Median Number Of Tumors Research Articles

Surgical microwave ablation of 397 neuroendocrine liver metastases: a retrospective cohort analysis of 16 years of experience.

Neuroendocrine tumors (NET) constitute a heterogeneous group of malignancies whose incidence has been on the rise over the past two decades, currently documented at 5.25 per 100,000. Liver metastasis develops in over 60% of NET patients. Even after resection recurrence rates are high, underscoring the importance of parenchymal-sparing interventions. In this study, we conducted 105 surgical microwave ablations and examined outcomes related to survival and local recurrence. Retrospective review of patients who underwent a surgical microwave ablation (MWA) at a single-center, high-volume institution from September 2007 through December 2022 using a prospective database. Primary outcome was overall survival. A total of 105 operations were performed on 94 patients, with 397 tumors undergoing MWA. Median tumor size was 1.3cm (range 0.3-8.0), and the median number of tumors ablated was 2 (range 1-12). Laparoscopic approach was utilized 69.5% of the time. The most common concomitant procedure performed was hepatectomy (33.3%) and cholecystectomy (23.8%). Clavien-Dindo grade III or IV complications occurred in 9 patients (9.6%). Mortality within 30days occurred in 1 patient (1.1%). The rate of incomplete ablation was 0.3% per tumor. Local recurrence occurred in 2.8% of tumors. Median OS was 9.43years [95% CI 4.23-14.63years], with a 5- and 10-year survival probability of 70.2% and 48.2%, respectively. Surgical MWA offers an efficacious, parenchymal-sparing treatment of hepatic metastasis of NET, with low rates of incomplete ablation and local recurrence per tumor.

Living donor liver transplantation for hepatocellular carcinoma using expanded criteria and alpha-fetoprotein threshold of 1000 ng/mL

BackgroundNew guidelines propose a minimum 5-year survival of 60% for hepatocellular carcinoma (HCC) with living donor liver transplantation (LDLT). This study aimed to evaluate the 5- and 10-year survival rates after transplantation for the expanded criteria for HCC. MethodsThis single-center retrospective cohort study included 208 patients who underwent LDLT for the expanded criteria (the largest tumor diameter of ≤10 cm, any tumor number, and alpha-fetoprotein [AFP] level of <1000 ng/mL) and analyzed 5- and 10-year overall survival (OS) and recurrence risk (RR) rates. ResultsWith a median follow-up of 65.1 months (IQR, 19.1–80.2), the 5- and 10-year OS and RR rates were 67.0% and 61.0% and 20.5% and 22.5%, respectively. The largest tumor diameter of >6 cm (hazard ratio [HR], 3.7; 95% CI, 1.7–8.2; P = .001) and AFP level of >400 ng/mL (HR, 4.0; 95% CI, 1.8–9.0; P = .001) were predictors of recurrence. Patients outside the Milan criteria (MC) were grouped into low- and high-risk HCC based on tumor size and AFP level. For low-risk HCC (tumor size of <6 cm, any tumor number, and AFP level of <400 ng/mL), the 5-year RR was comparable to the MC and increased the transplant pool by 35.7% (P > .5). The median number of tumors and the rate of microvascular invasion in the high-risk group, low-risk group, and MC were 2.0 (1.0–3.2), 4.0 (2.0–5.0), and 1.0 (1.0–2.0) (P < .001) and 72.2% (13/18), 44.0% (22/50), and 22.8% (32/140) (P < .001), respectively. ConclusionThe expanded criteria met the benchmark for 5-year survival. LDLT for the low-risk HCC in the expanded criteria was associated with an acceptable RR.

The safety and short-term efficacy of selective internal radiation therapy combined with systemic treatment for unresectable malignant hepatic tumors in Chinese patients.

e16247 Background: There are many systemic treatment options for patients with unresectable malignant hepatic tumors. In China, selective internal radiation therapy (SIRT) with yttrium-90 (Y90) resin microspheres was approved until 2022. The aim of this retrospective study was to investigate the safety and short-term efficacy of SIRT with Y90 resin microspheres followed by systemic treatment in Chinese patients. Methods: The study analyzed patients who received SIRT with Y90 combined with systemic treatment at our center between June 2022 and October 2023. The study's primary endpoint was to determine the objective response rate (ORR), while safety was the secondary endpoint. Response was measured based on modified Response Evaluation Criteria in Solid Tumors criteria (mRECIST) up to 90 days after the initial therapy. Safety was evaluated using the Common Terminology Criteria for Adverse Events Version 5.0. Results: 21 patients wereincluded, of whom 22 times of SIRT were performed. 18 patients had HCC, and 3 had mCRC.The baseline characteristics of the patients are shown in Table. The median age was 54 years (IQR, 48-59 years) and 90.5% of patients were male. According to Eastern Cooperative Oncology Group performance status, grade 0 and grade 1 were 81% and 19%, respectively, whereas Child-Pugh A represented 90.5% of cases. The proportion of patients with hepatitis B virus infection was 95.2%. Thirteen (61.9%) patients received different treatments before SIRT. The median number of tumors was 2.5 (IQR, 1-4.3), whereas the median diameter of the largest lesion was 100.4 mm (IQR, 68.3-127.7 mm). PVTT was classified as follows: Vp1 (n = 3), Vp2 (n = 2), Vp3 (n = 2) and Vp4 (n = 1). Median AFP was 33.2 ng/mL (IQR, 5.9-401 ng/mL). The median total radiation activity administered was 1.4 GBq (IQR, 0.9-2.7 GBq) and the median target tissue dose was 205 Gy (IQR, 155-242 Gy). Nine (43%) patients were downstaged to surgery. Four (19%) patients had a complete response, fifteen (71.4%) had a partial response and two (9.5%) had a progressive disease. ORR and disease control rate were 90.5% and 90.5%, respectively. None of the patients experienced grade 3 and higher adverse events. The most common treatment-related adverse events were fever and abdominal pain, which required no special treatment. Conclusions: SIRT with Y90 resin microspheres combined with systemic treatment is safe and effective in patients with unresectable malignant hepatic tumors, which resulted in encouraging ORR (90.5%) and a downstaging rate (43%). Clinical trial information: ChiCTR2300077524. [Table: see text]

Outcomes after Surgical Microwave Ablation for the Treatment of Colorectal Liver Metastasis.

Colorectal cancer (CRC) is the third most common cause of cancer mortality worldwide. Of these, approximately 25% will have liver metastasis. We performed 394 microwave ablations (MWAs) and analyzed outcomes for survival and ablation failure. We conducted a retrospective review of patients who underwent a surgical MWA at a single-center high-volume institution from October 2006 to September 2022 using a prospectively maintained database. The primary outcome was overall survival. A total of 394 operations were performed on 328 patients with 842 tumors undergoing MWA. Median tumor size was 1.5 cm (range 0.4 to 7.0 cm), with the median number of tumors ablated per operation being 1 (range 1 to 11). A laparoscopic approach was used 77.9% of the time. Concomitant procedures were performed 63% of the time, most commonly hepatectomy (22.3%), cholecystectomy (17.5%), and colectomy (6.6%). Clavien-Dindo grade III or IV complication occurred in 12 patients (3.6%), and all of these patients had undergone concomitant procedures. Mortality within 30 days occurred in 4 patients (1.2%). The rate of incomplete ablation was 1.5% per tumor. Local recurrence occurred at a rate of 6.3% per tumor. Black patients were found to have a higher incidence of incomplete ablation and local recurrence. One-year survival probability was 91% (95% CI 87.9 to 94.3), with a mean overall survival of 57.6 months (95% CI 49.9 to 65.4 months). Surgical MWA offers a low-morbidity approach to treatment of colorectal liver metastasis, with low rate of failure. This large series reviews the outcomes of MWA as definitive treatment for colorectal liver metastasis.

The Role of Colour Segmented Fluorescence (CSF) Mode and Same-day Administration of Low-dose Indocyanine Green in Liver Surgery: Our Initial Experience : Indocyanine Green Fluorescence Guided Resection of Liver Tumours.

Indocyanine green (ICG) fluorescence image guidance (I-FIGS) is increasingly used in liver surgery. Several regimens have been described regarding the optimum timing and dose of administration. This study presents our early experience with utilising monochromatic Colour Segmented Fluorescence (CSF)-mode and same-day administration of low-dose-ICG in the resection of liver tumours. Between November 2020 and March 2022, I-FIGS was used in 15 patients with suspected liver tumours. ICG was administered intravenously at 0.02 to 0.05mg/kg dose 2-3h before surgery. ICG camera was switched to CSF-grey-scale mode to visualise the tumour and to avoid the interference of the green background liver. Using the SPY-CSF mode, the image was scaled to near-infra-red (NIR) fluorescence intensity to accurately identify the tumours and resection margins. Fifteen patients (eight males) with a median age of 71 years (range: 36-86) underwent I-FIGS. Of these, 67% underwent laparoscopic liver surgery, 78% had non-anatomical resections, and 33% underwent redo liver surgery. The mean tumour size was 40.6 mm (SD+/-41mm). The median number of tumours was two (1-7). All colorectal liver metastases (CRLM) had a signet ring appearance. Hepatocellular carcinomas (HCC) showed partial fluorescence. Tumours were well/moderately differentiated, with CRLM in 86% and HCC in two patients. The R0 resection rate was 72%. In our experience, low-dose-ICG administered at least 2-3 h before surgery can identify liver tumours and their margins in CSF-grey-scale mode. Further research is needed to evaluate its role in reducing R1 resection rates and surgical outcomes.

Single-Session Gamma Knife Radiosurgery for Patients With 20 or More Brain Metastases.

Stereotactic radiosurgery (SRS) is a widely accepted treatment modality for brain metastases. The role of SRS in patients with higher numbers of metastases remains controversial. To define outcomes in patients with ≥20 brain metastases managed using single-session SRS. This single-institution retrospective cohort study studied 75 patients (26 non-small-cell lung cancer, 21 small-cell lung cancer, 14 breast cancer, and 14 melanoma) undergoing single-session SRS. The median number of tumors per patient was 24, and the median cumulative tumor volume was 3.70 cc. The median margin dose prescribed to each individual tumor was 16 Gy. The median integral cranial dose was 5492 mJ. The median beam on time was 160 minutes. Univariate and multivariate analyses were performed with significance set at P < .05. The median overall survival after SRS was 8.8 months (patients with non-small-cell lung cancer), 4.6 months (patients with small-cell lung cancer), 11.3 months (patients with breast cancer), and 4.1 months (patients with melanoma). Primary cancer type, number of brain metastases, and concurrent immunotherapy were significant factors in predicting survival. Local tumor control rate per patient was 97.3% and 94.6% at 6 and 12 months after SRS, respectively. Thirty-six patients underwent additional SRS for new tumor development with a median time after SRS of 5 months. Three patients experienced adverse radiation events. Single-session SRS is a well-tolerated palliative treatment option even in patients with ≥20 brain metastases, achieving local control rate >90% with low risks of neurotoxicity while continuing concurrent systemic oncological care.

Gamma Knife radiosurgery for gynecologic metastases to the brain: Analysis of pathology, survival, and tumor control

ObjectiveThis study aims to evaluate the efficacy of stereotactic radiosurgery (SRS) in improving health outcomes of patients with gynecologic brain metastases. MethodsPatients with gynecologic metastases treated with SRS from 2008 to 2020 were retrospectively reviewed. The median age at SRS was 63 years old (cervical 45.5, endometrial 65.5, ovarian 61). The median number of tumors was 3 (range 1–27), and cumulative tumor volume was 2.33 cc (range 0.03–45.63). Median margin dose prescribed was 16 Gy (range 14 Gy – 20 Gy). The median 12 Gy volume was 7.30 cc (range 0.21–74.14 cc). Outcome variables included overall survival (OS) after SRS, local tumor control (LTC), distant tumor control, and adverse radiation effect (ARE). ResultsFifty patients (4 cervical, 25 endometrial, and 21 ovarian cancer) were identified. The OS at 6 and 12 months after SRS was 48%, and 44%, respectively. Eight patients (16%) died from CNS disease progression. The number of brain metastases (p = 0.011) and the Karnofsky Performance Scale (KPS) ≥ 70 (p = 0.020) were significant predictors of OS. LTC rate at 6 and 12 months were 92%, and 87%, respectively. Margin dose ≥16Gy correlated with significantly better local tumor control (p = 0.0001) without increased risk of ARE (p = 0.055). The risk of developing new metastases at 6 and 12 months were 12% and 24% respectively. SRS-induced ARE events occurred in 7 patients. ConclusionIntracranial metastases from gynecologic malignancy can be effectively treated using SRS with low risk of neurotoxicity. Margin dose ≥16Gy can provide significantly better tumor control. Repeat SRS can be utilized to treat new metastases while avoiding the potential cognitive symptoms associated with WBRT.

HPB P35 Fluorescence guided resection of Liver Tumours: Same day administration of indocyanine green with SPY- Colour Segmented Fluorescence imaging to identify tumours intra-operatively

Abstract Background Indocyanine green (ICG) fluorescence imaging is a real-time navigation tool that has shown promising liver surgery results. Several regimes have been described regarding optimum timing and dose of ICG administration. Visually different fluorescent enhancement patterns correlate with different pathologies to aid the identification of lesions intra-operatively. This study aims to present our experience with using the Colour Segmented Fluorescence (CSF) model and same-day administration of low dose ICG in the resection of liver tumours. Methods We present a single surgeon (SA) experience using indocyanine green fluorescence image-guided surgery (I-FIGS) at University Hospitals Plymouth, UK. I-FIGS was used between November 2020 and March 2022 in 15 patients with suspected liver tumours. ICG was administered intravenously at a dose of 0.02 to 0.03 mg/kg IV 2–3 hours prior to liver surgery. Using the SPY CSF mode, the image is scaled to NIRF fluorescence intensity to identify the liver tumours and their margins intra-operatively. Results A total of fifteen patients (eight males) with a median age of 71 years (36–86) underwent I-FIGS during the study period. Of these, 67% underwent laparoscopic liver surgery, 78% underwent non-anatomical resections, and 33% underwent re-do liver surgery. The average size of the tumour was 40.6 mm, and median number of tumours was one. All lesions were visible in CSF mode, and all had a signet ring appearance. The histology of the tumours confirmed a well to moderately differentiated colorectal metastasis in 13 (86%) patients and hepatoma in two patients. R0 resection was achieved in 11 (76%) of patients. In two patients with R1 resection, the tumour was right on the right hepatic vein, and R0 would not have been possible. The resection margins were clear in two other patients but &amp;lt;1mm. The overall false positive rate in our experience with I-FIGS was 3%. Conclusions In our limited experience, low-dose ICG administered at least 2–3 hours prior to surgery can accurately identify liver tumours and their margins in CSF mode. Superficially located lesions are easily identifiable under CSF mode, and CSF mode helped us identify the lesions and mark the resection margin. The use of ICG is an important advancement in liver surgery, and further research is needed to optimise image interpretation and correlate with clinical resection outcomes.

RADT-04. SINGLE SESSION GAMMA KNIFE RADIOSURGERY TO TREAT PATIENTS WITH 20 OR MORE BRAIN METASTASES

Abstract BACKGROUND Stereotactic Radiosurgery (SRS) has become a primary management option for brain metastases (BMs). This present study aims to review outcomes in patients with ≥ 20 BMs treated in a single session SRS and to identify predictors of local tumor control (LTC) and overall survival (OS). METHODS We identified 75 patients including 26 non-small cell lung cancer (NSCLC), 21 small cell lung cancer (SCLC), 14 breast cancer (BC), and 14 melanoma patients who underwent SRS for ≥ 20 BMs between 2014 and 2020. The median number of tumors was 24 (range 20 – 52), and the median cumulative tumor volume was 3.70 cc (0.13 – 62.49 cc). The median margin dose was 16 Gy (14 – 20 Gy). Median skull integral dose was 5492 mJ (range 1372 – 11243 mJ). The median treatment time for each session was 160 min. Outcome variables were assessed using univariate and multivariate analyses with p &amp;lt; 0.05. RESULTS Median OS after SRS was 5.8 months (range 0.1 – 73.2 months). Primary cancer type and concurrent immunotherapy were significant predictive factors for patient OS after SRS (p = 0.01, 0.05, and 0.02, respectively). LTC rate at 6 and 12 months after SRS was 95.7% and 83.7%, respectively. Thirty (40.0%) patients underwent additional SRS and 3 patients (4%) received post-SRS WBRT due to distant tumor recurrence. The median time to distant recurrence was 5 months (range 2-28 months). SRS-induced adverse radiation effects (ARE) events were observed in 3 patients (4.0%; 1 NSCLC, 1 SCLC, and 1 melanoma). CONCLUSIONS Our results suggest that patients with ≥ 20 BMs can be safely treated with SRS with an excellent LTC rate and a low risk of ARE. Newly developed BMs can be treated with repeat SRS. This single-session SRS allows patients to proceed with systemic cancer care without interruption.

NEO-GAP: A phase II single-arm prospective feasibility study of neoadjuvant gemcitabine/cisplatin/nab-paclitaxel for resectable high-risk intrahepatic cholangiocarcinoma.

4097 Background: Given a high recurrence rate, surgical resection for localized intrahepatic cholangiocarcinoma (IHCC) is curative in only 30-35% of patients. BILCAP has established a standard of care for adjuvant therapy with monotherapy capecitabine. Gemcitabine, cisplatin and nab-paclitaxel combination chemotherapy (GAP) was associated with a response rate of 45% in biliary cancer and 20% of patients who were previously inoperable underwent margin negative resection. Based on these data, we conducted a neoadjuvant study of GAP for resectable but high-risk IHCC. Methods: A multi-institutional prospective single-arm phase II trial was conducted for patients with resectable high-risk disease, as defined by tumor size &gt; 5cm, multiple tumors, presence of radiographic major vascular invasion, and lymph node involvement. Patients were administered 4 cycles (3 months) of preoperative GAP (gemcitabine 800 mg/m2, cisplatin 25 mg/m2 and nab-paclitaxel 100 mg/m2 on days 1 and 8 of a 21-day cycle) prior to an attempt at curative-intent surgical resection. The primary endpoint was completion of all therapy, including both preoperative chemotherapy and resection. Secondary endpoints were toxicity, radiologic response according to Response Evaluation Criteria in Solid Tumor (RECIST) criteria, RFS, and OS. Thirty evaluable patients provided 73% power to reject a null therapy completion rate of 50%, with a target completion rate of 70% using a one-sided exact test with a Type I error of 0.05. Results: Thirty-seven patients were screened and 30 evaluable patients were enrolled. The trial was sequentially activated at each of the 4 sites from 09/18-02/21 and the final patient was enrolled in 09/21. Median age was 60.5 years and 40% were female. Twenty-three patients (77%, 90% CI: 60.6-88.5%; p = 0.0026) completed all preoperative chemotherapy and underwent surgical resection. Ten patients (33%) experienced grade 3-4 treatment-related adverse events, the most common being neutropenia and diarrhea; 47% required at least one dose reduction. Partial response rate was 23% and disease control rate was 90% (PD: 10%, PR: 23%, SD: 67%). Of the 23 patients who successfully underwent surgical resection, 2 (9%) had minor postoperative complications. Median size of largest tumor was 5.5cm, median number of tumors was 3, and 39% were lymph node positive. Median length of hospital stay was 4 days. There was zero treatment related mortality. Conclusions: This study met its primary endpoint and demonstrated that neoadjuvant gemcitabine/cisplatin/nab-paclitaxel is feasible and safe prior to resection of intrahepatic cholangiocarcinoma and does not adversely impact perioperative outcomes. Continued follow-up for RFS and OS with this treatment strategy is underway and larger validation studies are planned. Clinical trial information: NCT03579771.

Machine Learning Approach to Stratifying Prognosis Relative to Tumor Burden after Resection of Colorectal Liver Metastases: An International Cohort Analysis.

Assessing overall tumor burden on the basis of tumor number and size may assist in prognostic stratification of patients after resection of colorectal liver metastases (CRLM). We sought to define the prognostic accuracy of tumor burden by using machine learning (ML) algorithms compared with other commonly used prognostic scoring systems. Patients who underwent hepatectomy for CRLM between 2001 and 2018 were identified from a multi-institutional database and split into training and validation cohorts. ML was used to define tumor burden (ML-TB) based on CRLM tumor number and size thresholds associated with 5-year overall survival. Prognostic ability of ML-TB was compared with the Fong and Genetic and Morphological Evaluation scores using Cohen's d. Among 1,344 patients who underwent resection of CRLM, median tumor number (2, interquartile range 1 to 3) and size (3 cm, interquartile range 2.0 to 5.0) were comparable in the training (n = 672) vs validation (n = 672) cohorts; patient age (training 60.8 vs validation 61.0) and preoperative CEA (training 10.2 ng/mL vs validation 8.3 ng/mL) was also similar (p > 0.05). ML empirically derived optimal cutoff thresholds for number of lesions (3) and size of the largest lesion (1.3 cm) in the training cohort, which were then used to categorize patients in the validation cohort into 3 prognostic groups. Patients with low, average, or high ML-TB had markedly different 5-year overall survival (51.6%, 40.9%, and 23.1%, respectively; p < 0.001). ML-TB was more effective at stratifying patients relative to 5-year overall survival (low vs high ML-TB, d = 2.73) vs the Fong clinical (d = 1.61) or Genetic and Morphological Evaluation (d = 0.84) scores. Using a large international cohort, ML was able to stratify patients into 3 distinct prognostic categories based on overall tumor burden. ML-TB was noted to be superior to other CRLM prognostic scoring systems.

Survival following liver transplantation for locally advanced, unresectable intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) has previously been considered a contraindication to liver transplantation (LT). However, recent series showed favorable outcomes for LT after neoadjuvant therapy. Our center developed a protocol for neoadjuvant therapy and LT for patients with locally advanced, unresectable iCCA in 2010. Patients undergoing LT were required to demonstrate disease stability for 6months on neoadjuvant therapy with no extrahepatic disease. During the study period, 32 patients were listed for LT and 18 patients underwent LT. For transplanted patients, the median number of iCCA tumors was 2, and the median cumulative tumor diameter was 10.4cm. Patients receiving LT had an overall survival at 1-, 3-, and 5-years of 100%, 71%, and 57%. Recurrences occurred in seven patients and were treated with systemic therapy and resection. The study population had a higher than expected proportion of patients with genetic alterations in fibroblast growth factor receptor (FGFR) and DNA damage repair pathways. These data support LT as a treatment for highly selected patients with locally advanced, unresectable iCCA. Further studies to identify criteria for LT in iCCA and factors predicting survival are warranted.

A217 TREATMENT ADHERENCE OF CHRONIC HEPATITIS B PATIENTS WITH HEPATOCELLULAR CARCINOMA FROM THE CANHEPB NETWORK

BackgroundChronic hepatitis B (CHB) is the most common cause of hepatocellular carcinoma (HCC) worldwide.AimsThe primary aim of this study is to explore the degree of treatment adherence to the American Association For The Study of Liver Disease (AASLD) HCC treatment guidelines for patients with CHB-HCC.MethodsThis is a retrospective, cross-sectional study of available data (2005–2020) in patients mono-infected with CHB collected from the Canadian HBV Network; a national consortium across 8 Canadian provinces. We analyzed data using descriptive statistics along with parametric and nonparametric statistical methods with a significance level of p < 0.05.ResultsOf the 6500 patients, 132 (2.0%) patients met inclusion criteria. The median age was 64 (IQR: 53.5- 71.5) with 101 (76%) being male. The median ALT was 40 (IQR: 26–59.5) and the median tumor number was 1(IQR: 1- 2) with a median tumor size of 2.6 cm (IQR: 1.9- 4.5). 98 (74.5%) patients were HBeAg negative with a median viral load of 3.8 logs (IQR 1.9 – 5.8). 58 (43%) patients had cirrhosis at diagnosis. 36% of patients were diagnosed with HCC on their first screening imaging whereas 39% were found to have HCC on repeated surveillance imaging. 116 (87.9%) were on treatment at the time of diagnosis or after (70 (60.3%) NA and 46 (39%) Combination therapy with double NA or NA plus interferon). Out of the 132 patients, BCLC stage 0, A, B, and C represented 30 (23%), 42 (32%), 17 (13%), and 5 (4%) patients, respectively, with 38 (28%) patients with unknown BCLC stage. The overall adherence to AASLD guidelines was 61%. The HCC treatment adherence rate for patients with BCLC stage 0, A, B were 63%, 97.5%, and 23.5%, respectively. BCLC stages C and D did not have a sufficient sample size for analysis. The adherence rate ranged from 53% (Eastern Canada) to 71% (Western Canada) across Canada.ConclusionsIn this retrospective nationwide cohort study of patients with CHB-related HCC, the overall treatment adherence rate to AASLD guidelines was low with notable regional differences. Further analysis will determine the cause of regional differences.Funding AgenciesNone

P-L15 Fluorescence guided laparoscopic resection of Colorectal Liver Metastases: Same day administration of indocyanine green with use of SPY- Colour Segmented Fluorescence imaging to identify tumours intra-operatively

Abstract Background Near-infrared fluorescent (NIRF) imaging using indocyanine green (ICG) has various applications in minimally invasive surgery. There are a number of techniques in timing and dose administration. Visually different fluorescent enhancement patterns correlate with different pathologies to aid identification of lesions intra-operatively. The aim of this study is to present our experience with utilisation of Colour Segmented Fluorescence ICG mode in laparoscopic liver surgery for colorectal liver metastases. Methods We present a single surgeon (SA) experience with the use of laparoscopic fluorescence guided imaging surgery (L-FGIS). Between November 2020 and July 20201, L-FGIS was used in seven patients with suspected CRLM. ICG was administered intravenously at a dose of 0.2 to 0.3 mg/kg IV 2-3 hours prior to liver surgery. Through use of the SPY Colour Segmented Fluorescence (CSF) imaging mode, the image is scaled as to NIRF fluorescence intensity to allow for the clear identification of the CRLM intra-operatively. Results A total of seven patients (Four males) with median age of 74.3 years (range: 30.5 -86) underwent L-FGIS during the study period. Two out of seven patients underwent re-do liver surgery. The median size of the tumour was 27mm (range: 10-65mm) and median number of tumours were one (range: 1-2). To visualise the tumour and to avoid interference of green background liver, ICG camera was switched to CSF mode. All lesions had signet ring appearance under CSF mode (see figure 1). Except in one patient (necrotic lesion), the histology of resected specimen contained a well to moderately differentiated colorectal adenocarcinoma metastasis. R0 resection was achieved in all patients and median clearance of the tumour was 3mm (range 0.4-10mm). Conclusions In our limited experience ICG administered at least 2-3 hours prior to surgery can identify superficially located colorectal metastases, provided ICG camera is switched to CSF mode. Superficially located lesions are easily identifiable under CSF mode. CSF mode helped us to identify the lesions and to mark the resection margin. The use of ICG is an important advancement in CRLM surgery and further research is needed to optimise image interpretation and correlate with clinical resection outcomes.

Survival in Patients with ≥5 Brain Metastases From Non-Small Cell Lung Cancer Treated With Upfront Stereotactic Radiosurgery

Multiple brain metastases (BM) from non-small cell lung cancer (NSCLC) historically has a dismal prognosis. Advances in systemic therapy for NSCLC have significantly improved survival, but the effect on prognosis in patients with NSCLC and BM is poorly understood. Stereotactic radiosurgery (SRS) may result in local control even with higher numbers of BM. We report survival outcomes of upfront SRS for ≥5 BM from metastatic NSCLC.Review of our registry identified 177 patients treated for ≥5 BM from NSCLC between 2012 and 2020, and did not undergo prior intracranial radiation or resection.Adenocarcinoma was found in 129 patients (73%). EGFR/ALK mutations were identified in 54 patients (31%). The median number of tumors at initial SRS were 8 (range 5-35). 121 patients (68%) were treated for 5-10 BM, 31 patients (18%) for 11-15 BM, and 25 patients (14%) for > 15 BM. The median overall survival (OS) from initial SRS for all patients was 15.1 months (95% CI 11.5-18.7). Survival at 1, 2, and 3 years was 57%, 39%, and 28% respectively. Adenocarcinoma was associated with improved survival compared to non-adenocarcinoma (P < 0.001), median OS 17.1 months (95% CI 11.4-22.9) and median OS 5.7 months (95% CI 2.8-8.6), respectively. Patients with EGFR/ALK mutations had a significantly greater survival time compared to those without (P = 0.008), and median OS of 26.3 months (95% CI 19.1-33.6) versus 10.4 months (95% 6.2-14.6). Treatment of 5-10, 11-15, or > 15 tumors at initial GK were not associated with differences in survival (P = 0.48). On multivariate analysis, survival benefit remained significant in patients with adenocarcinoma (HR 0.42, 95% CI 0.24-0.72, P = 0.002), and patients with EGFR/ALK mutations (HR 0.58, 95% CI 0.37-0.91, P = 0.02).Patients treated with initial SRS for multiple BM from NSCLC in the modern era demonstrate longer survival as compared with historical reports. Adenocarcinoma subtype, particularly in the setting of EGFR/ALK mutation is associated with improved prognosis, even in patients with higher number of metastases.J. Gurewitz: None. D. Patel: None. C. Benjamin: None. B.R. Donahue: None. J. Silverman: None. M. Mureb: None. K. Bernstein: None. D. Kondziolka: None.

Characterization of the Entire Metastatic Spectrum for Non-Small Cell Lung Cancer in the Immunotherapy Era

Several randomized trials have demonstrated that metastasis-directed therapy for oligometastatic non-small cell lung cancer (NSCLC) improves outcomes. It is not clear what proportion of patients with metastatic disease fall into the oligometastatic category at presentation. Rational design of studies for patients beyond the oligometastatic range will require understanding the numerical and anatomic distributions of metastases in this population. To address this gap in knowledge, we comprehensively characterized the number and distribution of malignant lesions in a modern cohort of advanced NSCLC patients who were staged with FDG-PET/CT and treated with first-line immunotherapy.Advanced NSCLC patients with stage IV disease or recurrent incurable disease who underwent staging PET and were started on first-line immune checkpoint inhibitors targeting the PD-1/PD-L1 axis (with or without chemotherapy) at our institution between 2015 and 2019 were included in this analysis. A commercially available gradient-based segmentation tool was used to contour all visible hypermetabolic extracranial lesions on each staging PET. Counts and anatomic distributions of hypermetabolic lesions were recorded.One hundred twenty-four patients met inclusion criteria. Sixty-six patients (53%) received immunotherapy as monotherapy, and 58 (47%) received immunotherapy with chemotherapy. The median number of hypermetabolic lesions identified for each patient was 6 (range 0 to 53). The distribution of hypermetabolic lesion counts was as follows: 33 (27%) 0-3 lesions, 30 (24%) 4-6 lesions, 25 (20%) 7-10 lesions, 36 (29%) 11 or more lesions. The median number of lung tumors and regional lymph nodes per patient was 4 (range 0 to 33). Excluding parenchymal lung tumors and regional lymph nodes, the median number of distant metastases per patient was 2 (range 0 to 37). The distribution of distant metastasis counts was as follows: 60% 0-3 lesions, 21% 4-6 lesions, 11% 7-10 lesions, 8% 11 or more lesions. Distant metastases were most commonly located in bone (35%), distant lymph nodes (22%), and the liver (10%).To our knowledge, this is the first study to characterize the anatomic disease spectrum in a modern cohort of advanced NSCLC. Most patients had 3 or fewer metastatic lesions, meeting a conservative definition of oligometastatic disease. However, many patients had multifocal thoracic disease. Technological radiotherapy approaches that can efficiently ablate multiple lesions in diverse anatomic locations will enable investigation of aggressive local therapy in a broad NSCLC population.

Preventing Futile Liver Resection: A Risk-Based Approach to Surgical Selection in Major Hepatectomy for Colorectal Cancer.

BackgroundEarly recurrence following liver resection for metastatic colorectal cancer generally portends poor survival. We sought to identify factors associated with early disease recurrence after major hepatectomy for metastatic colorectal cancer in order to improve patient selection and prevent futile hepatectomy.MethodsSequential major (four or more segments) liver resections performed for metastatic colorectal cancer between 1995 and 2019 were selected from our prospectively maintained database. Univariate analyses, multivariable regression modelling, and survival analyses were used to identify predictors of futile resection (recurrence within 6 months of hepatectomy).ResultsOf 259 patients included, the median age was 61.3 years (interquartile range [IQR] 15.3) and the median number of liver tumors was 3.0 (IQR 2.0); 78.0% of patients received prehepatectomy chemotherapy. Surgeries were right (56.4%), left (19.3%), and extended hepatectomy (24.3%). Futile resection occurred in 26 (12.6%) patients. Margin positivity was similar in the futile resection group compared with the non-futile resection group (11.5% vs. 11.4%). Extrahepatic disease that disappeared with chemotherapy was present in 23.1% of patients with a futile resection and 7.2% of those without (p = 0.019). After multivariable regression, the factors predictive of futile resection were extrahepatic disease (odds ratio [OR] 5.6; p = 0.004), more than three liver lesions (OR 4.9; p = 0.001), and extended hepatectomy (OR 2.6; p = 0.038). Notably, 70.8% of futile recurrences occurred within the liver remnant and 20.8% were pulmonary metastases. Overall survival was 11.7 months (95% confidence interval [CI] 7.1–16.2) for the futile resection cohort versus 45.6 (95% CI 39.1–52.1) for non-futile hepatectomies (p < 0.001).ConclusionsFutile hepatic resection can be predicted based on preoperative factors and carries a poor prognosis. Improved risk stratification for futility will aid in patient selection and treatment discussions.

MP45-09 ACTIVE SURVEILLANCE IN NONHEREDITARY BILATERAL MULTIFOCAL TYPE I PAPILLARY RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance I (MP45)1 Sep 2021MP45-09 ACTIVE SURVEILLANCE IN NONHEREDITARY BILATERAL MULTIFOCAL TYPE I PAPILLARY RENAL CELL CARCINOMA Jeunice Owens-Walton, Chinonyerem Okoro, Alexis Rompre-Brodeur, Maria Merino, and Mark W. Ball Jeunice Owens-WaltonJeunice Owens-Walton More articles by this author , Chinonyerem OkoroChinonyerem Okoro More articles by this author , Alexis Rompre-BrodeurAlexis Rompre-Brodeur More articles by this author , Maria MerinoMaria Merino More articles by this author , and Mark W. BallMark W. Ball More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002066.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nonhereditary Bilateral Multifocal (BMF) Type 1 Papillary Renal Cell Carcinoma (pRCC) represents a subtype of renal cancer which exists in the absence of a family history of RCC and without germline MET mutations. This patient population is at risk for recurrent renal surgeries, and potentially renal deterioration. Paucity of data exists surrounding management strategies, clinical and oncological outcomes, and active surveillance of these patients. We report our surgical experience with this unique cohort at the National Cancer Institute. METHODS: Patients with BMF pRCC, negative germline MET mutation and no family history evaluated at the National Cancer Institute from 2002 to 2020 were reviewed. Demographics, clinical presentation, tumor size, and renal functional outcomes were retrospectively analyzed. Patients were managed similarly to hereditary RCC, with active surveillance (AS) until the largest tumor is 3 cm, followed by multiplex partial nephrectomy when feasible. AS was defined as a visible kidney lesion on imaging with at least 6 months follow-up. Percent change creatinine and eGFR on active surveillance were evaluated. RESULTS: There were 77 patients with BMF pRCC and 129 surgical interventions. Median number of tumors per patient was 6. Five(6.5%) patients presented with metastatic disease (median tumor size 6.5cm), 1(1.3%) progressed to metastasis during follow up. No patients developed metastatic disease when their largest tumor was 3cm or less. At presentation, the median serum creatinine (Cr) =1.85 mg/dl, median eGFR=60. Thirty-eight patients were managed with AS (median 51 months). Median tumor size at enrollment on AS was 2.1cm. At the start of AS median Cr=1.23 mg/dl (1.01–1.47) and eGFR=62 (54–83). At the end of AS median Cr=1.24 mg/dl (1.13–1.53) and eGFR=62 (50–72). Percent change Cr from baseline on AS was 6.90% (-5.81–20.0), and eGFR was -9.07% (20.69–3.27). No patients developed metastatic disease on AS. CONCLUSIONS: Nonhereditary BMF pRCC represents a unique entity. Despite presenting with renal impairment, this cohort had stable renal function during AS. AS until the largest renal tumor reaches 3 cm followed by nephron sparing surgery has acceptable oncologic outcome and is recommended. Source of Funding: NIH Intramural Research Funding, NIH Medical Research Scholars Program, Foundation for the NIH © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e806-e806 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeunice Owens-Walton More articles by this author Chinonyerem Okoro More articles by this author Alexis Rompre-Brodeur More articles by this author Maria Merino More articles by this author Mark W. Ball More articles by this author Expand All Advertisement Loading ...

Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite

ObjectivesIn two-stage hepatectomy for bilateral liver metastases, patient dropout between stages is a major issue. We recently proposed a novel approach of fast-track two-staged hepatectomy (FT-TSH), in which patients undergo concurrent first-stage hepatectomy (FSH) with portal vein embolization (PVE) in a hybrid interventional radiology surgical suite. However, its efficacy remains unclear. MethodsPatients with bilateral liver metastases scheduled for FT-TSH at MD Anderson Cancer Center between October 2017 and December 2020 were included on a prospective registry. The effectiveness and feasibility were evaluated. ResultsNineteen patients were scheduled for FT-TSH. Primary site of tumor was colon/rectum in 18 patients and ovary in one patient. Median number of tumors was 10 and median size of largest tumor before surgery was 2.4 cm. Two (11%) patients did not undergo PVE and seventeen patients (89%) completed FSH + PVE. None of the patients had a major complication (Clavien-Dindo grade ≥ III) after FSH + PVE. Median kinetic growth rate after FSH + PVE was 2.9%/week (range 0.8–5.6). Twelve patients (71%) among the seventeen who underwent FSH + PVE proceeded to second-stage hepatectomy, and ten patients (59%) finally completed second-stage hepatectomy. Median interval between stages was 5.6 weeks (4.0–20.1). One patient (10%) had a major morbidity after SSH, and there was no 90-day mortality. ConclusionsFT-TSH is safe and allows for short intervals between hepatectomy stages while achieving favorable liver hypertrophy. Further investigation is needed to evaluate the true efficacy of FT-TSH.

A Prognostic Prediction Model of Transarterial Radioembolization in Hepatocellular Carcinoma: SNAP-HCC.

Prognosis prediction in patient with hepatocellular carcinoma (HCC) after transarterial radioembolization (TARE) remains difficult. The aim of this study was to develop a prognostic model to aid in the decision to use TARE. A total of 174 patients in Korea who underwent TARE for HCC as the initial treatment were included. We developed a prediction model for overall survival (OS) based on independent risk factors for OS and validated the model by bootstrap method. The median maximal size of the tumors was 8.2cm, the median number of tumors was 2, and the median albumin level was 4.0g/dL. Portal vein tumor thrombosis was found in 46.0% (Vp1-3 [39.7%] and Vp4 [6.3%]). Four independent risk factors associated with OS (maximal tumor size, tumor number, albumin, and portal vein tumor thrombosis) were used to develop the SNAP-HCC score. Bootstrap validation of the scoring index determined that the Harrell's c-index for OS was 0.756 (95% confidence interval: 0.729-0.783). Patients grouped based on their SNAP-HCC (scores 0-5) were well discriminated, with significant differences between the groups (all P < 0.05). Patients with SNAP-HCC < 3 showed significantly longer OS than patients with SNAP-HCC ≥ 3 (P < 0.001). The respective survival probabilities at years 1 and 3 were 0.81 and 0.73 in the low-risk (SNAP-HCC < 3) and 0.32 and 0.14 in the high-risk (SNAP-HCC ≥ 3) patients. The SNAP-HCC scoring system predicted the outcome of HCC patients undergoing TARE as an initial treatment. This model could be helpful for initial planning the treatment of HCC patients.