Hepatic Resection For Colorectal Metastases Research Articles

Hepatic Artery Infusion: Still an Option?

Time and science have been kind to patients with colorectal cancer metastatic to the liver. The combination of a decrease in surgical mortality, increased operative tools, increase in the number of active chemotherapeutic drugs— both general and targeted—accompanied by an acceptance of multimodality therapies have improved patient outcomes. A few tools have maintained a quiet hum in the treatment cacophony. The focus of the paper by Ammori et al. is one of those tools: the continuous hepatic artery infusion (CHAI) pump. Emerging in the 1980s as an effective method of delivering floxuridine to the liver via the hepatic artery, its success was consistent but simultaneously limited to a few centers and physicians (medical oncologists and surgeons) who had adequate and specific skill in using this treatment modality. There were many challenges to the use of continuous infusion hepatic artery delivery of floxuridine. They included the complexities of managing the idiopathic liver transaminitis with appropriate dose reductions, surgically placing the pump and working through the vagaries of the hepatic arterial anatomy, dealing with the mechanical challenges of accessing the chambers for filling, and removing the drug and replacing with heparinized saline, and a continued surveillance for late biliary sclerosis. Clearly, using the technology in the ‘‘adjuvant setting,’’ i.e., following hepatic resection for colorectal metastases, was most problematic. The saving grace in this setting was that the patient did not require an additional surgery for the pump placement; however, concerns of functional liver reserve and recovery created an enhanced anxiety. Despite all the challenges, the committed group of oncologists (medical and surgical) consistently demonstrated in pilot and phase 2 studies, a series of outcomes that exceeded those generated with only the systemic chemotherapy available during the same time period. When the limited choice for chemotherapy morphed from 5-fluoruracil and leucovorin—excellent agents with known toxicity and carefully studied therapeutic regimens— to oxaliplatin, irinotecan, capecitabine, and subsequently the targeted agents led initially by bevacizumab and cetuximab, that’s when things changed. An enthusiasm for the new agents with potential for sequential use and improved response rates emerged. The CHAI with the reasonably toxic floxuridine fell from favor and nearly all medical oncologists began to transition their clinical practice to the new systemic agents. A few strongholds of CHAI remained active but the incorporation of pump based chemotherapy rapidly lost ground. The clinical trials that had been developed during the height of interest in pump therapy suffered poor accrual and failed to definitively answer the question of superiority or even equivalence (noninferiority). During this same timeframe came the battle cry for more aggressive surgical approaches following successful ‘‘neoadjuvant’’ conversion chemotherapy. The selection of neoadjuvant treatments were focused on efficacy measured as response and safety as measured by the morbidity and mortality of the subsequent operations. Those practitioners with experience in CHAI accepted and worked around the hepatocyte damage as measured in the hepatic transaminitis and the measurable and presumed intraand extrahepatic biliary injury that resulted from the chemotherapy-infused blood bathing the biliary structures. Thoughtful attempts to reduce the injury with dexamethasone were admirable but not adequate to consistently reduce hepatic injury. The ‘‘soft’’ hepatic damage of oxaliplatin (sinusoidal injury), fluoropyrimidine and irinotecan (steatosis), and bevacizumab pales compared with a liver arterially infused 2 weeks on and 2 weeks off with floxuridine. It is almost ironic to consider the current restrictions on timing of hepatic surgery after systemic chemotherapy compared with the post-CHAI liver. So where does this leave us when faced with colorectal cancer metastatic to the liver? Metastatic disease that is resectable at presentation may or may not be treated with Society of Surgical Oncology 2013

Association of KRAS mutation with worse recurrence-free survival and site of metastatic progression after resection of hepatic colorectal metastases.

3609 Background: There are conflicting results regarding the influence of KRAS mutation status and outcome in patients (pts) with colorectal cancer. A recent report suggested worse outcome in KRAS mutated (MUT) pts who underwent resection of hepatic metastases (Karagkounis et al, ASCO 2012). Methods: Recurrence patterns and survival were evaluated in 169 patients who had undergone resection of liver metastases, then received adjuvant hepatic arterial infusion and systemic chemotherapy, and for whom KRAS data were available. Kaplan-Meier methods were used to estimate recurrence free survival (RFS) and overall survival (OS). Log-rank test was used to determine whether survival functions differed by KRAS mutation status. Cumulative incidence function was used to estimate the probability of time from adjuvant therapy to bone, brain, lung and liver metastases separately. Mutations in KRAS (codons 12, 13) were detected using the iPLEX assay (Sequenom, Inc). Results: Median follow-up for the entire cohort was 38.8 months. 118 were KRAS wildtype (WT), and 51 were KRAS MUT (45 G12, 5 G13, 1 K117N). The 3 year RFS was 48% [95%CI: 37-58%] for KRAS WT pts and 30% [15-44%] for MUT pts (p<0.01). OS at 3 years was 96% [88-98%] for KRAS WT and 80% [61-90%] for MUT pts (p=0.08). Cumulative incidence of developing bone, brain, lung, and liver metastases by 2 years is presented in Table 1. The cumulative incidence of metastases to bone at 2 years was 0% and 13.7% in KRAS WT versus MUT pts (p<0.01), to brain 0% versus 4.6% for KRAS WT versus MUT (p=0.05), and to lung 27% versus 47.5% in KRAS WT versus MUT pts (p<0.01). Conclusions: In pts who have had liver resection followed by adjuvant therapy, those with KRAS MUT have a worse RFS and seemingly worse OS than those who are KRAS WT. Also, patients with KRAS MUT appear more likely to develop bone, brain, and lung metastases. Further investigation of a larger number of patients is warranted. [Table: see text]

Perioperative complications influence recurrence and survival after resection of hepatic colorectal metastases

Perioperative outcomes, such as blood loss, transfusions, and morbidity, have been linked to cancer-specific survival, but this is largely unsupported by prospective data. Patients from a previous, randomized trial that evaluated acute normovolemic hemodilution during major hepatectomy (≥3 segments) were reevaluated and those with metastatic colorectal cancer (n=90) were selected for analysis. Survival data were obtained from the medical record. Disease extent was measured using a clinical-risk score (CRS). Log-rank test and Cox proportional hazard model were used to evaluate recurrence-free survival (RFS) and overall survival (OS). Median follow-up was 71months. The CRS was ≥3 in 45% of patients; 59% had extrahepatic procedures. Morbidity and mortality were 33 and 2%, respectively. Postoperative chemotherapy was given to 87% of patients (78/90) starting at a median of 6weeks. RFS and OS were 29 and 60months, respectively. Postoperative morbidity significantly reduced RFS (23 vs. 69months; P<0.001) and OS (28 vs. 74months; P<0.001) on uni- and multi-variate analysis; positive resection margins and high CRS also were significant factors. Delayed initiation of postoperative chemotherapy (≥8weeks) was common in patients with complications (37 vs. 12%; P=0.01). In this selected cohort of patients from a previous RCT, perioperative morbidity was strongly (and independently) associated with cancer-specific outcome. It also was associated with delayed initiation of postoperative chemotherapy, the impact of which on survival is unclear.

Surgical management of colorectal cancer metastases to the liver: multimodality approach and a single institutional experience.

Over the past 30 years, the treatment of metastatic colorectal cancer to the liver has undergone major changes. Once considered terminal and incurable, the prognosis of patients with colorectal hepatic metastases has seen dramatic improvements using modern multimodality therapy and now long-term survival and even cure are possible in some patients. Despite the advances seen in systemic therapy, hepatic resection offers the longest survival potential and remains the only curative option. Based on long-term outcomes and the improved safety of hepatic resection using modern operative techniques and critical care support, an aggressive locoregional approach to colorectal hepatic metastasis has become the standard of care. This article focuses on the management of colorectal hepatic metastases and highlights the importance of multimodality therapy. We also report our 18-year experience treating patients with hepatic resection for colorectal metastases.

Influence of KRAS mutation on recurrence patterns in patients undergoing hepatic resection of colorectal metastases.

398 Background: There have been conflicting results about whether KRAS mutation influences outcome in patients (pts) with colorectal cancer. In pts who underwent liver resection, Karagkounis reported a worse recurrence and survival in KRAS mutated (MUT) patients (ASCO 2012, abs 3616). Methods: In 105 pts who underwent liver resection and received adjuvant (adj) hepatic arterial infusion and systemic chemotherapy and in whom KRAS data was available, we evaluated recurrence patterns and survival. Correlation between KRAS and clinical factors such as prior chemotherapy, post operative CEA, clinical risk score, and stage at diagnosis was evaluated using Fisher’s exact test and the Wilcoxon rank sum test. Kaplan-Meier methods were used to estimate median overall recurrence free survival (RFS) and overall survival (OS) at 4 years. Log-rank test was used to determine whether survival functions differed by KRAS mutation status. Cumulative incidence function was used to estimate the probability of time from adj therapy to bone, brain, lung and liver metastases separately. Results: Of 105 patients, 76 were KRAS wildtype (WT), and 29 were KRAS MUT (26-G12 and 3-G13). The median RFS was 26 months for KRAS WT pts and 15 months for KRAS MUT pts (p=0.08). OS at 4 years was 88% [95% CI: 78%-94%] for KRAS WT and 78% [95% CI: 57%-90%] for KRAS MUT pts (p= 0.15). Cumulative incidence of developing bone, brain, lung, and liver metastases by 2 years is presented in the Table. The cumulative incidence of bone and brain metastases at 2 years was 0% and 0% in KRAS WT pts versus 16.4% [95% CI: 1.1%-31.7%] and 4.7% [95% CI: 0%-14.1%] in KRAS MUT pts (Table). There was no association between clinical factors and KRAS status. Conclusions: KRAS MUT pts appeared to have worse OS and RFS, although we were unable to show a significant difference between KRAS WT and MUT for OS and RFS. In addition, cumulative incidence of bone and brain metastases at 2 years appeared to be higher for KRAS MUT pts as compared to WT pts. Results are based on small sample size and further investigation is needed. [Table: see text]

Hepatic histopathology and postoperative outcome after preoperative chemotherapy for Chinese patients with colorectal liver metastases

To assess the effects of preoperative treatment on the hepatic histology of non-tumoral liver and the postoperative outcome. One hundred and six patients underwent hepatic resection for colorectal metastases between 1999 and 2009. The surgical specimens were reviewed with established criteria for diagnosis and grading of pathological hepatic injury. The impact of preoperative therapy on liver injury and postoperative outcome was analyzed. Fifty-three patients (50%) received surgery alone, whereas 42 patients (39.6%) received neoadjuvant chemotherapy and 11 (10.4%) patients received preoperative hepatic artery infusion (HAI). Chemotherapy included oxaliplatin-based regimens (31.1%) and irinotecan-based regimens (8.5%). On histopathological analysis, 16 patients (15.1%) had steatosis, 31 (29.2%) had sinusoidal dilation and 20 patients (18.9%) had steatohepatitis. Preoperative oxaliplatin was associated with sinusoidal dilation compared with surgery alone (42.4% vs 20.8%, P = 0.03); however, the perioperative complication rate was not significantly different between the oxaliplatin group and surgery group (27.3% vs 13.2%, P = 0.1). HAI was associated with more steatosis, sinusoidal dilation and steatohepatitis than the surgery group, with higher perioperative morbidity (36.4% vs 13.2%, P = 0.06) and mortality (9.1% vs 0% P = 0.02). Preoperative oxaliplatin was associated with sinusoidal dilation compared with surgery alone. However, the preoperative oxaliplatin had no significant impact on perioperative outcomes. HAI can cause pathological changes and tends to increase perioperative morbidity and mortality.

Negative Effects of Transfused Blood Components after Hepatectomy for Metastatic Colorectal Cancer

There has been conflicting evidence regarding negative effects of blood transfusion in oncology patients. This study was undertaken to determine any negative effects of specific blood product transfusion after resection of hepatic colorectal metastases (CRM). Retrospective review of patients undergoing hepatectomy for CRM from 1995 to 2009 at a single institution was performed. Specific attention was paid to the effect of blood transfusion within 30 days of operation on overall survival, disease-free survival (DFS), and complications. To mitigate the bias introduced by complications that require blood transfusion to treat, only nonbleeding complications were considered. Complications were analyzed with univariate and multivariate logistic regression. Survival was analyzed according to Kaplan-Meier and Cox proportional hazards. There were 239 patients included in the study. There were 64 (26.8%) receiving a transfusion of any kind with 25.5 per cent getting red cells (PRBCs), 7.11 per cent getting fresh-frozen plasma, and 3.77 per cent getting platelets. Multivariate analysis revealed only PRBC transfusion to be independently associated with nonbleeding complications (odds ratio, 1.980; 95% confidence interval, 1.094 to 3.582; P = 0.0239). There was no significant adverse effect of transfusion with any product on overall or DFS. PRBC transfusion appears to increase the risk of postoperative complications; thus, strategies to minimize blood use may be warranted.

Optimal Morphologic Response to Preoperative Chemotherapy: An Alternate Outcome End Point Before Resection of Hepatic Colorectal Metastases

The purposes of this study were to confirm the prognostic value of an optimal morphologic response to preoperative chemotherapy in patients undergoing chemotherapy with or without bevacizumab before resection of colorectal liver metastases (CLM) and to identify predictors of the optimal morphologic response. The study included 209 patients who underwent resection of CLM after preoperative chemotherapy with oxaliplatin- or irinotecan-based regimens with or without bevacizumab. Radiologic responses were classified as optimal or suboptimal according to the morphologic response criteria. Overall survival (OS) was determined, and prognostic factors associated with an optimal response were identified in multivariate analysis. An optimal morphologic response was observed in 47% of patients treated with bevacizumab and 12% of patients treated without bevacizumab (P < .001). The 3- and 5-year OS rates were higher in the optimal response group (82% and 74%, respectively) compared with the suboptimal response group (60% and 45%, respectively; P < .001). On multivariate analysis, suboptimal morphologic response was an independent predictor of worse OS (hazard ratio, 2.09; P = .007). Receipt of bevacizumab (odds ratio, 6.71; P < .001) and largest metastasis before chemotherapy of ≤ 3 cm (odds ratio, 2.12; P = .025) were significantly associated with optimal morphologic response. The morphologic response showed no specific correlation with conventional size-based RECIST criteria, and it was superior to RECIST in predicting major pathologic response. Independent of preoperative chemotherapy regimen, optimal morphologic response is sufficiently correlated with OS to be considered a surrogate therapeutic end point for patients with CLM.

Laparoscopic versus open resection of hepatic colorectal metastases

This study was undertaken to assess the safety and efficacy of laparoscopic versus open resection of hepatic colorectal metastases (CRM). We reviewed retrospectively of all patients undergoing initial resection of CRM at a single institution between 1995 and 2010. The study cohort consisted of all patients undergoing laparoscopic resection and a cohort of patients undergoing open resection matched on a 4:1 basis by propensity scoring. Variables analyzed included patient and tumor characteristics, short-term outcomes, and OS and disease-free (DFS) survivals. The 35 patients in the laparoscopic cohort and 140 patients in the open cohort were equivalent in terms of age, Charlson Comorbidity Index, tumor characteristics, and Clinical Risk Score. Similar proportions of patients in the laparoscopic and open groups underwent synchronous colectomy (9% in both; P = .976) and major hepatectomy (54% vs 51%; P = .705). Blood loss (202 vs 385 mL; P < .001), complications (23% vs 50%; P = .004), and duration of stay (4.8 vs 8.3 days; P < .001) wereless in the laparoscopic cohort. Five-year OS (36% vs 42%; P = .818) and DFS (15% vs 22%; P= .346) were also similar in the laparoscopic and open groups. Laparoscopic resection of hepatic CRM seems to be a beneficial alternative to open surgery in appropriately selected patients.

PMO-089 Preoperative neutrophil: lymphocyte ratio is not a predictor of outcome following hepatic resection for colorectal metastases

IntroductionA high pre-operative neutrophil:lymphocyte ratio (NLR) has been shown in several studies to be associated with shorter disease-free and overall survival for a number of malignancies, including colorectal1 and both...

Effect of perioperative complications on recurrence and survival after resection of hepatic colorectal metastases: Analysis of data from a randomized controlled trial.

3620 Background: Perioperative outcomes such as blood loss, transfusions and morbidity have been associated with cancer specific survival, but this is unsupported by prospective data. Methods: Patients were derived from a previously reported prospective randomized trial of acute normovolemic hemodilution (ANH) versus standard management during major hepatectomy. Patients with metastatic colorectal cancer (mCRC) were selected for analysis. Chemotherapy and survival data were obtained from the medical record. Disease extent was measured using a clinical risk scoring (CRS) system. Log-rank test and Cox proportional hazard model were used to evaluate recurrence free (RFS) and overall survival (OS). Results: This trial enrolled 130 patients, 90 of whom had mCRC. Median follow up was 54 m; median age was 53 yr; 56% were men. The CRS was ≥3 in 55% of patients, and 57% had additional extrahepatic procedures. Morbidity and mortality were 33% and 3%. Chemotherapy was split before and after surgery in 70%; 10% received only preoperative and 19% only postoperative treatment, which was initiated after a median time of 6 wks (IQR = 4-7). RFS and OS were 29 and 59 m. On multivariate analysis, (+) resection margin, high CRS and perioperative complications predicted shorter RFS and OS. Delayed initiation of postoperative chemotherapy (≥ 8 wks) while most common in patients with complications (37 vs 12%; p: 0.01), was not a significant predictor of shorter RFS or OS. Randomization (ANH vs standard) was also not significant in this regard. (See Table.) Conclusions: In this prospective randomized cohort, perioperative morbidity was a highly significant independent predictor of cancer specific outcome, associated with but not entirely explained by delayed initiation of chemotherapy. [Table: see text]

Changes in spleen volume after resection of hepatic colorectal metastases

To identify and describe changes in spleen volume occurring in patients with colorectal metastases to the liver after partial hepatectomy. Forty-one consecutive patients (20 men, 21 women) with histopathology-proven colorectal liver metastases who underwent partial hepatectomy between August 2007 and April 2011 were included. Liver and spleen volumes were measured by computed tomography (CT) volumetry on the most recent CT prior to surgery and on all CTs obtained within a year after partial hepatectomy. Patients were carefully evaluated for and excluded if they had co-morbid conditions known to cause splenomegaly or risk factors for portal hypertension such as underlying liver disease and portal vein thrombosis. Thirty-two (78%) patients demonstrated an increase in spleen volume on the first post-operative CT, with more than a double increase in volume amongst five patients. Spleen volume increased by an average of 43% within 3 months of partial hepatectomy (p<0.0001) and remained increased through 6 months after surgery, returning to near baseline thereafter. In the remaining nine (22%) patients, the spleen was observed to decrease an average of 11% in volume on first postoperative CT (p<0.005). Splenic enlargement after partial hepatectomy of colorectal metastases is a common finding on CT. Increased familiarity amongst radiologists of this phenomenon as likely reflecting physiological changes is important in order to avoid unnecessary evaluation for underlying conditions causing interval enlargement of the spleen.

Thermal tumor ablation therapy for colorectal cancer hepatic metastasis.

Surgical resection for colorectal hepatic metastases (CRHM) is the preferred treatment for suitable candidates, and the only potentially curative modality. However, due to various limitations, the majority of patients with CRHM are not candidates for liver resection. In recent years, there has been an increasing interest in the role of thermal tumor ablation (TTA) as a component of combined resection-ablation strategies, staged hepatic resections, or as standalone adjunct treatment for patients with CRHM. Thus, ablative approaches have expanded the group of patients with CRHM that may benefit from liver-directed treatment strategies.

Chemotherapy Before Liver Resection of Colorectal Metastases

We conducted a systematic review of the published literature to critically assess benefits and risks of the use of preoperative chemotherapy in patients presenting with colorectal liver metastases. In many centers, chemotherapy is used before hepatic resection of colorectal metastases, even in the presence of a single lesion. Application of chemotherapy requires clear conceptual distinction between patients presenting with resectable lesions (neoadjuvant) versus patients presenting with unresectable lesions, for which chemotherapy is used to reach a resectable situation (downsizing). The literature (PubMed) was systematically reviewed for publications related to liver surgery and chemotherapy according to the methodology recommended by the Cochrane Collaboration. For unresectable liver metastases, combination regimens result in enhanced tumor response and resectability rates up to 30%, although the additional benefit from targeted agents such as bevacizumab or cetuximab is marginal. For resectable lesions, studies on neoadjuvant chemotherapy failed to convincingly demonstrate a survival benefit. Most reports described increased postoperative complications in a subset of patients due to parenchymal alterations such as chemotherapy-associated steatohepatitis or sinusoidal obstruction syndrome. Preoperative standard chemotherapy can be recommended for downsizing unresectable liver metastases, but not for resectable lesions, for which adjuvant chemotherapy is preferred.

Impact of subcentimeter margin on outcome after hepatic resection for colorectal metastases: A meta-regression approach

The optimal margin width and its influence on outcomes after hepatic resection for colorectal liver metastases is still controversial: a meta-analysis was conducted to analyze the impact of subcentimeter margin width on patient and disease-free survival after resection. A systematic search was performed, covering the last decade, following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Relative risks (RRs) for patient and disease-free survival (DFS) were calculated after resection in relationship to a margin width >1 cm (R0 > 1 cm) and between 1 mm and 1 cm (R0 < 1 cm) using the DerSimonian and Laird random-effects model. Meta-regression was applied for covariate adjustment. Eleven observational studies were identified involving 2823 patients. Overall, 59.1% of patients were R0 < 1 cm and 40.9% were R0 > 1 cm. Meta-analysis showed that compared with patients with margins R0 > 1 cm, a R0 < 1 cm margin lead to decreased 1-, 3-, and 5-year DFS with a RR of 1.17 (95% confidence interval [CI] 1.07-1.27), 1.38 (95% CI 1.16-1.65), and 1.55 (95% CI 1.25-1.91), respectively, but patient survival was obviously affected (P > .05 in all cases). Patients with margins of R0 < 1 cm differ from those with R0 > 1 cm for greater proportions of multiple metastases (RR 1.43; 95% CI 0.25-1.61) and synchronous bowel disease (RR 1.42; 95% CI 0.8-1.92). Meta-regression showed that these two covariates had a significant impact on DFS but not on patient survival. A resection margin width >1 cm is desirable even if patient survival is at best only slightly affected by subcentimeter margin as a consequence of a decreased DFS. The presence of multiple metastases and synchronous bowel neoplasm represent potential study selection biases that significantly decrease DFS; well-conducted, matched analyses consequently are essential to clarify the issue.

Safety of hepatic resection for colorectal metastases in the era of neo-adjuvant chemotherapy

The relationship between neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases and post-operative morbidity still has to be clarified. Data from 242 patients undergoing hepatectomy for colorectal liver metastases, judged resectable at first observation, were reviewed and their clinical outcome was related to neo-adjuvant chemotherapy (125 patients). Selection biases were outlined and properly handled by means of propensity score analysis. Post-operative death was 1.2% and morbidity 40.9%. Pre-operative chemotherapy was only apparently related to higher morbidity (P = 0.021): multivariate analysis identified extension of hepatectomy and intra-operative blood loss as independent prognostic variables (P < 0.05). Patients receiving and not receiving neo-adjuvant chemotherapy were significantly different for several covariates, including extension of hepatectomy (P = 0.049). After propensity score adjustment, 94 patients were identified as having similar covariate distribution (standardized differences <|0.1|) except for neo-adjuvant treatment (47 patients for each group). In this matched sample, mortality was similar and post-operative complications were only slightly higher (hazard ratio = 1.38) in treated patients. A significantly higher need for fluid replacement was only observed in patients receiving neo-adjuvant chemotherapy (P = 0.038). Neo-adjuvant chemotherapy showed a limited role in determining post-operative morbidity after hepatic resection and did not modify mortality.

Accuracy of gadoxetic acid-enhanced magnetic resonance imaging for the diagnosis of sinusoidal obstruction syndrome in patients with chemotherapy-treated colorectal liver metastases

To assess whether reticular hypointensity on hepatobiliary phase images of gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) is a diagnostic finding of sinusoidal obstruction syndrome (SOS) in patients with hepatic metastases who have undergone chemotherapy. We retrospectively analysed EOB-MRI of 42 patients who had undergone chemotherapy before hepatic resection of colorectal hepatic metastases. Two radiologists, who were unaware of whether or not the patients had SOS, reviewed the hepatobiliary phase images to determine the presence of hypointense reticulation in the liver using a 5-point scale. The sensitivity, specificity and area under the receiver operating characteristics curve (A(z)) were calculated for each reviewer. The sensitivity, specificity and A(z) for the diagnosis of SOS were 75%, 100% and 0.957 for reader 1 and 75%, 96.2% and 0.936 for reader 2, respectively. In one patient who received a false-positive diagnosis by one reader, there was sinusoidal fibrosis on histological examination, but not diagnostic for SOS. False-negative diagnosis occurred in four patients for both readers; histology of these patients showed minimal and localised sinusoidal congestion and fibrosis. Reticular hypointensity on hepatobiliary phase images of EOB-MRI is highly specific for the diagnosis of SOS in patients with treated colorectal hepatic metastases. Gadoxetic acid enhanced magnetic resonance imaging (EOB-MRI) can identify the sinusoidal obstruction syndrome (SOS). The diagnosis can be achieved with high specificity and good interobserver agreement. SOS typically demonstrates diffuse hypointensity on hepatobiliary phase images on EOB-MRI. EOB-MRI may be falsely negative in patients with minimal degree of SOS.

Influence of Margins on Overall Survival After Hepatic Resection for Colorectal Metastasis

The aim of our study was to conduct a meta-analysis of reports published on hepatic resection for colorectal liver metastasis (CRLM) and determine whether a negative margin of 1 cm or more confers a survival advantage over subcentimeter negative margins. Surgical margin is an important prognostic factor in patients undergoing hepatic resection for CRLM. Although there is a consensus that positive margins portend a worse outcome than negative margins, the extent of negative margins remains controversial. A PubMed search was conducted to identify articles on hepatic resection for CRLM. The 357 initially located articles were screened to identify 90 articles of interest. The texts of these 90 articles were completely reviewed to finalize 18 articles for inclusion in the study on the basis of absolute and relative inclusion criteria. Patients with positive margins were excluded from the meta-analysis. Meta-analysis was performed using STATA 9.2 statistical software. A total of 4821 patients with negative margins from the 18 studies were included in the meta-analysis. The overall 5-year survival for all patients was 41% [95% confidence interval (CI), 40%-43%]. The overall 5-year survival for the ≥1 cm negative margin subgroup was 46% (95% CI, 44%-48%) when compared with 38% (95% CI, 36%-40%) for less than 1 cm negative margin subgroup. The odds ratio for 1-cm or more negative margins was found to be 0.773 (95% CI, 0.638-0.938; P = 0.009) when compared with less than 1 cm negative margins. The results of this meta-analysis demonstrate that in patients undergoing hepatic resection for CRLM, a negative margin of 1 cm or more confers a survival advantage when compared with subcentimeter negative margins.

Clinical Scoring Systems for Stratifying Risk after Resection of Hepatic Colorectal Metastases: Still Relevant?

Clinical Scoring Systems for Stratifying Risk after Resection of Hepatic Colorectal Metastases: Still Relevant?

Effect of blood transfusion on early outcome of liver resection for colorectal hepatic metastases.

314 Background: The useof intraoperative blood transfusions (IBT) has been associated with worse surgical outcome in patients undergoing liver resection for malignancy. However, detailed analyses are required to define clinical findings impacting short-term outcome in this scenario.The aim of this study is to evaluate whether IBT are associated with a worse short-term outcome of liver resection in patients with colorectal hepatic metastases, and to assess whether certain patient characteristics and/or surgical variables affect the need for IBT. Methods: In a series of 127 consecutive patients who underwent partial liver resection for colorectal metastases, between July 1999 and March 2010, we studied postoperative 90 days surgical outcome relative to IBT, and the effect of a variety of factors, including type of resection, surgical technique used, concomitant colo-rectal resection, non-tumoral hepatic histological findings, site of primary tumor, and comorbidities, on the incidence of IBT. Results: Patients who received IBT during their liver resection were more likely to have a longer postoperative length of stay (p = 0.02), to experience complications (p = 0.0003), and to experience a Clavien Grade IIIa or worse complication (p = 0.003). Furthermore, undergoing a major resection, and the presence of portal fibrosis in the non-tumoral liver were both correlated with an increase in IBT (respectively, p = 0.003 and p = 0.049), while the surgical technique used (Kellyclasia or TissueLink), the presence of steatosis, undergoing a concomitant major colonic or rectal resection, and having a major comorbidity had no effect on the incidence of IBT (p ≥ 0.05). Conclusions: This study confirmed that receiving IBT during partial liver resection for colorectal hepatic metastases is associated with a worse short-term surgical outcome. These clinical findings suggest that although several significant factors (surgical technique chosen, comorbidities present, etc.) do not seem to influence the short-term outcome of surgery, it is important to be aware of the deleterious effects of the type of resection performed and the presence of portal fibrosis on blood loss during partial liver resection. No significant financial relationships to disclose.