Number Of Liver Metastases Research Articles

Surgical resection for gastric cancer patients with liver metastasis

Objective: To explore the surgical results and clinicopathological features of gastric cancer patients with liver metastases. Methods: The clinicopathological data and post-operative survival of 37 patients who underwent resection of liver metastasis from gastric cancer at our department from Dec. 2007 to Dec. 2014 were analyzed. Results: The 1-, 3-, and 5-year overall survival rates after resection were 91.4%, 57.9%, and 22.0%, respectively, with a median survival of 37 months. Univariate analysis revealed that lymph node metastasis, multiple hepatic metastases and no preoperative chemotherapy are unfavorable prognostic factors for overall survival. Multivariate analysis identified that lymph node metastasis and number of liver metastasis are independent prognostic factors. Conclusions: Gastric cancer patients with a solitary liver metastasis may be good candidates for gastric D2 resection combined with liver R0 resection.

Prognostic analysis of colorectal liver metastases treated by surgery combined with intraoperative radiofrequency ablation

Objective: To investigate the clinical value of intraoperative radiofrequency ablation (RFA) in the treatment of colorectal liver metastasis (CLM). Methods: A retrospectively analysis of 187 patients with CLM who underwent liver resection with or without RFA from January 2009 to August 2016 in Department of Hepatobiliary Surgery, Cancer Hospital, Chinese Academy of Medical Sciences was performed. According to whether RFA was used intraoperatively, patients were divided into resection only group and combined treatment group. The clinical and pathological characteristics of the two groups were compared to explore factors influencing survival and recurrence. Imbalance of background characteristics between the two groups was further overcome by propensity score matching method (PSM). Results: The number of liver metastases (267), simultaneous liver metastases (100%), bilobar involvement (73.3%) and preoperative chemotherapy (93.3%) rates were significantly higher in the combined treatment group than those in the resection only group(471, 74.7%, 42.0% and 63.1%)(all P<0.05). In the combined treatment group, median overall survival (OS) was 25.7 months; and 3-year and 5-year OS were 47.9% and 28.8%, respectively. In the resection only group, the median survival time was 46.9 months; and 3-year and 5-year OS rate was 59.1% and 42.4%, respectively (χ(2)=4.579, P=0.034). Median disease-free survival (DFS) was 5.4 months in the combined treatment group, and 10.1 months in the resection only group (χ(2)=5.399, P=0.023). In multivariate analysis, intraoperative RFA was not an independent prognostic factor for OS and DFS (HR=0.98, 95%CI: 0.47-2.08, P=0.965; HR=1.21, 95%CI: 0.71-2.07, P=0.465). After PSM, the median OS of the resection only and the combined treatment groups were 30.2 and 25.7 months (χ(2)=0.876, P=0.350). The median DFS in the two groups was 5.3 and 4.2 months, respectively (χ(2)=0.199, P=0.650). Conclusion: In patients with similar tumor burden, liver resection combined with intraoperative RFA for unresectable CLM can achieve long-term outcomes similar to hepatectomy alone for resectable CLM.

Predictive value of long chain noncoding RNA SH3PXD2A-AS1 in the diagnosis of postoperative liver metastasis of gastric cancer

Objective To investigate the predictive value of long chain non coding RNA SH3PXD2A-AS1 in the diagnosis of postoperative liver metastasis of gastric cancer. Methods Human gastric cancer and matched normal gastric tissues were collected, and SH3PXD2A-AS1 was detected by fluorescence quantitative real-time polymerase chain reaction (PCR). The relationship between SH3PXD2A-AS1 expression and patient’s sex, age, tumor location, tumor diameter, histological differentiation, depth of tumor invasion, lymph node metastasis, the number of liver metastases and the time of liver metastasis distant metastasis was analyzed, respectively. Results The positive rate of SH3PXD2A-AS1 in 37 cases of gastric cancer was 91.89% (34/37), and that in normal gastric tissues was 5.40% (2/37). The difference was very significant (χ2=55.392, P=0.000). SH3PXD2A-AS1 expression was not significantly correlated with the age (χ2=0.560, P=0.756) and sex (χ2=1.718, P=0.190), tumor location (χ2=2.839, P=0.242), histological differentiation (χ2=0.924, P=0.336), but with the primary tumor diameter (χ2=4.788, P=0.029), depth of tumor invasion (χ2=8.815, P=0.012), lymph node metastasis (χ2=6.801, P=0.009), the number of liver metastases (χ2=10.157, P=0.001), and liver metastasis time (χ2=6.903, P=0.032). Conclusion SH3PXD2A-AS1 has important predictive value in the diagnosis of postoperative liver metastasis of gastric cancer. Key words: Gastric carcinoma; Liver metastasis; Long chain noncoding RNA; SH3PXD2A-AS1

Robotic procedure versus open surgery for simultaneous resection of colorectal cancer with liver metastases: Short-term outcomes of a randomized controlled study.

3575 Background: The simultaneous resecting both colorectal cancer and liver metastases is a safety and efficacy surgical procedure for treating colorectal cancer patients with liver metastases (CRCLM).The safety and efficacy of robot-assisted simultaneous resection of CRCLM is unclear. Furthermore, what kind of selective CRCLM patients would obtain benefits from robotic procedure need identify. The aim of this study was designed to compare robotic procedure with open surgery, and establish robotic surgery indications to identify benefit population of CRCLM. Methods: CRCLM patients were evaluated and confirmed with surgical indication by multidisciplinary team (MDT), and randomized to two groups, robotic arm (n = 58) and open arm (n = 57). The primary endpoint is 3-year DFS, the second endpoints include short-term surgical outcomes, complications and safety. Results: A total of 115 patients were randomized between September 2013 and September 2016. Despite longer operating time, patients assigned to robot-assisted surgery had less blood loss (100ml vs. 150ml, P &lt; 0.001), a shorter time to pass first flatus (3 d vs. 4 d, P &lt; 0.001) and return to diet (3 d vs. 5 d, P = 0.002), shorter hospital stay with improved sexual function. Furthermore, followed benefits were observed in robotic arm versus open arm: lower serum C reactive protein (CRP) level on postoperative day 1 (POD1) (16 mg/L vs. 37 mg/L,P &lt; 0.001), and POD3 (112 mg/L vs. 160 mg/L, P &lt; 0.001), lower level of liver transaminase on POD5, and lower liver-related complication morbidity(10.3% vs 28.1%, p = 0.016). In addition, we identified and recommended selective CRCLM patients with the number of liver metastases &lt; 3, maximal tumor size &lt; 5cm, tumor not located in segment I to accept robotic procedure. Conclusions: We identified and recommended selective CRCLM patients to accept robotic surgery for treating liver metastases. Robotic surgery result in similar safety as open procedure, with shorter recovery time, decreased morbidity, and improved sexual function. Clinical trial information: NCT02642978.

Clinical significance of long chain noncoding AK022914 in human gastric carcinoma with metachronous liver metastasis

Objective To investigate the clinical significance of long chain non coding RNA AK022914 in human gastric cancer with metachronous liver metastasis. Methods Human gastric cancer and matched normal gastric tissue were collected, and AK022914 were detected by fluorescence quantitative real-time PCR assay. The relation of between AK022914 expression and patient’s sex, age, tumor location, tumor diameter, histological differentiation, depth of tumor invasion, lymph node transfer shift, infiltration of blood vessels, nerve infiltration, the number of liver metastases and the time of liver metastasis distant metastasis was analyzed, respectively. Results The positive rate of AK022914 in 37 cases of gastric cancer was 86.49% (32/37), while the positive rate of AK022914 in normal gastric tissues was 2.70% (1/37). Comparison of the two, the difference is very significant. Further results showed that, AK022914 expression was not significantly related with the age (χ2=2.005, P=0.367) and sex (χ2=0.506, P=0.477) of patients, tumor location (χ2=1.227, P=0.542), primary tumor diameter (χ2=3.734, P=0.053), histological differentiation (χ2=0.908, P=0.341), but with the depth of tumor invasion (χ2=8.281, P=0.016), lymph node metastasis (χ2=9.225, P=0.026) and vascular invasion (χ2=8.157, P=0.004), neural invasion (χ2=10.690, P=0.001), the number of liver metastases (χ2=9.785, P=0.002), and liver metastasis time (χ2=8.259, P=0.016). Conclusion These results indicate that AK022914 is closely related to gastric cancer with metachronous liver metastasis. AK022914 might be one of the important targets of metachronous liver metastasis in gastric cancer. Key words: Gastric carcinoma; Metachronous liver metastasis; Long chain noncoding RNA; AK022914; Significance

Microwave ablation is effective against liver metastases from gastric adenocarcinoma

Purpose: The resection rate for liver metastases from gastric cancer is only 1.4–21.1%. This study aimed to evaluate the safety and therapeutic efficacy of microwave ablation (MWA) for liver metastases from gastric adenocarcinoma (LMGC).Materials and methods: A database of 108 gastric adenocarcinoma patients with liver metastases who underwent MWA (n = 32) or systemic chemotherapy (n = 76) for LMGC between 2008 and 2016 was reviewed. Overall survival curves were assessed and compared based on different therapies.Results: All the patients were followed up for a median of 15 months (range, 2–68 months). The median cumulative survival times of patients after MWA and systemic chemotherapy were 25 (95% confidence interval (CI) 16.5–33.5) months and 12 (95% CI 7.7–16.3) months, respectively (HR 1.751, 95% CI 1.077–2.845; p = .015). The 1-, 3-, and 5- year survival rates were 80.9%, 31.2%, and 16.7% (MWA group); and 50.0%, 18.8%, and 5.4% (chemotherapy group), respectively. In the MWA group, side effects were reported in eight patients who developed abdominal pain, transient fever, or nausea. Dominant size, number of liver metastases, therapeutic modalities, and presence of extrahepatic metastases showed significant prognostic value in univariate analyses; while the latter three were identified as independent prognostic factors in multivariate regression analysis.Conclusions: MWA is a safe and useful alternative for liver metastases from gastric adenocarcinoma in selected patients.

Surgical treatment of stage IV gastric cancer

Stage Ⅳ gastric cancer is defined as gastric cancer with non-curative factors, and the long-term survival rate of patients with stage Ⅳ gastric cancer is around 10%. Chemotherapy has been used for the main therapy of the patients with unresectable stage Ⅳ gastric cancer. Palliative resection of the primary tumor has been recommended only for presence of obstruction, bleeding and other surgical emergency. Debulking operation was irrelevant to the outcome that has been considered by research results. However, the patients with stage Ⅳ gastric cancer of only one non-curative factors (No.16a2, b1 lymph node enlargement; degree of peritoneal metastasis as P0 and positive peritoneal cytology; a small number of liver metastases) have good long-term survival when these patients have achieved R0 or R1 resection. In this regard, comprehensive treatment including surgical resection is the main treatment policy for the patients with stage Ⅳ gastric cancer. In recent years, some clini-cal studies on improvement of prognosis through surgical resection after conversion therapy have received extensive attention. Key words: Gastric neoplasms, stage Ⅳ; Surgical procedures, operative; Chemotherapy; Conversion therapy

Role of surgery for gastric cancer with liver limited multiple metastases.

170 Background: Although it has been suggested that surgery provides favorable outcome for gastric cancer (GC) patients (pts) with liver limited multiple metastases (LLM), the survival benefit of surgery comparing to systemic chemotherapy (CTx) has yet to be elucidated, especially in pts with LLM. The aim of this study was to explore the role of surgery for GC with LLM. Methods: We retrospectively reviewed the data of consecutive GC pts with LLM who underwent hepatectomy or received systemic CTx as initial therapy at Shizuoka Cancer Center between Dec. 2004 and Dec. 2015. Inclusion criteria were as follows: ECOG PS 0-1; histologically proven adenocarcinoma; synchronous or metachronous LLM; 2 or 3 LLM technically resectable disease; no prior CTx or radiotherapy Pts who were refractory to adjuvant CTx were excluded. Results: Nine of 24 pts who met the inclusion criteria underwent hepatectomy, and 15 pts received CTx. Pts’ background who received hepatectomy versus (vs) CTx was as follows: median age (range), 74 (64-81) vs 59 (42-76) years; male/female, 8/1 vs 14/1 pts; Histology intestinal/diffuse, 9/0 vs 10/5 pts; HER2 positive/negative/unknown 0/0/9 vs 2/5/8 pts; number of liver metastases 2/3, 9/0 vs 9/6; unilobar/bilobar, 5/4 vs 5/10 pts. In hepatectomy group, all 9 pts underwent radical hepatectomy (with gastrectomy for synchronous metastases), and 3 pts received adjuvant CTx. No in-hospital death or severe complication was observed. In CTx group, 11 pts received fluoropyrimidine plus cisplatin therapy, and trastuzumab was combined in 2 pts with HER2 positive tumor. Three pts underwent radical hepatectomy after CTx. Eight pts in hepatectomy group had recurrence. Recurrent sites were remnant liver (7), lymph node (1), and peritoneum (2). With median follow-up time of 47.9 months, median progression free survival was 8.0 months in hepatectomy group and 27.9 months in CTx group (p = 0.02). In CTx group, 3 pts who underwent subsequent radical hepatectomy after CTx had no recurrence or death. Median overall survival was 24.1 months in hepatectomy group and 38.4 months in CTx group (p = 0.15). Conclusions: Initial surgery for GC pts with LLM did not show survival benefit. But radical hepatectomy subsequent to CTx may associate with preferable outcome.

Repeat hepatectomy is independently associated with favorable long-term outcome in patients with colorectal liver metastases.

Up to three‐quarters of patients undergoing liver resection for colorectal liver metastases (CRLM) develop intrahepatic recurrence. Repeat hepatic resection appears to provide the optimal chance of cure for these patients. The aim of this study was to analyze short‐ and long‐term outcomes following index and repeat hepatectomy for CRLM. Clinicopathological data were obtained from a prospectively maintained database. Perioperative variables and outcomes were compared using the Chi‐squared test. Variables associated with long‐term survival following index and second hepatectomy were identified by Cox regression analyses. Over the study period, 488 patients underwent hepatic resection for CRLM, with 71 patients undergoing repeat hepatectomy. There was no significant difference in rates of morbidity (P = 0.135), major morbidity (P = 0.638), or mortality (P = 0.623) when index and second hepatectomy were compared. Performance of repeat hepatectomy was independently associated with increased overall and cancer‐specific survival following index hepatectomy. Short disease‐free interval between index and second hepatectomy, number of liver metastases >1, and resection of extrahepatic disease were independently associated with shortened survival following repeat resection. Repeat hepatectomy for recurrent CRLM offers short‐term outcomes equivalent to those of patients undergoing index hepatectomy, while being independently associated with improved long‐term patient survival.

Prognostic significance of TBL1XR1 in predicting liver metastasis for early stage colorectal cancer

BackgroundLiver metastasis is the leading cause of lethal colorectal cancer (CRC). For patients with early stage CRC, metachronous liver metastasis is the primary risk for poor prognosis. Accordingly, identification of prospective biomarkers for metachronous liver metastasis would be invaluable in evaluating patients' clinical outcomes and developing personal treatment therapy. MethodsHere we investigated the role of transducin (β)-like 1 X-linked receptor 1 (TBL1XR1) in predicting liver metastasis for early stage CRC. To accomplish this goal, a multi-center retrospective study was performed which included three stages: exploration stage (43 patients), identification stage (162 patients) and validation stage (38 patients). TBL1XR1 expression was evaluated using immunohistochemical staining and RT-qPCR. The prognostic significance of TBL1XR1 in both stage IV CRC patients and early stage CRC patients were evaluated by Kaplan-Meier survival analysis and multivariate analysis, respectively. ResultsFor stage IV CRC patients, TBL1XR1 expression was correlated with the number of liver metastases (P = 0.036), and high levels of TBL1XR1 in liver metastases indicated poor overall survival (P = 0.028). Moreover, high expressions of TBL1XR1 can serve as a predictor for liver metastasis in early stage CRC patients (P = 0.003). ConclusionsTBL1XR1 is a promising biomarker for predicting liver metastasis in early stage CRC patients.

Role of BCL9L in transforming growth factor-β (TGF-β)-induced epithelial-to-mesenchymal-transition (EMT) and metastasis of pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) has a low overall survival rate, which is approximately 20% during the first year and decreases to less than 6% within five years of the disease. This is due to premature dissemination accompanied by a lack of disease-specific symptoms during the initial stages. Additionally, to date there are no biomarkers for an early prognosis available.A growing number of studies indicate that epithelial to mesenchymal transition (EMT), triggered by WNT-, TGF-β- and other signaling pathways is crucial for the initiation of the metastatic process in PDAC. Here we show, that BCL9L is up-regulated in PDAC cell lines and patient tissue compared to non-cancer controls. RNAi-induced BCL9L knockdown negatively affected proliferation, migration and invasion of pancreatic cancer cells. On a molecular basis, BCL9L depletion provoked an increment of E-cadherin protein levels, with concomitant increase of β-catenin retention at the plasma membrane. This is linked to the induction of a strong epithelial phenotype in pancreatic cancer cells upon BCL9L knockdown even in the presence of the EMT-inducer TGF-β. Finally, xenograft mouse models of pancreatic cancer revealed a highly significant reduction in the number of liver metastases upon BCL9L knockdown. Taken together, our findings underline the key importance of BCL9L for EMT and thus progression and metastasis of pancreatic cancer cells. Direct targeting of this protein might be a valuable approach to effectively antagonize invasion and metastasis of PDAC.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective.

Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453mL (213-790mL). Following the first surgery, the mean FLR volume increased to 634mL (410-957mL), which indicated a mean volume increase of 181.1mL (95% CI 149.7-212.5mL; p<0.001) and a mean absolute volume increase of 48% (19%-88%). The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.

Pattern of tumour growth of the primary colon cancer predicts long-term outcome after resection of liver metastases

Objective: To identify significant predictive factors for overall survival (OS) and disease-free survival (DFS) after liver resection for colon cancer metastases, with special focus on features of the primary colon cancer, such as lymph node ratio (LNR), vascular invasion, and perineural invasion.Methods: Patients operated for colonic cancer liver metastases between 2006 and 2014 were included. Details on patient characteristics, the primary colon cancer operation and metastatic disease were collected. Multivariate analysis was performed to select predictive variables for OS and DFS.Results: Median OS and DFS were 67 and 20 months, respectively. 1-, 3- and 5-year OS were 97, 76, and 52%. 1-, 3- and 5-year DFS were 65, 42, and 37%. Multivariate analysis showed LNR to be an independent predictive factor for DFS but not for OS. Other identified predictive factors were vascular and perineural invasion of the primary colon cancer, size of the largest metastasis and severe complications after liver surgery for OS, and perineural invasion, number of liver metastases and preoperative CEA-level for DFS. Traditional N-stage was also considered to be an independent predictive factor for DFS in a separate multivariate analysis.Conclusions: LNR and perineural invasion of the primary colon cancer can be used as a prognostic variable for DFS after a concomitant liver resection for colon cancer metastases. Vascular and perineural invasion of the primary colon cancer are predictive for OS.

Effect of bevacizumab on the development of oxaliplatin-associated liver injury in colorectal cancer liver metastasis

Introduction: Oxaliplatin is an essential drug for treating colorectal liver metastasis (CRLM). Conversely, oxaliplatin has also been shown to cause sinusoidal injury (SI). Some authors previously reported that chemotherapy-associated SI increases the morbidity and mortality after liver resection due to an impaired remnant liver function. Therefore, it is important to prevent oxaliplatin-associated SI. Considering the estimated developmental mechanism of SI, a protective effect of bevacizumab is suggested. However, the effect of bevacizumab on the development of oxaliplatin-associated SI in CRLM remains unclear. The aim of this study was to clarify the effect of bevacizumab on the development of oxaliplatin-associated SI in CRLM. Method: Sixty-four patients undergoing liver resection for CRLM after oxaliplatin-based chemotherapy (OBC) were studied. They underwent pathological assessments to clarify the degree of histopathological liver injury of the nontumoral liver parenchyma. We divided the patients into the SI and non-SI group according to the pathological findings and compared the groups. Results: The median number of OBC cycles was 5.0 and duration of chemotherapy cessation was 7 weeks. Forty-seven patients (73.4%) received chemotherapy with bevacizumab. The non-SI group included 46 cases (71.9%) and the SI group included 18 cases. There were no significant differences between the two groups regarding sex, age, BMI and number of liver metastasis. The number of OBC cycles was more frequent in the SI group (p = 0.02), however, there was no difference in the duration of OBC cessation. Bevacizumab was more frequently administered in the non-SI group (p = 0.046). Conclusions: Bevacizumab may prevent oxaliplatin-associated SI in CRLM.

Adjuvant pelvic radiotherapy in patients with stage IVA rectal adenocarcinoma.

711 Background: For patients with stage IVA rectal cancer with liver metastases treated with curative-intent chemotherapy and surgery, the role of adjuvant pelvic radiotherapy (RT) is unclear. The purpose of this study was to evaluate the impact of pelvic RT on oncologic outcomes in this patient population. Methods: We retrospectively reviewed medical records of all patients with stage IVA rectal adenocarcinoma with liver metastases treated with curative-intent resection of the primary tumor and all liver metastases at our institution between 1991 and 2010. Patient and treatment characteristics were compared between patients who did or did not receive pelvic RT using chi-square and unpaired ttests. Survival and recurrence estimates were calculated from date of initial diagnosis using the Kaplan-Meier method. Local recurrence (LR) was defined as recurrence in the pelvis occurring at or before distant recurrence (DR). Cox regression was used to compare rates of freedom from LR (FFLR), freedom from DR (FFDR), and overall survival (OS) between patients who did or did not receive pelvic RT. Results: The analysis included 65 patients. Median patient age at diagnosis was 59 years (range, 27-87). Tumor stage was T2 (n = 4), T3 (n = 53), or T4 (n = 8). The median number of liver metastases was 2 (range, 1-14). Surgery was low anterior resection (n = 54) or abdominoperineal resection (n = 11). All patients received perioperative fluoropyrimidine based chemotherapy. Pelvic RT was administered to 35 patients (54%), either preoperatively (n = 22) or postoperatively (n = 13). Median RT dose was 50.4 Gy (range 25-58). Patient characteristics were similar for those who did or did not receive pelvic RT. Median follow-up was 3.7 years. The 3-year estimates of FFLR, FFDR and OS were 81% vs 58% (p =.056), 35% vs 29% (p =.75), and 66% vs 71% (p =.81) for RT vs no RT, respectively. Conclusions: In this analysis of patients with stage IVA rectal cancer with liver metastases undergoing curative intent therapy, pelvic RT (vs. no pelvic RT) was associated with a trend to lower rates of LR and similar rates of DR and OS.

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

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

Colorectal Liver Metastases: A Never Ending Story.

See Article on Page 92-100 To improve the quality of life and outcomes for patients with colorectal liver metastases, we would like to emphasize some points. First, a colorectal multidisciplinary teams (MDT) should also include a specialized hepatobiliary MDT that has the expertise and the facilities to provide surgery for patients with liver metastases. The cases of patients being considered for treatment of hepatic metastases should be discussed at a multidisciplinary meeting in which the participants have experience in the management of liver metastases [1]. Second, traditional risk factors, as well as the indications and the contraindications, for a hepatic resection should be abandoned. The present principle as to resectability is that resection should be performed if all metastases, regardless of their sizes, number, locations and distribution, can be removed while leaving a sufficient remaining liver parenchyma [2]. As is known, the number of liver metastases, the spread of colorectal cancer to the lymph nodes, the maximum size of the metastases, the preoperative carcinoembryonic antigen level, the extrahepatic spread, and the use of a nonradical resection represent independent risk factors for recurrence [3,4]. Third, All resources should be used. Perioperative chemotherapy, portal vein embolization, a 2-stage hepatectomy, and local ablative therapies might improve outcomes.

Outcomes of Simultaneous Major Liver Resection and Colorectal Surgery for Colorectal Liver Metastases

BackgroundThe optimal surgical strategy for treating colorectal cancer liver metastases (CRLM) in patients requiring major liver resection (MLR) is controversial, especially in rectal cancer patients. MethodBetween March 2004 and January 2015, 103 patients underwent MLR for CRLM and underwent MLR simultaneously with colorectal surgery (simultaneous group; n = 55) or MLR after colorectal surgery (liver-only group; n = 48). ResultsThere were no significant differences in sex, age, ASA score, BMI, size and number of liver metastases, liver resection margin, surgical outcomes, and estimated blood loss. The rates of postoperative complications (simultaneous group vs. liver-only group; 76.4 % vs. 62.5 %; P = 0.126) and major complications (29.0 % vs. 25.0 %; P = 0.513) were also similar in both groups. The time to starting a soft diet was longer in the simultaneous group (6.0 days vs. 3.4 days; P < 0.001), but the length of hospital stay was similar (14.9 days vs. 13.3 days; P = 0.345). There were no perioperative deaths, anastomotic leakage, or septic complications. Among patients who underwent rectal surgery, the frequency of complications was greater in the simultaneous group (87.0 % vs. 56.2 %; P = 0.031), but there was no difference in major complications (34.7 % vs. 25.0 %; P = 0.822). The postoperative morbidity index was 0.204 and 0.180 in the simultaneous and liver-only groups, respectively, in all patients, and was 0.227 and 0.136, respectively, in the rectal surgery subgroup. ConclusionSimultaneous MLR is feasible and safe in synchronous CRLM patients, including rectal cancer patients.

The Prognosis of Patients with Liver Metastases from Colorectal Cancer still Depends on Anatomical Presentation more than on Treatments.

The best management of liver metastases from colorectal cancer is still debated and little is known about the true impact of treatments on survival. The study involved 122 patients (77 males), aged 64.0 ± 11.0 years (range: 27.8-86.1) at diagnosis of liver metastatization (synchronous in 59). All underwent chemotherapy and at least one procedure of radiofrequency ablation; 53 also had partial hepatic resections. Demographics, tumor characteristics and survival outcomes from liver metastatization were analyzed with univariate and multivariate techniques. This analysis was performed also taking into account relative survival as the best estimate of specific survival. The analysis with observed survival selected the categorized number of involved lymph nodes in the colorectal specimens as the only statistically significant predictor, while the analysis with relative survival also showed site of the primary tumor (above the sigmoid colon or otherwise) and number of liver metastases as significant factors. The standardized mortality ratio was 9.673 (95% CI: 7.668-11.663) and a total of 201.85 years of life were lost in comparison with the survival of the reference population. The computation of relative survival – better than observed survival – selected a more adequate number of predictors, making investigation of even limited series of patients with confounding factors reliable. The finding that prognosis was mainly dependent on the anatomical presentation of the primary tumor and of liver metastases – instead of treatments – could explain the still contrasting opinions on the role of the available therapies in this field.

Distribution of liver metastases based on the site of primary pancreatic carcinoma.

To investigate whether the different location of pancreatic adenocarcinoma affects the lobar distribution of metastases to the liver. From all patients who underwent multidetector computed tomography (MDCT) examinations for staging of pancreatic adenocarcinoma in the last 4 years we selected 80 patients (42 men, 38 women; mean age, 60.56 years) with liver metastases and a pancreatic adenocarcinoma of the head (group A, 40 patients; diameter, 32.41 ± 2.28 mm) or body-tail (group B, 40 patients; diameter, 52.21 ± 2.8 mm). We analysed tumour site, diameter, vascular invasion and number of metastases in each lobe of the liver. The total number of metastases was compared between the two groups with an unpaired t-test, while Fisher's test was used to compare the number of metastases within the two lobes. As expected, the number of liver metastases was higher in group B than in group A. The ratio of metastases in the right-to-left hemi-liver was 7.4:1 for group A compared with 3.3:1 for group B (p < 0.0001). Although the number of liver metastases is higher in the right lobe than in the left lobe in both groups, there is a significant difference in the ratio of metastases between the right and the left hemi-liver. This supports the existence of a streamline phenomenon and a selective lobar distribution of metastases within the liver. • Pancreatic adenocarcinoma presents with liver metastases in 40% of cases • The presence of liver metastases disqualifies the patient from curative surgery • The distribution of metastases within the liver depends on the site of pancreatic adenocarcinoma • The distribution of liver metastases is due to the streamline phenomenon.