more common, and a more severe health issue. The highly studied RT2 B6 mouse, in which the SV40 T antigen is expressed from an insulin promoter in an inbred C57Bl/6 genetic background, is a model for functioning pancreatic neuroendocrine tumors: liver metastasis is uncommon in RT2 B6 mice, which are very hypoglycemic and often die when tumors are very small. We have changed the genetic background and are studying RT2 AB6F1 hybrid mice, which have a C57Bl/6 father and a mother from an A/J inbred background. RT2 AB6F1 mice are much less hypoglycemic, and these mice develop liver metastasis with high frequency. We have mated the hybrid AB6F1 mice to their littermates in order to map metastasis genes by F2 analysis, and have discovered that a locus at mouse chromosome 2qG1 links tightly to liver metastasis. One gene within this locus, InsM1, is less expressed in the primary tumors of mice with liver metastatic disease. InsM1 is also less expressed in primary tumors from humans with liver metastatic disease. Previous studies of InsM1 have shown that this protein maintains the differentiated status of pancreatic beta cells. We find that tumors from mice with low expression of InsM1 also express lower amounts of several distinctive markers of differentiated beta cells, but higher amounts of several markers of liver cells. These data suggest that dedifferentiation to stem cells, which can then redifferentiate to other cell types such as liver cells, promotes metastasis of pancreatic beta cell tumors. Intratumoral expression of liver markers may be a useful predictor of metastatic disease in these patients. Dedifferentiation of mature beta cells is also a mechanism by which type 2 diabetes occurs, so there may be similarities between these two diseases. Citation Format: Tanupriya Contractor, Shinta Kobayashi, Richard Clausen, Edaise da Silva, Laura Tang, Chang Chan, Chris R. Harris. A mouse model for highly metastatic, nonfunctioning pancreatic neuroendocrine tumors. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 478.

Abstract 1539: Live circulating tumor cells as a predictive biomarker of response to neoadjuvant chemoradiotherapy for resectable pancreatic cancer

Abstract The detection of increase in the number of circulating tumor cells (CTCs) during a patient's clinical course may be a harbinger of forthcoming overt metastasis. To detect live CTCs (l-CTCs) in blood samples of cancer patients (pts), we employed a new genetically modified telomerase-specific replication-selective adenovirous, expressing GFP (TelomeScanF35), containing both type 35 fiber that induce broad infectivity and miR-142-3p target sequence that can prevent a false positive toward blood cells. Recently, we indicated that preoperative chemoradiation therapy comprising gemcitabine and S-1 administration concurrent with full-dose radiation (NACRT) lead to encouraging survival rate in pts with resectable pancreatic cancer. But, NACRT may have disadvantages. NACRT requires several months, potentially delaying surgical resection, and can be waste of time and may result in the pts missing the chance for surgery. We assessed the l-CTCs burden in pts treated with NACRT. This study was approved by the Osaka Police Hospital IRB. Pts with resectable cytologically or histologically proven ductal adenocarcinoma of the pancreas were enrolled. Treatment consisted of an intervenous infusion of Gem 800 mg/m2 on day 1, 8, 22, and 29; and S-1 80 mg/m2 orally on day 1-5, 8-12, 22-26, and 29-33 given concurrently with IMRT to 60 Gy. Surgical exploration was scheduled 4-7 weeks after the final radiation fraction. 7.5 ml of blood samples were obtained from the pts included in this clinical study before NACRT, after 1 month of NACRT, and after 2 months of surgical resection. To distinguish between leucocyte and cells with epithelial origin, cells were stained with anti-CD45 and anti-Cytokeratin Abs. To distinguish cells with mesenchymal origin, cells were labeled with anti-Vimentin Ab. GFP-positive and CD45-negative cells were counted as l-CTC. 16 pts aged 44-78 years (5 males and 11 females) were enrolled. No treatment-related deaths occurred. CA19-9 was reduced to &amp;lt;50% of baseline values in 10 of 12 measureable pts. 13 of 16 enrolled pts successfully underwent surgical resection. 5 of 16 enrolled pts had l-CTCs (1∼4CTCs,Vimentin[+]) detected before NACRT. An increase in CTCs was seen in 4 of 5 pts after NACRT, but no detectable l-CTCs were observed in only 1 pt after NACRT. These 4 CTC-positive pts continuously had CTCs detected after surgery. 2 of 4 CTC-positive pts early developed liver metastasis and died, despite R0 resection. On the contrary, small increase (1∼2CTCs) of CTCs was seen after NACRT in 4 of 11pts, who had no CTCs detected before NACRT. But, no l-CTCs were detected in these 11 pts after surgery and they survived without recurrence. CTC-positive pts before NACRT presented a higher rate of liver metastasis after surgery than CTC-negative pts (50% vs. o%). We may consider surgery first for the CTC-positive pts before NACRT. The capture of l-CTCs may be useful biomarker for prognosis assessment or stratification. Citation Format: Masahiro Tanemura, Kenta Furukawa, Masaki Wakasugi, Kentaro Kishi, Yasuo Urata, Kiyomi Taniyama, Hiroki Akamatsu. Live circulating tumor cells as a predictive biomarker of response to neoadjuvant chemoradiotherapy for resectable pancreatic cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1539.

Liver recurrence in endometrial cancer: a multi-institutional analysis of factors predictive of postrecurrence survival.

Predictive factors for survival following liver metastasis in endometrial cancer (EC) have not been studied to date. It is expected that patients who initially presented with liver metastasis or developed liver metastasis as the subsequent metastatic site of progressive disease are likely to have poor outcomes. However, patients developing liver metastasis as the first site of recurrence may have a chance of benefiting from the salvage therapies. Therefore, we aimed to determine factors influencing postrecurrence survival in EC patients who developed liver metastasis as the first site of recurrence. Patients with EC who underwent primary surgery at three centers between 1993 and 2013 were reviewed. Liver recurrence was defined as documentation of parenchymal liver metastasis either by radiologically or biopsy, after a disease-free interval of ≥3months. Patients with liver metastasis at presentation, or liver metastasis as the subsequent metastatic site of progressive disease were excluded. Forty-six patients were identified. Median time to liver recurrence was 12months, with 91.3% of recurrences detected within 3years. Most patients (73.9%) had liver recurrence concomitant with extra-hepatic disease. Median survival after the diagnosis of liver recurrence was 9months. While in univariate analysis, time to liver recurrence (p<0.001) and presence of concomitant extra-hepatic metastasis (p=0.048) were potential predictors of survival, multivariate analysis revealed that time to liver recurrence (p<0.001) was the only independent predictor. This criterion may be used as a marker for stratifying patients into different prognostic risk groups and for selection of patients for salvage therapies.

Liver resection for metastases from colorectal cancer in very elderly patients: New surgical horizons

Introduction and aimPatients with colorectal cancer (CRC) may develop liver metastases. Surgical resection remains the best treatment of choice for colorectal liver metastases (CRLM) according to resectability criteria, with a long-term survival of 25% up to 41% after 5 years. Advanced age is associated with a higher incidence and co-morbidity, particularly cardiovascular disease, as well as deteriorating physiological reserves. The aim of this study was to analyse the overall and disease-free survival for patients with CRLM according to their chronological age. MethodsPatients with CRLM were enrolled in the study. Data on gender, age, co-morbidity, metastasis characteristics (number, size and total metastatic volume (TMV)), use of perioperative chemotherapy and operative and post-operative complications were collected. Then, according to recent World Health Organization (WHO) guidelines, the patients were grouped by age. Statistical analysis was performed using the software R (ver. 2.14.1). ResultsHepatic resection was performed in 149 patients (21 patients in the very elderly group, 79 in the elderly group and 49 in the younger group). The three groups were comparable in terms of operative duration, transfusion rate, length of high-dependency unit (HDU) stay and post-operative hospital stay. The very elderly group showed a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates increased with age without any significant statistically difference between the three groups (very elderly group 4.8% and 4.8%; elderly group: 2.5% and 3.8%; and younger group 0% and 2%). At 5 years, the overall survival was 28.6% for very elderly patients (≥75 years), 33.3% for elderly patients (≥65 to <75 years) and 43.5% for younger patients (≤65 years). The 1-, 3- and 5-year disease-free survival was similar across the groups. ConclusionsLiver resection for CRLM in carefully selected patients above the age of 75 can be performed with acceptable morbidity and mortality rates, similar to those in younger patients. Moreover, the severity of CRLM in elderly patients is proven to be lesser than in younger patients. Thus, we can conclude that advanced chronological age cannot be considered a contraindication to hepatic resection for CRLM.

Clinical features and prognosis of patients with first-episode liver metastasis of different molecular subtypes of breast cancer

To investigate the clinical features and prognosis of patients with first-episode liver metastasis of different molecular subtypes of breast cancer and risk factors for liver metastasis of breast cancer. A retrospective analysis was performed for 122 breast cancer patients with first-episode liver metastasis from January 2009 to January 2014. According to the cell surface receptors of breast cancer, these patients were divided into the four molecular subtypes of Luminal A, Luminal B, human epidermal growth factor receptor 2 (HER2) overexpression, and triple-negative breast cancer (TNBC). The association of patients' age at initial diagnosis, body mass index (BMI), menstruation status, clinical TNM (cTNM) stage, levels of lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) at recurrence, liver metastasis, and treatment condition with the patients' prognosis were analyzed. The chi-square test and Fisher's exact test were used for categorical data, the Kaplan-Meier method was used for survival analysis, the log-rank test was used for univariate analysis of influencing factors, and the Cox regression model was used for multivariate analysis. Among the 122 patients, 12 had Luminal A subtype, 61 had Luminal B subtype, 30 had HER2 overexpression subtype, and 19 had TNBC subtype. In the patients with Luminal A, Luminal B, HER2 overexpression, and TNBC subtypes, the median disease-free survival (DFS) was 32, 23, 16, and 10 months, respectively (P = 0.001), the median overall survival (OS) was 54, 35, 26, and 13 months, respectively (P = 0.003), and the median OS after liver metastasis was 30, 16, 10, and 9 months, respectively (P = 0.019). In HER2-positive patients, the application of trastuzumab in the past significantly prolonged the patients' DFS by 11 months and OS by 18 months (P < 0.05). The results of the multivariate analysis showed that cTNM stage, molecular subtype, and targeted therapy were independent influencing factors for DFS of breast cancer patients with liver metastasis (P < 0.05), and that BMI, increased LDH at recurrence, cTNM stage, molecular subtype, salvage chemotherapy, radiotherapy, and targeted therapy were independent influencing factors for OS of breast cancer patients with liver metastasis (P < 0.05). The patients with TNBC, HER2 overexpression, and Luminal B subtypes exhibited worse prognosis and had a risk of recurrence 15.97, 8.81, and 4.76 times higher than those with Luminal A subtype. The risk of death in the patients with TNBC, HER2 overexpression, and Luminal B subtypes was 8.42, 6.02, and 3.86 times that in those with Luminal A subtype. The prognosis of breast cancer patients with first-episode liver metastasis is associated with the increase in LDH when liver metastasis occurs, BMI, cTNM stage, and molecular subtype. Compared with the patients with Luminal subtypes, those with HER2 overexpression and TNBC subtypes tend to develop liver metastasis in early stage and have a shorter OS. Salvage chemotherapy, targeted therapy, and radiotherapy can significantly improve the prognosis of patients with liver metastasis.

Growth and Metastasis of Intraocular Tumors in Aged Mice.

PurposeSince deterioration of the immune apparatus is closely associated with cancer, we examined the effect of aging on the growth and metastasis of intraocular melanomas in mice.MethodsMurine B16LS9 melanoma cells were transplanted into the posterior compartment of the eye (vitreous chamber) and intraocular tumor growth and development of liver metastases were evaluated in young (8–10 weeks of age) and old (>18 months of age) mice. Liver metastases were also induced by intrasplenic injection of melanoma cells. Natural killer (NK) cells from the livers of mice harboring liver metastases were evaluated in vitro for their cytolytic activity.ResultsTumors grew more rapidly in the eyes of young mice than old mice, yet old mice developed significantly more liver metastases. Increased liver metastasis in old mice was evident even when melanoma cells were injected intrasplenically as a means of bypassing the influence of the ocular immunosuppressive environment. Increased liver metastases in old mice correlated with reduced cytolytic activity of liver NK cells. Lethally irradiated young mice reconstituted with bone marrow from old donors developed significantly more liver metastases than young mice reconstituted with bone marrow from young donors, indicating that bone marrow–derived cells were the root cause of the heightened development of metastases in old mice.ConclusionsAging affects the growth and metastasis of intraocular melanomas. Even though intraocular melanomas grow slower in old mice, the development of liver metastases is exacerbated and correlates with a reduction in liver NK cell activity in the old mouse.

Neutrophil Extracellular Traps Promote the Development and Progression of Liver Metastases after Surgical Stress.

Risks of tumor recurrence after surgical resection have been known for decades, but the mechanisms underlying treatment failures remain poorly understood. Neutrophils, first-line responders after surgical stress, may play an important role in linking inflammation to cancer progression. In response to stress, neutrophils can expel their protein-studded chromatin to form local snares known as neutrophil extracellular traps (NET). In this study, we asked whether, as a result of its ability to ensnare moving cells, NET formation might promote metastasis after surgical stress. Consistent with this hypothesis, in a cohort of patients undergoing attempted curative liver resection for metastatic colorectal cancer, we observed that increased postoperative NET formation was associated with a >4-fold reduction in disease-free survival. In like manner, in a murine model of surgical stress employing liver ischemia-reperfusion, we observed an increase in NET formation that correlated with an accelerated development and progression of metastatic disease. These effects were abrogated by inhibiting NET formation in mice through either local treatment with DNAse or inhibition of the enzyme peptidylarginine deaminase, which is essential for NET formation. In growing metastatic tumors, we found that intratumoral hypoxia accentuated NET formation. Mechanistic investigations in vitro indicated that mouse neutrophil-derived NET triggered HMGB1 release and activated TLR9-dependent pathways in cancer cells to promote their adhesion, proliferation, migration, and invasion. Taken together, our findings implicate NET in the development of liver metastases after surgical stress, suggesting that their elimination may reduce risks of tumor relapse.

An Oral Salmonella-Based Vaccine Inhibits Liver Metastases by Promoting Tumor-Specific T-Cell-Mediated Immunity in Celiac and Portal Lymph Nodes: A Preclinical Study.

Primary tumor excision is one of the most widely used therapies of cancer. However, the risk of metastases development still exists following tumor resection. The liver is a common site of metastatic disease for numerous cancers. Breast cancer is one of the most frequent sources of metastases to the liver. The aim of this work was to evaluate the efficacy of the orally administered Salmonella Typhi vaccine strain CVD 915 on the development of liver metastases in a mouse model of breast cancer. To this end, one group of BALB/c mice was orogastrically immunized with CVD 915, while another received PBS as a control. After 24 h, mice were injected with LM3 mammary adenocarcinoma cells into the spleen and subjected to splenectomy. This oral Salmonella-based vaccine produced an antitumor effect, leading to a decrease in the number and volume of liver metastases. Immunization with Salmonella induced an early cellular immune response in mice. This innate stimulation rendered a large production of IFN-γ by intrahepatic immune cells (IHIC) detected within 24 h. An antitumor adaptive immunity was found in the liver and celiac and portal lymph nodes (LDLN) 21 days after oral bacterial inoculation. The antitumor immune response inside the liver was associated with increased CD4+ and dendritic cell populations as well as with an inflammatory infiltrate located around liver metastatic nodules. Enlarged levels of inflammatory cytokines (IFN-γ and TNF) were also detected in IHIC. Furthermore, a tumor-specific production of IFN-γ and TNF as well as tumor-specific IFN-γ-producing CD8 T cells (CD8+IFN-γ+) were found in the celiac and portal lymph nodes of Salmonella-treated mice. This study provides first evidence for the involvement of LDLN in the development of an efficient cellular immune response against hepatic tumors, which resulted in the elimination of liver metastases after oral Salmonella-based vaccination.

Intra-individual genetic heterogeneity among liver metastases in metastatic colorectal cancer.

555 Background: Almost 50% of patients with colorectal cancer (CRC) develop liver metastases, often as multiple simultaneous metastatic deposits. Up to 25% of the patients are eligible for partial liver resection, but 70% will relapse after surgery and there are currently no good criteria to select patients who will benefit from the treatment. Genetic heterogeneity among metastatic deposits has great potential impact on disease progression, but has not been well described. Methods: Totally 134 liver metastatic deposits were collected from 45 patients undergoing partial liver resection for metastatic CRC according to a prospective study protocol. All deposits were analyzed for high-resolution DNA copy number variation using the Affymetrix SNP Array 6.0. A novel bioinformatic approach was used to measure intra-individual genetic heterogeneity among the metastatic deposits. Results: The patients showed a large variation in the level of intra-individual metastatic heterogeneity, and heterogeneity was independent of the number of liver metastases analyzed per patient. Heterogeneity was a strong and independent prognostic factor in multivariate analysis with known clinicopathological prognostic factors. Patients with a high level of heterogeneity (above the median) had a three-year overall survival rate of 18%, compared with 66% for patients with a low level (hazard ratio, HR = 3.7, P = 0.007). The corresponding survival rates for progression-free survival were 6% and 24% (HR = 2.6, P = 0.01). Conclusions: A high level of intra-individual genetic heterogeneity among liver metastatic deposits is associated with poor survival after partial liver resection in patients with metastatic CRC.

Current treatment options for patients with initially unresectable isolated colorectal liver metastases.

The development of liver metastases is a common clinical entity in the clinical course of colorectal cancer. For patients with isolated liver involvement, surgical resection is the only treatment that can provide a chance of prolonged survival and cure. However, most of these patients are not initially eligible for the surgery. Selected patients with initially considered to have unresectable disease may become resectable after systemic (chemotherapy ± biological therapy) and loco-regional treatment modalities including hepatic arterial infusion. Patients who have colorectal liver metastases ideally should be referred to a multidisciplinary cancer care team in order to identify the most optimal management approach.

Hyperglycemia Promotes the Epithelial-Mesenchymal Transition of Pancreatic Cancer via Hydrogen Peroxide.

Diabetes mellitus (DM) and pancreatic cancer are intimately related, as approximately 85% of patients diagnosed with pancreatic cancer have impaired glucose tolerance or even DM. Our previous studies have indicated that high glucose could promote the invasive and migratory abilities of pancreatic cancer cells. We therefore explored the underlying mechanism that hyperglycemia modulates the metastatic potential of pancreatic cancer. Our data showed that streptozotocin- (STZ-) treated diabetic nude mice exhibit larger tumor size than that of the euglycemic mice. The number of nude mice that develop liver metastasis or ascites is much more in the STZ-treated group than that in the euglycemic group. Hyperglycemic mice contain a higher plasma H2O2-level than that from euglycemic mice. The injection of polyethylene glycol-conjugated catalase (PEG-CAT), an H2O2 scavenger, may reverse hyperglycemia-induced tumor metastasis. In addition, hyperglycemia could also modulate the expression of epithelial-mesenchymal transition- (EMT-) related factors in pancreatic tumor tissues, as the E-cadherin level is decreased and the expression of mesenchymal markers N-cadherin and vimentin as well as transcription factor snail is strongly increased. The injection of PEG-CAT could also reverse hyperglycemia-induced EMT. These results suggest that the association between hyperglycemia and poor prognosis of pancreatic cancer can be attributed to the alterations of EMT through the production of hydrogen peroxide.

Modified mismatch polymerase chain reaction-restriction fragment length polymorphism detected mutations in codon 12 and 13 of exon 2 of K-ras gene in colorectal cancer patients and its association with liver metastases: Data from a South Asian country.

Mutations in K-ras codon 12 and 13 of exon 2 are known to affect prognosis and impart resistance to anti-epidermal growth factor monoclonal antibody therapy in colorectal carcinoma (CRC). Our aim was to investigate the utility value of modified mismatch polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay to detect mutation in K-ras codons of CRC patients and to relate the mutational status to liver metastasis. Mismatch PCR-RFLP was developed to detect K-ras mutations in DNA isolated from paraffinized tumor tissue of thirty CRC patients. All patients had 5 year follow-up data to detect liver metastasis. Cross-tabulations were generated between K-ras mutations and the metastatic status. The Chi-square test was used to indicate statistical significance of the association. Of the 30 CRC patients investigated, K-ras mutations of codons 12 and/or 13 of exon 2 were detected in 14 (46.6%). Meanwhile, 13 patients (43.3%) were observed to have developed liver metastases. There was a significant association between the presence of the K-ras mutation in codon 12 and the occurrence of liver metastasis (χ2 = 4.693, P = 0.030) on the contrary to the mutation in codon 13 to which such occurrence of liver metastases was not seen (χ2 = 1.884, P = 0.169). Codon 12 of exon 2 of K--ras gene detected by modified mismatch PCR-RFLP assay is significantly associated with liver metastasis in CRC patients during the first 5 years after surgery. Thus, modified mismatch PCR-RFLP protocol is a suitable method in this setting to detect K-ras gene mutations predicting liver metastasis in CRC patients.

Multisciplinary management of patients with liver metastasis from colorectal cancer.

Colorectal cancer (CRC) is one of the leading causes of cancer-related death. Surgery, radiotherapy and chemotherapy have been till now the main therapeutic strategies for disease control and improvement of the overall survival. Twenty-five per cent (25%) of CRC patients have clinically detectable liver metastases at the initial diagnosis and approximately 50% develop liver metastases during their disease course. Twenty-thirty per cent (20%-30%) are CRC patients with metastases confined to the liver. Some years ago various studies showed a curative potential for liver metastases resection. For this reason some authors proposed the conversion of unresectable liver metastases to resectable to achieve cure. Since those results were published, a lot of regimens have been studied for resectability potential. Better results could be obtained by the combination of chemotherapy with targeted drugs, such as anti-VEGF and anti-EGFR monoclonal antibodies. However an accurate selection for patients to treat with these regimens and to operate for liver metastases is mandatory to reduce the risk of complications. A multidisciplinary team approach represents the best way for a proper patient management. The team needs to include surgeons, oncologists, diagnostic and interventional radiologists with expertise in hepatobiliary disease, molecular pathologists, and clinical nurse specialists. This review summarizes the most important findings on surgery and systemic treatment of CRC-related liver metastases.

The Evaluation of Liver Function and Surgical Influence by ICGR15 after Chemotherapy for Colorectal Liver Metastases.

Background; Approximately 60% of patients with colorectal cancer develop liver metastasis at some point after diagnosis. The aim of this study is to investigate whether the evaluation of ICGR15 preoperatively is a useful clinical indicator of hepatic injury following chemotherapy and to investigate the influence of multiple chemotherapies on liver function.Results; Mean ICGR15 values were higher in patients ≥65 years (P = 0.047) and in patients with ≥3 cycles (P = 0.022) and ≥6 cycles (P = 0.001) of systemic chemotherapy. ICGR15 values tended to be higher in patients with postoperative complications (P = 0.085). Patients receiving systemic chemotherapy for ≥6 cycles had higher levels of AST (P = 0.003), ALT (P = 0.015), and alkaline phosphatase (ALP) (P = 0.041). Patients receiving systemic chemotherapy for ≥3 cycles had higher levels of AST (P = 0.015) and ALP (P = 0.015).Conclusions; Because the pathological diagnosis is usually established only after operation, preoperative evaluation such as the identification of sinusoidal injury is difficult. Based on this study, higher ICGR15 values may provide an indication of surgical complications and be a predictor of liver dysfunction following frequent cycles of chemotherapy. Hepatectomy should be performed with the utmost care in such patients, and the number of cycles of preoperative chemotherapy should probably be as low as possible.

A Rare Case of Mixed Neuroendocrine Tumor and Adenocarcinoma of the Pancreas.

Introduction. Neuroendocrine carcinoma (NEC) of pancreas is a rare tumor with aggressive progression and poor prognosis. Its coexistence with adenocarcinoma poses significant clinical problems and has not been addressed in the literature. Methods. We describe a case of a 51-year-old male who underwent pancreatoduodenectomy due to pancreatic head tumor 1.5 × 1 × 1.4 cm. Histological examination of the specimen revealed a mixed neoplasm: (1) a well differentiated adenocarcinoma, neoplastic blasts of which are extended focally to the submucosa without invading the muscular layer, and (2) a low differentiated NEC consisting of solid clusters and pagetoid formations. All 18 lymph nodes of the specimen were free of neoplastic disease and the surgical margins of the specimen were tumor-free. No adjuvant treatment was administered and two months after the operation the patient developed liver metastasis. FNA cytology of the hepatic lesions revealed low grade carcinoma with neuroendocrine characteristics. Five lines of chemotherapy were administered: VP + CDDP, paclitaxel + ifosfamide + Mesna + CDDP, Folfox + Avastin, Folfiri + Avastin, and CAV. During his treatment he revealed PD and succumbed to his disease 13 months after the operation. Conclusion. Coexistence of NEC with adenocarcinoma of the pancreas is a very rare entity presenting significant challenges regarding its adjuvant treatment and the treatment of distant relapse.