Resection Of Liver Metastases Research Articles

Resection of Gastric Cancer Liver Metastases: Literature Review and Case Report

Introduction: The treatment of gastric cancer has undergone changes in recent years, significantly impacting the morbidity and mortality caused by the disease. However, the treatment of metastatic disease remains a challenge. Whether in the intestinal or Lauren's diffuse tumor, the presence of liver metastases in gastric cancer is considered to be an unfavorable prognosis, given the possibility of the existence of other occult metastases at the time of this diagnosis. Given the changes in the panorama of this disease, it is necessary to review the proposed treatment, considering the possibility of oncological benefit from liver metastasectomy and which patients would benefit from this therapy. Clinical case: FAM, female, 65 years old, diagnosed with Lauren's intestinal-type gastric adenocarcinoma submitted to subtotal gastrectomy with D2 lymphadenectomy. Clinical staging IIIB (T4N2M0), referred for adjuvant chemotherapy protocol. At the time no synchronous distant metastases was identified. One year later PET-CT showed a liver nodule at the right lobe and peri-portal nodule. Submitted to right hepatectomy + peri-portal lymphadenectomy. Anatomopathological exame confirmed gastric adenocarcinoma. Conclusion: Review of published studies in the literature showed that patients who would benefit from this therapy would be those with 1-3 metastatic liver lesions, up to 5 cm in length in the largest one, without serosa invasion in the primary lesion and whose lymph node involvement was ≤ N1 . Overall patient survival was increased from 9.5-14.1 months to 31.1-40.8 months in these groups. We therefore conclude that there is benefit in resection of liver metastases in selected cases of gastric cancer.

Indocyanine Green Fluorescence Guided Resection of Neuroendocrine Liver Metastases: A Proof-of-Concept Study

Introduction: Even though the relative indolent character of neuroendocrine neoplasms, unresected neuroendocrine liver metastases (NELM) have a detrimental impact on survival outcomes. Therefore, complete resection should always be considered if technically possible. The aim of this study was to assess the value of fluorescence guided surgery with indocyanine green (ICG) to resect NELM. Methods: This is a proof-of-concept study including patients who underwent resection of NELM of any grade. Patients who underwent liver resection for other tumour types (colorectal liver metastases, CRLM and hepatocellular carcinoma, HCC) were included to compare ICG uptake. Patients received a bolus infusion of 10 mg ICG approximately 24 hours prior to surgery. Resection of liver metastases were performed using guidance of fluorescence cameras and intra-operative ultrasonography. All resected lesions underwent histopathological assessment by an expert pathologist. Results: Six patients were included in the study: three with NELM, two with CRLM and one with HCC. Five patients underwent a minimally invasive liver resection, and had uptake of ICG in the liver metastases. Uptake of ICG was both homogenous and “rim-shaped” in NELM. A resection was not performed in one patient with NELM, due to unforeseen bilobar metastases. There were no adverse events related to use of ICG fluorescence. All resection margins were negative (R0). Conclusion: This is to our knowledge the first proof-of-concept study describing ICG fluorescence guided resection of NELM. Fluorescence guided resection of NELM using ICG was possible, and uptake of ICG by NELM is comparable to CRLM and HCC.

Efficacy of Upfront Hepatectomy without Neoadjuvant Chemotherapy for Resectable Colorectal Liver Metastasis

Introduction: Hepatectomy for resectalbe colorectal liver metastasis (CRLM) is recommended. However the efficacy of upfront hepatectomy without neoadjuvant chemotherapy (NAC) is unclear due to the uncertainty of perioperative systemic chemotherapy. It is also important to predict the prognosis when considering perioperative chemotherapy. This study evaluated the impact of neoadjuvant chemotherapy on the prognosis of patients with resectable colorectal liver metastasis and assessed the usefulness of Beppu’s nomogram for predicting prognosis. Methods: This retrospective study identified 88 consecutive inpatients who underwent primary hepatic resection for colorectal liver metastasis; 58 received neoadjuvant chemotherapy and 30 underwent upfront surgery. Factors associated with recurrence-free survival were identified via univariate and multivariate analysis. Propensity score analysis using inverse probability of treatment weighting (IPTW) was also performed. Results: On univariate analysis, poor recurrence-free survival was associated with multiple tumors, advanced primary tumor stage, vascular invasion by the primary tumor, a Beppu’s nomogram score ≥6, and neoadjuvant chemotherapy. On multivariate analysis, a Beppu’s nomogram score ≥6 and neoadjuvant chemotherapy were independent risk factors for recurrence. Neoadjuvant chemotherapy recipients had a higher incidence of lymph node metastasis and vascular invasion than non-recipients. Propensity score analysis revealed no significant difference in the recurrence-free survival rate between these groups. Conclusions: Our results show that upfront hepatectomy without neoadjuvant chemotherapy can be considered for resectable colorectal liver metastasis treatment. Beppu’s nomogram score can be an option as one of the tools for predicting the prognosis of patients with colorectal liver metastasis.

Long Term Follow up Strategy for CRLM Following Liver Resection

Introduction: Liver resection for colorectal liver metastasis (CRLM) can be achieved with curative intent in 10 – 20% of these cases, and 5 year survival is approaching 50%. There is evidence that those patients who survive beyond 10 years are effectively cured of their disease. Currently there are no consensus guidelines regarding long term follow up for patients who have undergone liver resection for CRLM. Methods: We retrospectively analysed all patient undergoing at least one repeat liver resection for recurrent CRLM at our instution since 1997. We assessed time between resections as a marker of time to recurrence. Results: In total 279 patients underwent at least 2 liver resections for recurrent CRLM. Some patients went on to have third and fourth resections for recurrent CRLM. In total 279 patients underwent 348 resections. Median time to recurrence between resections was; 15.5 months (n=279) to second recurrence, 15.7 months to third recurrence (n=59), and 20.7 months to 4threcurrence (n=10). Overall 96.6 of patients recurred within 5 years. There were 12 (3.4%) patients who recurred after 5 years. Conclusion: This study demonstrates that the majority of recurrent CRLM occurs within the first 5 years following liver resection. There are a small proportion of patients that recur after 5 years that still have a potential benefit from surgery. We recommend that follow up for patients undergoing liver resection for CRLM should be for 10 years in selected patients, in particular those that are fit enough for consideration of further surgery

Circulating metabolites as a concept beyond tumor biology determining disease recurrence after resection of colorectal liver metastasis.

Micro-metastatic growth is considered the main source of early cancer recurrence. Nutritional and microenvironmental components are increasingly recognized to play a significant role in the liver. We explored the predictive potential of preoperative plasma metabolites for postoperative disease recurrence in colorectal cancer liver metastasis (CRCLM) patients. All included patients (n=71) had undergone R0 liver resection for colorectal cancer liver metastasis in the years between 2012 and 2018. Preoperative blood samples were collected and assessed for 180 metabolites using a preconfigured mass-spectrometry kit (Biocrates Absolute IDQ p180 kit). Postoperative disease-free (DFS) and overall survival (OS) were prospectively recorded. Patients that recurred within 6 months after surgery were defined as "high-risk" and, subsequently, a three-metabolite model was created which can assess DFS in our collective. Multiple lysophosphatidylcholines (lysoPCs) and phosphatidylcholines (PCs) significantly predicted disease recurrence within 6 months (strongest: PC aa C36:1 AUC=0.83, p=0.003, PC ae C34:0 AUC=0.83, p=0.004 and lysoPC a C18:1 AUC=0.8, p=0.006). High-risk patients had a median DFS of 183 days versus 522 days in low-risk population (p=0.016, HR=1.98 95% CI 1.16-4.35) with a 6 months recurrence rate of 47.6% versus 4.7%, outperforming routine predictors of oncological outcome. Circulating metabolites identified CRCLM patients at highest risk for 6 months disease recurrence after surgery. Our data also suggests that circulating metabolites might play a significant pathophysiological role in micro-metastatic growth and concomitant early tumor recurrences after liver resection. However, the clinical applicability and performance of this proposed metabolomic concept needs to be independently validated in future studies.

Impact of Microscopic Incomplete Resection for Colorectal Liver Metastases on Surgical Margin Recurrence: R1-Contact vs. R1≪1mm Margin Width

Introduction: Several studies highlighted an inferior oncologic outcome of parenchyma R1 vs. R0 resection for colorectal cancer liver metastasis (CRLM); however, it is still unclear whether directly involved microscopic margins(R1-contact) are associated with a poorer outcome compared to R1<1mm. The aim of this study is to analyze the impact on surgical margin recurrence (SMR) of R1-contact (0mm) vs.R1<1mm resection in patients with CRLM.

KRAS Mutation at Codon 12 Predicts Clinical Outcome in Repeat Hepatic Resection for Recurrent Colorectal Liver Metastases

Introduction: Repeat hepatic resection for recurrent colorectal liver metastasis (CRLM) has been shown to be associated with improved overall survival. Our aim was to elucidate the prognostic role of KRAS mutational status in predicting outcome in patients with CRLM undergoing repeat surgical resection after liver recurrence.

RE-HEPATECTOMY MEANS MORE MORBIDITY? A MULTICENTRIC ANALYSIS.

ABSTRACT - BACKGROUND:Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival.AIM: This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy.METHODS: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant.RESULTS: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407).CONCLUSIONS: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

Uloga stereotaksične radioterapije u lečenju metastaza u jetri kolorektalnog karcinoma

Colorectal cancer is third most common malignant disease and second leading cause of cancer-related deaths worldwide. In 2020, there were 5900 new cases in Serbia and around 3300 number of deaths related to this disease. Metastatic disease is most frequently located in liver. Surgery is first option if complete resection of liver metastases is achievable. Since liver metastases are resectable in 10 - 20% of cases, there is a possibility of implementation of other treatment modality. Alternative for surgery in local treatment of unresectable metastases are stereotactic body radiation therapy (SBRT), interstitial and intraluminal brachytherapy, transarterial chemoembolization, hepatic arterial infusion chemotherapy, selective internal radiation therapy with yttrium-90 resin microspheres, cryoablation, radiofrequency, chemical, and microwave ablation. Candidates for SBRT are patients with unresectable liver metastatic disease and patients with comorbidities which disable surgical treatment, with adequate function of uninvolved liver tissue. Respiration induced motion of target volume can be reduced by introduction of motion management strategies such as infrared markers, deep inspiration breath hold, abdominal compression, respiratory tracking and gating. CyberKnife, TomoTherapy machine and modified linear accelerators are used for delivering SBRT. These units allow us to deliver dose more precisely and to make dose escalation. Different regimes of fractionation are optional, from single fraction to hypo fractionation regimes, and doses are typically around 30 - 60 Gy in 3 fractions. Low toxicity rates in patients with liver metastases treated with SBRT are in relation with precise treatment planning, dose prescription and fractionation. Results of research suggest that delivery of large doses can provide high rate of local response, but on the other hand there is possibility of disease progression out of target volumes. With adequate selection of patients with unresectable liver metastases, the implementation of SBRT, especially in combination with effective systematic treatment modalities, can provide better local control with extension of survival.

Advances in liver transplantation for unresectable colon cancer liver metastasis.

It is estimated that 50% of patients with colorectal cancer will develop liver metastasis. Surgical resection significantly improves survival and provides a chance of cure for patients with colorectal cancer liver metastasis (CRLM). Increasing the resectability of primary unresectable liver metastasis provides more survival benefit for those patients. Considerable surgical innovations have been made to increase the resection rate and decrease the potential risk of hepatic failure postoperation. Liver transplantation (LT) has been explored as a potential curative treatment for unresectable CRLM. However, candidate selection criteria, chemotherapy strategies, refined immunity regimens and resolution for the shortage of grafts are lacking. This manuscript discusses views on surgical indication, peritransplantation anti-tumor and anti-immunity therapy and updated advances in LT for unresectable CRLM. A literature review of published articles and registered clinical trials in PubMed, Google Scholar, and Clinicaltrials.gov was performed to identify studies related to LT for CRLM. Some research topics were identified, including indications for LT for CRLM, oncological risk, antitumor regimens, graft loss, administration of anti-immunity drugs and solutions for graft deficiency. The main candidate selection criteria are good patient performance, good tumor biological behavior and chemosensitivity. Chemotherapy should be administered before transplantation but is not commonly administered posttransplantation for preventive purposes. Mammalian target of rapamycin regimens are recommended for their potential oncological benefit, although there are limited cases. In addition to extended criterion grafts, living donor grafts and small grafts combined with two-stage hepatectomy are efficient means to resolve organ deficiency. LT has been proven to be an effective treatment for selected patients with liver-only CRLM. Due to limited donor grafts, high cost and poorly clarified oncological risks, LT for unresectable CRLM should be strictly performed under a well-organized study plan in selected patients. Some vital factors, like LT indication and anti-tumor and anti-immune treatment, remain to be confirmed. Ongoing clinical trials are expected to delineate these topics.

Survival after cytoreductive surgery for peritoneal metastases in colorectal cancer patients: Does a history of resected liver metastases worsen the prognosis?

BackgroundNowadays, resection of two (liver and peritoneum) concomitant colorectal cancer metastatic sites is no longer contraindicated. However, the oncologic outcomes of resecting peritoneal metastases (PM) occurring more than six months after resection of liver metastases (LM) are unknown. AimThe aim of this study was to compare patients with complete cytoreductive surgery (CRS) with or without a history of previous liver resection (LR). MethodsAnalysis from a prospective database of 74 patients with metachronous PM treated with CRS between 2010 and 2020. ResultsAll patients had PM metachronous to primary, 64 patients underwent CRS alone (CRSa) and 10 CRS more than six months after LR (LR-CRS). There was no statistical difference between the groups for clinical or therapeutic characteristics. There were more signet ring cell/mucinous adenocarcinomas in the CRSa group than in the LR-CRS group (19% vs. 0%, p = 0.049). The median peritoneal cancer index (PCI) was 4 and 6 (p = 0.749) in the LR-CRS and CRSa groups, respectively. Median overall survival (OS) and disease-free survival (DFS) were not statistically different between the two groups with 43.6 and 13 months for the CRSa group and 31.1 months and 9.4 months for LR-CRS. Advanced age was an independent negative prognostic factor for OS and high PCI was limit significant. No prognostic factor for DFS was found. ConclusionsLR before CRS has no major prognostic impact. Resection of iterative liver and peritoneum metastases can achieve long-term survival.

Kolorektal kanserin karaciğer metastazında sağ kalımı etkileyen faktörler

Aim: Colorectal cancer is among the most common malignancies and liver metastasis is developed in 50% of the patients. Hepatic resection is the most effective treatment in liver metastasis of colorectal cancer. The present study aimed to determine the factors that affect survival in patients who underwent hepatic resection in liver metastasis of colorectal cancer. Materials and Methods: The data on patients who underwent hepatic resection due to liver metastasis of colorectal cancer in Ege University, Faculty of Medicine, General Surgery Department were retrospectively analyzed. Survival data were collected with the review of patient follow-up files. The effects of the factors pertaining to the patients on survival were determined. Results: The mean age of the 62 participating patients was 58.08 ± 10.92 years. Total survival rate was 50.4 months (CI: 41.2-59.7). The factors that statistically significantly reduced the survival rate were determined as follows: Patient age&amp;gt; 65 (&amp;lt;65 years: 56.4 ± 5.5 months / ≥65 years: 29.3 ± 4.8 months, p = 0.007), presence of more than four lymph node metastases in the primary tumor (N0: 56.1 ± 7.9 months / N1: 56.5 ± 6.5 months / N2: 18.0 ± 3.0, p = 0.001), presence of bilobular liver metastasis (Uni-lobular: 53.4 ± 5.0 months / bilobular: 24.0 ± 4.4 months, p = 0.026), and liver resection margin closer than 2 mm (&amp;lt;2 mm: 28.4 ± 7.7 months / 2-9 mm: 61.1 ± 7 , 6 months, ≥10mm: 46.3 ± 5.9 months, p = 0.003). No statistically significant differences were determined in survival based on gender, location of the primary tumor, the invasion depth of the primary tumor, the time between colorectal and liver surgery, the carcinoembryonic antigen level, the metastasis diameter, the number of metastases and the extent of surgical resection. Conclusion: In patients who underwent surgical resection for liver metastasis of colorectal cancer, age older than sixty-five years, the presence of more than four lymph nodes in the colon resection material, bilobular liver metastasis, and a surgical margin closer than 2 mm were poor prognostic factors.

O-L07 Role of liver resection for metastases from uveal melanoma: Experience from a supra-regional centre, current evidence, and future prospects

Abstract Background Management of liver metastases from uveal melanoma (LMUM) requires a ‘multi-modal’ approach including surgical resection. This study aimed to evaluate the role, safety, and oncological effectiveness of liver surgery for patients with LMUM in the context multidisciplinary management. A comprehensive treatment pathway developed upon current published evidence, prevalent national guidelines and novel treatment options is presented (Figure 2) Methods Retrospective review of prospectively maintained database between February 2005 to August 2018 was performed using the institutional electronic patient record system from oncology and surgical department. Demographic data, MDT outcome letters, operative records, clinic letters, letters from referring hospitals, discharge summaries, radiology reports, and histology findings were reviewed. Focused literature review was conducted to identify all relevant publications. All advanced statistical analysis was performed using SPSS version 27.0 software (IBM Corp., Armonk, NY, USA). A p-value of &amp;lt; 0.05 was considered to be statistically significant. The work was approved by the institutional clinical governance department (Audit ID 6661). Results 31 patients underwent diagnostic laparoscopy and 17 patients received 19 liver resections locally (Figure 1). 7 major (≥ 3 seg) and 12 minor liver resections (14 laparoscopic) were done without any mortality or major complications. 10/19 (52.6%) were R0 resections. Overall survival positively correlated with the time from UM to LMUM (rs = 0.859, p&amp;lt;0.0001). R0 or R1 resection margin status did not significantly influence survival outcomes (OS 25 Vs 28, p = 0.404; RFS 13 Vs 6 months, p = 0.596), though R1 cohort had longer lead time (100 Vs 24 months, p = 0.0408). Conclusions Liver resection for LMUM is safe, effective and complements multimodal management. Lead time from development of UM to LMUM remains a key factor affecting survival outcomes. As novel treatment modalities for regional and systemic disease control for metastatic uveal melanoma continue to develop, surgical intervention will also continue to evolve as part of the multi-disciplinary management. We emphasise the need for developing a collaborative database at a national and international level. We present an evidence-based, multi-disciplinary management pathway for LMUM patients (Figure 2).

Outcomes of Hepatic Metastasectomy for Colorectal Cancer Metastases in the Philippine General Hospital

Rationale: The liver is the most common site of metastasis from colorectal cancer. Curative intent liver metastasectomy has shown improvement in overall survival. This manuscript will present the long-term oncologic outcomes of hepatic metastasectomy for colorectal cancer with resectable liver metastasis. Methods: Data of patients with resectable liver metastases from colorectal cancer who underwent hepatic resection at the Philippine General Hospital over a 10-year period was reviewed. The primary outcome investigated was overall survival. Results: Thirty patients were included in the study. The median overall survival was 20 months, with a 2-year and 5-year overall survival rate of 40% and 6.67% respectively. Eleven (36.67%) patients had disease recurrence, with a median disease-free survival of 16 months. A significant difference in survival was seen between patients with synchronous and metachronous liver metastasis (20.38 and 36.78 months respectively, p=0.0393) and in patients given adjuvant chemotherapy at any time in relation to the occurrence of the liver metastases versus patients who did not receive any adjuvant treatment (34.08 and 18.59 months respectively, p=0.0349). Trends towards improved overall survival were seen in patients 50 years old or less (36.86 versus 21.78 months, p=0.0837) and in patients with a clinical risk score of 2 or less (29.65 versus 19.62 months, p=0.1823), which may show significance in a higher-powered study. Conclusion: Improved overall survival was observed among patients with colorectal liver metastases undergoing hepatic metastasectomy compared to no liver resection. Conclusion: Improved overall survival was observed among patients with colorectal liver metastases undergoing hepatic metastasectomy compared to no liver resection. Key words: colorectal cancer, liver metastasis, metastasectomy, Philippines

Genomic Stratification of Resectable Colorectal Liver Metastasis Patients and Implications for Adjuvant Therapy and Survival.

To determine whether genomic risk groups identified by somatic mutation testing of colorectal liver metastasis (CRLM) can be used for "molecularly-guided" selection for adjuvant systemic chemotherapy and hepatic artery infusion of FUDR (SYS+HAI-FUDR). Several genomic biomarkers have been associated with clinical phenotype and survival for patients with resectable CRLM. It is unknown whether prognostication afforded by genomic stratification translates into enhanced patient selection for adjuvant hepatic artery infusion therapy. Consecutive patients with resected CRLM and available mutational characterization via Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets were reviewed from a prospective institutional database. Patients were stratified into three genomic risk groups based on previously defined alterations in SMAD4, EGFR and the RAS/RAF pathway. The association between SYS+HAI-FUDR and overall survival, relative to adjuvant chemotherapy alone (SYS), was evaluated in each genomic risk group by Cox proportional hazard regression and propensity score matched analyses. A total of 334 patients (SYS+HAI-FUDR 204; SYS 130) were identified; the rates of RAS/RAF alterations and SMAD4 inactivation were 47.4% and 11.7%, respectively. After a median follow-up of 58 months, adjuvant SYS+HAI-FUDR was independently associated with a reduced risk of death (HR 0.50, 95%CI 0.26-0.98, P = 0.045) in the low-risk genomic group, but not in the moderate-risk (HR 1.07, 95%CI 0.5-2.07, P = 0.749) or high-risk (HR 1.62, 95%CI 0.29-9.12, P = 0.537) cohorts. Following propensity score matching, adjuvant SYS+HAI-FUDR remained associated with significant improvements in long-term survival selectively in the low-risk genomic cohort (5-year actuarial survival: 89% vs. 68%, P = 0.019). Genomic alterations in RAS/RAF, SMAD4, and EGFR may be useful to guide treatment selection in resectable CRLM patients and warrant external validation and integration in future clinical trial design.

Impact of Intraoperative Blood Loss and Blood Transfusion on the Prognosis of Colorectal Liver Metastasis Following Curative Resection.

The identification of risk factors for recurrence after resection of colorectal liver metastasis is necessary in order to establish a more effective treatment strategy. In addition to well-known prognostic factors, such as the tumor diameter and number of metastatic tumors, a large amount of intraoperative blood loss (IBL) and blood transfusion have recently been reported to be associated with shorter long-term survival. The aim of this study was to assess the impact of IBL and blood transfusion on the prognosis of colorectal liver metastasis after curative resection. A total of 104 patients who underwent R0 resection for colorectal liver metastasis were enrolled in this study. The high-IBL (>300 ml) group had significantly shorter relapse-free survival after hepatic resection in comparison to the low-IBL (≤300 ml) group (p=0.0025). Patients with blood transfusion had significantly shorter relapse-free survival after hepatic resection in comparison to patients without blood transfusion (p=0.0026). A large amount of IBL and blood transfusion may have a negative impact on long-term survival in patients who undergo hepatic resection for colorectal liver metastasis.

ASO Visual Abstract: A Prospective Multicenter Interventional Study of Surgical Resection for Liver Metastasis from Gastric Cancer: R0 Resection Rate and Operative Morbidity and Mortality

ASO Visual Abstract: A Prospective Multicenter Interventional Study of Surgical Resection for Liver Metastasis from Gastric Cancer: R0 Resection Rate and Operative Morbidity and Mortality

SP6.1.11 The Effect of the Enhanced Recovery Programme for Liver Surgery on Long Term Survival

Abstract Aims The Enhanced Recovery Programme for Liver Surgery (ERPLS) has been shown to promote functional recovery and reduce hospital stay. However, its effect on long term survival has yet to be established. The aim of this study was to determine the effect of the ERPLS on 5-year patient survival. Methods This was a retrospective study of patients who underwent liver resection for colorectal liver metastasis (CRLM) between January 2011 and December 2016 at a regional hepatobiliary centre. The cohort comprised of 60 pre-ERPLS and 60 post-ERPLS patients. The primary outcome was 5-year patient survival. The secondary outcomes were length of stay (LOS), postoperative complications and 90-day readmission rates. Multivariate analysis was performed to identify independent predictors of overall survival. Results There was no significant difference in the age (p = 0.960), gender (p = 0.332) and type of resection (p = 0.198) between both groups. ERPLS was not an independent predictor for overall survival (Gehan Wilcoxon Test, p = 0.828). There was no significant difference in the LOS (p = 0.874) and 90-day readmission rates (p = 0.349). Major postoperative complications (&amp;gt;3a Clavien-Dindo classification) were significantly less in the ERPLS group (p = 0.02). On multivariate analysis, positive resection margins and major postoperative complications were independent predictors for overall survival. Conclusions ERPLS does not seem to have an effect on long term patient survival. However, it appears to reduce the rate of major postoperative complications. LOS and 90-day readmission rates were not influenced by ERPLS.

A case of laparoscopic partial hepatic S7 resection for postoperative liver metastasis of rectal malignant melanoma

BackgroundAnorectal malignant melanoma (ARMM) has an extremely poor prognosis, and there is no report of resection of liver metastases so far. We report herein a rare case of postoperative laparoscopic partial hepatic S7 resection for rectal malignant melanoma.Case presentationA 51-year-old female patient with a diagnosis of an ARMM underwent a laparoscopic rectal amputation. Eleven months later, computed tomography (CT) revealed a 14-mm nodule in liver segment 7 (S7), which was diagnosed as a hepatic recurrence of the ARMM. Because no other recurrences were found, a laparoscopic partial resection of S7 was performed. Pathological analysis found intracellular melanin deposition, and immunostaining was S-100 (+), HMB-45 (+), and SOX-10 (+). Based on these findings, a liver metastasis of malignant melanoma was diagnosed. The patient is alive 7 months after the second surgery and has so far experienced no recurrences.ConclusionWe reported an extremely rare case of a laparoscopic resection of a liver metastasis following surgery for ARMM.

Prognostic value of a novel biomarker combining DNA ploidy and tumor burden score for initially resectable liver metastases from patients with colorectal cancer

BackgroundColorectal cancer liver metastases (CRLM) has not been identified as a unified disease entity due to the differences in the severity of metastatic disease and tumor aggressiveness. A screen for specific prognostic risk subgroups is urgently needed. The current study aimed to investigate the prognostic value of DNA ploidy, stroma fraction and nucleotyping of initially resectable liver metastases from patients with CRLM.MethodsOne hundred thirty-nine consecutive patients with initially resectable CRLM who underwent curative liver resection from 2006 to 2018 at Sun Yat-sen University Cancer Center were selected for analysis. DNA ploidy, stroma fraction and nucleotyping of liver metastases were evaluated using automated digital imaging systems. Recurrence-free survival (RFS) and overall survival (OS) were analyzed using the Kaplan-Meier method and Cox regression models.ResultsDNA ploidy was identified as an independent prognostic factor for RFS (HR, 2.082; 95% CI 1.053–4.115; P = 0.035) in the multivariate analysis, while stroma-tumor fraction and nucleotyping were not significant prognostic factors. A significant difference in 3-year RFS was observed among the low-, moderate- and high-risk groups stratified by a novel parameter combined with the tumor burden score (TBS) and DNA ploidy (72.5% vs. 63.2% vs. 37.3%, P = 0.007). The high-risk group who received adjuvant chemotherapy had a significantly better 3-year RFS rate than those without adjuvant chemotherapy (46.7% vs. 24.8%; P = 0.034).ConclusionsOur study showed that DNA ploidy of liver metastases is an independent prognostic factor for patients with initially resectable CRLM after liver resection. The combination of DNA ploidy and TBS may help to stratify patients into different recurrence risk groups and may guide postoperative treatment among the patients.