Resection Of Liver Metastases Research Articles

Clinical Outcome of Patients Submitted to Liver Resection in the Context of Metastatic Breast Cancer: A Study of a Tertiary Hospital Center.

Introduction: Breast cancer is the most incident cancer in the world, accounting for 25% of new cancers per year in females. It is the most frequent malignancy in women, being the fifth cause of death from cancer worldwide. Approximately 5 to 10% of patients already present with metastases at diagnosis, and the liver is the site of metastases in half of these cases. Liver metastasis (LM) resection, performed after neoadjuvant systemic treatment, has been reported to increase median overall survival in this population. Aim: The aim of this analysis is to assess the outcomes of patients undergoing breast cancer liver metastasis surgical resection, including impact on survival, compared to patients where metastasectomy was not performed. Methods: retrospective review of 55 female patients with breast cancer liver metastases, diagnosed and treated in a single tertiary university hospital from January 2011 to December 2016 was performed. Results: In 32/55 patients (58.2%), multi-organ metastases were identified (the most common sites being bone, lungs, and lymph nodes). Of the remaining 23 patients, the liver was the unique metastatic site; thirteen patients had diffuse bilobar hepatic metastases. The remaining ten patients were proposed for surgical treatment; three of them had peritoneal carcinomatosis identified during surgery, and no hepatic metastasectomy was performed. As a result, only seven (12.7%) patients underwent liver metastasectomy. Overall survival was higher in patients who had LM surgery (65 months [Interquartile Range (IQR) 54–120]), in comparison to those diagnosed with diffuse bilobar hepatic metastases (17.5 months [IQR 11–41]), and with those showing concurrent liver and bone metastases (16.5 months [IQR 6–36]) (p = 0.012). In univariable analysis, the latter two groups showed worse overall survival outcomes (Hazard Ratio (HR) = 3.447, 95%CI: 1.218–9.756, p = 0.02 and HR = 3.855, 95% Confidence Interval (CI): 1.475–10.077, p = 0.006, respectively) when compared to patients with LM. Conclusion: In our series, patients submitted to metastasectomy had a median overall survival after diagnosis of LM three times greater than the non-operated patients with isolated LM, or concurrent LM and bone metastases (65 vs. 17.5 and 16.5 months, respectively). As is vastly known for colorectal cancer liver metastasis, resection of breast cancer liver metastasis may reduce tumor burden, and therefore may improve patient outcome.

Neoadjuvant Chemotherapy Versus Upfront Surgery for Resectable Liver Metastases from Colorectal Cancer: a Multicenter, Propensity Score–Matched Cohort Study

BackgroundAdjuvant chemotherapy for resectable colorectal liver metastasis (CRLM) is widely used, but its efficacy lacks clear evidence. This retrospective cohort study investigated the effectiveness of neoadjuvant chemotherapy (NAC) compared to upfront surgery for CRLM. MethodsData from patients with resectable CRLM were analyzed. Short-term outcomes and long-term prognosis were analyzed using propensity score matching. CRLM was stratified according to the H-classification (H1 and H2), and the effectiveness of adjuvant chemotherapy was analyzed in each group. ResultsWe analyzed 599 cases that were matched into an NAC group (n = 136) and an upfront surgery group (n = 136). The proportion of synchronous metastases, H2-classification, and postoperative chemotherapy rate did not differ between the groups. Overall survival (OS) after initial treatment was significantly worse in the NAC group than in the upfront surgery group (P = 0.029). The 5-, 7-, and 10-year OS rates for H1 patients were significantly better in the upfront surgery group than in the NAC group (64%, 51%, and 44% vs. 50%, 31%, and 18%, respectively) (P = 0.004). ConclusionPatients with resectable CRLM should undergo upfront surgery, because NAC did not improve OS after initial treatment in these patients.

Variable implementation of optimal therapeutic strategies in metastatic colorectal cancer: Reviewing rates of liver resection and triplet chemotherapy across Australian hospitals as potential quality indicators.

248 Background: Quality indicators (QI) are essential to monitor the efficacy of cancer care and to guide quality improvement, however many are derived from ‘expert consensus’ and are not validated against outcomes. Moreover, the majority of oncological QI are defined in the surgical setting, with only a paucity of QI for the treatment of metastatic disease. We aimed to define and validate novel QI for metastatic colorectal cancer (mCRC) based on therapeutic approaches associated with a proven survival benefit. Methods: Data was analysed from TRACC, a multisite Australian registry collecting prospective demographic, tumour, treatment and outcome data for mCRC. We identified all patients diagnosed across 11 hospitals and explored variation by site with regards to patient and tumour characteristics, first-line chemotherapy administration and resection of oligometastatic disease. Log-rank testing and Kaplan-Meier curves compare overall survival (OS) between sites, and Pearson correlation was used to assess associations with each QI. Results: We examined data from 3132 patients diagnosed with mCRC between July 2009 – April 2021. Median age was 66 years (range 62 – 71 years by site), ECOG 0-1 81% (range 69 – 96% by site), and Charlson Comorbidity Index ≤2 43% (33 – 59% by site). Multivariate analysis confirmed association of known adverse prognostic factors with inferior OS (poor ECOG, right sided primary, KRAS or BRAF mutation, all p <0.05). Median OS for entire cohort was 26.2 months (95%CI 24.9 – 27.3 months), and varied by hospital site from 20.1 – 36.1 months (p<0.001). Of the QI evaluated, rate of triplet chemotherapy (FOLFOXIRI) administration (2.8 – 13.2% by site) was very strongly correlated with OS (R2 = 0.851), rate of liver resection (9.8 – 23.2% by site) was moderately correlated (R2 = 0.523), and rates of active treatment with first-line chemotherapy (63 - 90% by site) were weakly correlated (R2 = 0.209). Other proposed QI such as rates of lung metastases resection or chemotherapy administration in the elderly showed significant variation by site, but did not correlate with survival. Conclusions: There is significant variation in OS for patients with mCRC in these Australian hospitals, with major differences in treatment approaches. Treatment strategies known to improve survival outcomes, such as triplet FOLFOXIRI chemotherapy and resection of liver metastases, may be potential QI to benchmark and track quality improvement over time. Further analysis will determine the impact of baseline patient populations between sites, and to correlate these QI with other quality measures.

Impact of multidisciplinary tumor board (MTB) discussion on the outcome of patients with liver-limited metastasis from colorectal cancer (LMCRC).

50 Background: MTB is a valuable tool in complex cases, since they involve different medical fields aiming for a more comprehensive decision-making process. Our aims are to describe MTB decisions in complex LMCRC, to analyze decisions compliance and evaluate outcomes. Methods: This is a retrospective analysis of medical records of patients diagnosed with liver metastasis of colorectal carcinoma (LMCRC) discussed at a single center, weekly-basis MTB from January 2019 to December 2020. Descriptive statistics was used for demographic and treatment characteristics and adhesion to MTB decisions. Survival was estimated by Kaplan-Meier method and log-rank tests. Results: Out of 1033 cases discussed at MTB, 63 met the inclusion criteria. Median age was 56.5 years (range 32 – 81), 61.9% were male, ECOG was 0-1 in 96.8%. Regarding primary tumor sidedness: 81% and 19% were left and right, respectively. Synchronous metastasis was present in 69.8% and wild-type RAS was found in 52.4% and MSI-H in 4.8%. At time of MTB, 68.3% and 4.8% had realized a first or second-line chemotherapy (CT) respectively. No previous therapy was described in 19% and 7.9% had received adjuvant CT. Previous hepatic resections occurred in 20.6%. After MTB, liver resection was recommended for 44.5%. Preoperative CT followed by one or two-stage surgery for 23.8%. Non-surgical treatments were offered for 17.5% and palliative CT for 14.3%. Decisions from the MTB were implemented in 93.6%. Reason for not performing (N = 4) were: one for disease progression, one for bureaucratic restriction and two for other reasons. Median follow-up time was 17.2m. At date of analysis, 31 patients (49.2%) had relapsed or progressed and 8 had died. Restricting for patients who underwent MTB decision (N = 59), mPFS was 14.71m. In resected cases (N = 40), who were discussed at the onset of liver metastasis diagnosis (without CT in the metastatic setting) had mPFS not reached, while who were discussed after first or second-line had mPFS of 9.39m (p 0.002). R0 resections were reached in 92.5%. Evaluating the 30-day postoperative mortality, there was one death. mPFS for palliative CT was 6.83m. Conclusions: In our analysis the adherence to MTB recommendation was high (above 90%) and patients selected for surgery presented a prolonged PFS. Our data suggest that selection of patients for liver metastasis resection in a MTB discussion should occur early in the course of treatment.

Aspirin as secondary prevention in colorectal cancer liver metastasis (ASAC trial): study protocol for a multicentre randomized placebo-controlled trial

BackgroundColorectal cancer is one the most common cancers in the western world with increasing incidence. Approximately 50% of the patients develop liver metastases. Resection of liver metastases is the treatment of choice although almost half of the resected patients get recurrence in the liver.MethodsThe ASAC trial is a Scandinavian, multicentre, double-blinded, randomized, placebo-controlled study to determine whether adjuvant treatment with low-dose aspirin (acetylsalicylic acid (ASA)) can improve disease-free survival in patients treated for colorectal cancer liver metastases (CRCLM). Up to 800 patients operated for CRCLM will be randomized to Arm#1 ASA 160 mg once daily or Arm#2 Placebo, for a period of 3 years or until disease recurrence. The patients will be recruited at all major hepatobiliary surgical units in Norway, Sweden and Denmark and have follow-up according to standard of care and the National Guidelines.DiscussionThe ASAC trial will be the first clinical interventional trial to assess the potential beneficial role of ASA in recurrence of CRCLM and survival. ASA is an inexpensive, well-tolerated and easily accessible drug that will be highly potential as adjuvant drug in secondary prevention of CRCLM if the study shows a beneficial effect. We will also determine the effect of ASA as adjuvant treatment on Health-Related Quality of Life and the cost-effectiveness.Trial registrationClinicalTrials.gov NCT03326791. Registered on 31 October 2017.

The Impact of Frailty on Patients Undergoing Liver Resection for Colorectal Liver Metastasis

BackgroundThe aim of this study is to assess the impact of frailty on short-term outcomes after hepatectomy for colorectal liver metastasis (CRLM). MethodsPatients were identified using the National Surgical Quality Improvement Program (NSQIP). Patients were divided into 3 categories using the 5-item Modified Frailty Index (mFI). ResultsThere were 5230 patients included. 52%, 35%, and 13% had mFI scores of 0, 1, and ≥ 2 respectively. Patients with a ≥ 2 mFI score were more likely to experience minor complication (OR 1.34, 95% CI 1.06–1.69), major complication (OR 1.56, 95% CI 1.15–2.12), readmission (OR 1.55, 95% CI 1.12–2.14), unfavorable discharge (OR 2.48, 95% CI 1.62–3.80), 30-day mortality (OR 3.02, 95% CI 1.02–8.95), prolonged length of stay (OR 1.47, 95% CI 1.18–1.83), and bile leak (OR 1.51, 95% CI 1.02–2.24). ConclusionFrailty is associated with increased post-operative complications. The 5-item mFI can guide risk stratification, optimization, and counseling.

Perioperative Systemic Chemotherapy for Colorectal Liver Metastasis: Recent Updates.

Simple SummaryThe development of cytotoxic chemotherapy, targeted agents and immune check point inhibitors has improved survival outcomes and quality of life in patients diagnosed with metastatic colorectal cancer (CRC). Long-term survival and cure are possible in well-selected CRC patients with liver metastases (LM). The criteria for resectable LM and the eligibility of patients should be evaluated at the time of diagnosis or during the clinical course via a multidisciplinary team approach. The advantages of adjuvant chemotherapy after curative resection of LM are uncertain currently. Systemic preoperative chemotherapy may convert unresectable LM to a resectable type. However, the optimal combination of systemic drugs and treatment strategy has yet to be established. This article summarizes recent reports of perioperative systemic treatment for patients with colorectal liver metastases (CLM). This review provides an update for physicians involved in managing patients with CLM.The liver is the most common site of metastases for colorectal cancer. Complete resection in some patients with resectable liver metastases (LM) can lead to long-term survival and cure. Adjuvant systemic chemotherapy after complete resection of LM improves recurrence-free survival; however, the overall survival benefit is not clear. In selected patients, preoperative systemic treatment for metastatic colorectal cancer can convert unresectable to resectable cancer. This review will focus on patient selection, and integration of perioperative and postoperative systemic treatment to surgery in resectable and initially unresectable LM. Additionally, new drugs and biomarkers will be discussed.

Is Surgical Treatment Effective or Contraindicated in Patients with Colorectal Cancer Liver Metastases Exhibiting Extrahepatic Metastasis?

BackgroundSurgical resection for patients with hepatic and extrahepatic colorectal metastases remains controversial. This study aimed to determine the efficacy of curative resection of distant extrahepatic metastatic lesions in patients with colorectal liver metastases (CRLM). MethodsFrom 2007 to 2019, 377 patients with CRLM were treated; of these, 323 patients underwent hepatectomy, and 54 patients with extrahepatic metastases (EHM) had received only chemotherapy. Survival and recurrence were compared between patients with and without EHM. Variables potentially associated with survival were analyzed in univariate and multivariate analyses. ResultsAmong patients who underwent hepatectomy, the median, 3-, and 5-year overall survival rates for patients with EHM (n = 60) were 32 months, 47%, and 28%, respectively, while those for patients without EHM (n = 263) were 115 months, 79%, and 66%, respectively (p < 0.001). Furthermore, outcomes were similar in R2 patients with EHM and those with unresectable tumors. However, outcomes were significantly better in the R0/1 group than in the R2 and unresectable groups (p < 0.001). Among patients with EHM, multivariate analysis revealed that higher clinical risk score, incomplete resection of all EHM, extrahepatic disease detected intraoperatively, and previous treatment with neoadjuvant chemotherapy were independently associated with worse survival. ConclusionsIn patients with CRLM with EHM (liver + one organ), gross curative resection is necessary when surgical treatment is contemplated, and resection of liver metastases should be performed in patients with CRLM with smaller and fewer tumors (e.g., H1).

A Multicenter Randomized Controlled Prospective Study to Assess Efficacy of Laparoscopic Electrochemotherapy in the Treatment of Locally Advanced Pancreatic Cancer.

Background: Eighty percent of patients with pancreatic adenocarcinoma present a locally advanced or metastatic disease at diagnosis and are not eligible for surgery if not with palliative intent. In cases of locally advanced disease (LAPC), the combination of chemo and radiotherapy is the only therapeutic option and correlates with a median survival of 15 months (10 months without treatment), with partial remission of disease in 50% of cases. The feasibility and safety of Electrochemotherapy (ECT) have been demonstrated in the treatment of deep tumors. Aim: The aim of the study is to evaluate the efficacy of electrochemotherapy (ECT) followed by conventional systemic treatment compared to the only conventional systemic treatment in LAPC in terms of objective response and overall survival. Patients and Methods: This study is a phase IIb prospective multicenter randomized controlled trial with two arms. The study will include 90 patients: 45 in the control group and 45 in the experimental group. Patients with LAPC in the control arm will receive conventional chemotherapy (FOLFOXIRI). Patients with LAPC in the experimental arm will be subjected to Electrochemotherapy and subsequently to FOLFOXIRI. The objective response at 30, 90, and 180 days from treatment will be based on the computed tomography (CT), magnetic resonance (MR), and positron emission tomography/CT response (PET/CT). The objective long-term treatment response will be evaluated with the modified response evaluation criteria in solid tumors (m-RECIST) criteria, which will take into account the difference in vascularization, determined by the images obtained by CT and MR of the tumor treated before and after ECT. Conclusions: Not resectable liver metastasis, pancreatic tumors, and locally advanced renal carcinomas can be treated with laparoscopic electrodes. ECT could represent an effective therapeutic option for patients not eligible for surgery susceptible to be managed only with palliative therapies.

Prospective Multicenter Interventional Study of Surgical Resection for Liver Metastasis from Gastric Cancer: R0 Resection Rate, and Operative Morbidity and Mortality.

The optimal treatment for liver metastasis from gastric cancer (LMGC) remains uncertain. The relevance of surgical resection is controversial. We conducted a prospective multicenter interventional study of surgical resection for LMGC. Patients with synchronous or metachronous LMGC who were surgically fit were registered. The primary endpoint was 3-year overall survival (OS) of patients who underwent R0 resection. Secondary endpoints were R0 resection rate, operative morbidity and mortality, 3-year recurrence-free survival (RFS) of R0 patients, and OS in all registered patients. Seventy patients were registered from 24 institutions between December 2011 and November 2019 and received preoperative chemotherapy. Three patients were ineligible, and 19 patients discontinued treatment, with disease progression in 12, adverse events in 4, and consent withdrawal in 3 before surgery. Of the 48 patients eventually undergoing surgery, R0 resection of the primary and/or metastatic GC was accomplished in 43 patients, while 1 patient discontinued treatment for positive peritoneal lavage cytology and 4 patients were considered ineligible based on postoperative pathological findings other than GC. The R0 resection rate of all eligible patients was 68.3% [95% confidence interval (CI) 55.3-79.4%, 43/63 patients], while that of all resected patients was 89.6% (95% CI 77.3-96.5%, 43/48 patients). Postoperative complications were identified in 12 out of 43 patients (27.9%), and Clavien-Dindo grade III or higher complications occurred in seven patients (16.3%). No hospital mortality was observed. R0 resection for LMGC could be performed in approximately two-thirds of all eligible patients, with acceptable surgical morbidity and mortality.

The prognostic significance of tumour FXYD-3 expression in patients with primary and secondary colorectal cancers

Purpose: The clinical significance of FXYD-3 expression in colorectal cancer (CRC) is uncertain. There are no studies examining FXYD-3 expression in colorectal liver metastases (CRLM). The aim was to examine the degree of FXYD-3 expression in CRC and CRLM and assess the relationship between expression and survival after resection of liver metastases. Methods: A matched case-control study, using conditional logistic regression, compared FXYD-3 expression in the primary tumours of patients without CRLM to those with CRLM. A retrospective cohort study on CRLM patients examined if FXYD-3 expression was associated with overall survival. Results: There were 220 patients; 110 CRLM patients and 110 CRC patients. There was no difference in FXYD-3 expression between primary tumours (p=0.62) and no difference in FXYD-3 expression between the primary tumour and liver metastases (p=0.55). Strong FXYD-3 expression in CRLM’s was associated with a reduced risk of mortality in comparison to weak FXYD-3 expression (HR: 0.51, 95% CI 0.28, 0.93). There was evidence of effect modification between FXYD-3 expression and chemotherapy (p&lt;0.001): patients with strong FXYD-3 expression in CRLM’s who received post-operative chemotherapy had longer survival compared to those who did not. Conclusion: There are no differences in FXYD-3 expression in primary tumours between patients who did or did not develop liver metastases. Similarly, no difference in FXYD-3 expression between the primary tumour and the corresponding liver metastases. However, strong FXYD-3 expression in CRLM proved to be a marker of long-term survival in patients who receive adjuvant chemotherapy post liver resection.

Liver transplantation versus liver resection for colorectal liver metastasis: a survival benefit analysis in patients stratified according to tumor burden score.

Liver transplantation (LT) for colorectal liver metastasis (CRLM) may provide excellent survival rates in patients with unresectable disease. High tumor load is a risk factor for recurrence and low overall survival (OS) after liver resection (LR). We tested the hypothesis that LT could offer better survival than LR in patients with high tumor load. LR performed at Padua University Hospital for CRLM was compared with LT for unresectable CRLM performed both at Oslo and Padua. High tumor load was defined as tumor burden score (TBS) ≥ 9, and inclusion criteria were as in the SECA-I transplant study. 184 patients were eligible: 128 LRs and 56 LTs. 5-year OS after LR and LT was 40.5% and 54.7% (P=0.102). In the high TBS cohort, 5-year OS after LR and LT was 22.7% and 52.2% (P=0.055). In patients with Oslo score ≤ 2 and TBS ≥ 9 (13 LR; 24 LT) the 5-year OS after LR and LT was 14.6% and 69.1% (P=0.002). The corresponding disease-free survival (DFS) was 0% and 22.9% (P=0.005). Selected CRLM patients with low Oslo score and high TBS could benefit from LT with survival outcomes that are far better than what is achieved by LR.

Multielectrode Radiofrequency Ablation for Resectable Metachronous Liver Metastasis from Colorectal Cancer.

The outcome of radiofrequency ablation (RFA) for liver metastases from colorectal cancer (CRLM) has been thought to be inferior to metastasectomy. However, the recent development of multielectrode RFA (multi-RFA) systems has made the ablation zone larger and more complete. Thus, we assessed the survival benefits of this modality in cases of metachronous CRLM. This retrospective study assessed patients diagnosed with resectable metachronous CRLM between 2013 and 2016; 132 patients were categorized by treatment for liver metastases: multi-RFA (n = 68), hepatectomy (n = 34), or systemic treatment only (n = 30). Therapeutic effectiveness, outcomes, and intervention-related complications were compared between groups. Median overall survival (OS), recurrence-free survival (RFS), and intrahepatic recurrence-free survival (IHRFS) were 69.8, 85.2, and 59.7 months for the hepatectomy group; 53.4, 41.3, and 32.3 months for the multi-RFA group; and 19.1, 7.1, and 7.1 months for the systemic treatment group. No significant differences were observed between the multi-RFA and hepatectomy groups after a median follow-up of 59.8 months. This study demonstrated that multi-RFA and hepatectomy provide similar survival benefits for patients with resectable CRLM. Multi-RFA may represent a reliable treatment option for the management of resectable liver metastases.

Image-guided marking techniques in interventional radiology: A review of current evidence

Precise marking of lesions using image-guided techniques is essential, as imprecise targeting of a tumor can result in either insufficient excision/treatment with an increased risk of recurrence, or excessive removal of healthy tissue. Most frequent indications include localization of nonpalpable lesions before surgical resection (i.e., hook-wire localization of pulmonary nodules before video-assisted thoracoscopy) and definite marking of liver metastasis before neoadjuvant therapy. Other indications include marking of hepatocellular carcinomas that are not visible on ultrasound and unenhanced computed tomography before thermal ablation, of bone lesions before surgical excision, and of different visceral tumors before stereotactic radiotherapy. This review presents the different existing indications, assesses their usefulness, gives systematic details on the technique and lastly analyzes the current literature with emphasis on results and complications.

Reevaluating the prognostic value of RAS mutation status in patients with resected liver metastases from colorectal cancer: A systematic review and meta-analysis.

Although the value of Rat Sarcoma Oncogene (RAS) mutation status in predicting long-term outcomes in patients with colorectal liver metastases (CRLM) is widely accepted, the magnitude of its impact has recently been challenged by three large cohort studies. The aim of this meta-analysis is to reevaluate the impact of RAS mutations on overall survival (OS) and disease-free survival (DFS) in patients who underwent curative-intent resection of CRLM. A comprehensive literature search was performed for studies reporting outcomes of patients undergoing curative-intent surgery stratified by RAS mutation status. Exclusion criteria were defined a priori. Subgroup analysis was performed to evaluate the effect of publication date, sample size, and KRAS vs any RAS mutation on overall outcomes. Ten studies incorporating 3115 patients with known RAS status were identified. Pooled results revealed significantly worse OS (Hazard Ratio 1.5, 95% CI 1.31-1.71) and DFS (Hazard Ratio 1.36, 95% CI 1.22-1.52) in RAS-mutated patients. Subgroup analyses revealed that studies including more than 300 patients or published after 2015 reported lower HR than their counterparts. The results of this meta-analysis suggest that the prognostic value of RAS mutation status in patients with CRLM has been previously overestimated.

P-230 Is stereotactic microwave ablation of resectable colorectal liver metastasis an alternative for liver resection in the Covid-19 pandemic?

Liver resection for resectable colorectal liver metastasis is still considered the standard local therapy. Recent studies showed no difference in overall survival between microwave ablation and resection of liver metastasis with a diameter less than 3 cm. Ablation by percutaneous approach and under CT guidance is considered less invasive than open or laparoscopic resection or ablation. On the other hand, percutaneous ablation by “free-hand” puncture is considered less accurate, potentially resulting in higher incomplete ablation and local recurrence rates.

P-191 Prognostic factors of colorectal cancer liver metastasectomy

In selected patients with metastatic colorectal cancer (MCRC), resection of liver metastases may offer the possibility of cure. The aim of this study was to evaluate possible preoperative prognostic factors for survival in patients with MCRC undergoing liver metastasectomy in order to select the ideal patient for this procedure. Retrospective analysis of 121 patients with MCRC followed at our center, who underwent liver metastasectomy with curative intent and who underwent primary chemotherapy between March 2004 and June 2017. Survival analyses was estimated through Kaplan-Meier method and multivariate analyses through Cox regression. The median age at diagnosis was 58 (19-79) and 61% were men. The median follow-up time was 53 months (10-143). The recurrence rate after the first metastasectomy was 73.6%. The median DFS after the first liver metastasectomy was 13 months (95% CI, 10.3-15.6). The median OS was 63 months (95% CI, 48.6-77.4). The preoperative factors which gave the worst prognosis in the analysis for OS and DFS were: the presence of ≥3 metastatic liver lesions (median OS: 101 months, CI 95% 57.4-144.6 vs 51 months, CI 95% 42.0-59.9, p = 0.010; DFS median: 18 months, CI 95% 0.0-36.9 vs 10 months, CI 95% 7.2-12.8, p = 0.013), extrahepatic metastasis (median OS: 71 months, CI 95% 58.4-83.6 vs 37 months, CI 95% 22.6-51.4, p = 0.001; median DFS: 15 months, CI 95% 12.2-17.8 vs 7 months, CI 95% 4.3-9.7, p = 0.002), pT4 (median OS: 65 months, CI 95% 50.2-79.8 vs 34 months, CI 95% 25.4-42.6, p = 0.008; Median DFS: 14 months, CI 95% 10.9-17.1 vs 5 months, CI 95% 2.9-7.1, p = 0.011), size of metastases ≥60 mm (median OS: 80 months, CI 95% 63.7-96.3 vs 51 months, CI 95% 42.8-59.2, p = 0.020; DFS median: 16 months, CI 95% 11.9-20.1 vs 10 months, CI 95% 7.4-12.6, p = 0.020). The factors which maintained a negative impact in the multivariate analysis for OS and DFS were pT4 (OS: p = 0.020, HR 1.98, CI 95% 1.1-3.5; DFS: p = 0.007, HR 2.11, CI 95% 1.2-3.6) and extrahepatic metastasis (OS: p = 0.011, HR 2.05, CI 95% 1.2-3.6; DFS: p = 0.024, HR 1.85, CI 95% 1.1-3.2). The presence of ≥3 metastatic liver lesions, extrahepatic metastasis, pT4 and the size of metastases ≥60 mm had a negative impact on OS and DFS.

Combined liver resection and radiofrequency ablation for bilobar multiple colorectal liver metastasis

Combined liver resection and radiofrequency ablation for bilobar multiple colorectal liver metastasis

Laparoscopic S1 resection

Laparoscopic isolated caudate lobectomy remains a challenging procedure because of its deep location and proximity to the important vessels. Despite of the popularity of laparoscopic liver resection, laparoscopic isolated caudate lobectomy is not commonly performed because of the rarity of isolated caudate lesion in addition to its challenging nature of procedure. In this expert video session, the author would present two cases of isolated S1 (Spigelian lobe) resection for a colorectal liver metastasis and recurred hepatocellular carcinoma respectively.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology.

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.