Hepatic Resection For Colorectal Metastases Research Articles

Analysis of survival outcomes following robotic hepatectomy for malignant liver diseases

BackgroundDespite increased adoption of the robotic platform for complex hepatobiliary resections for malignant disease, little is known about long-term survival outcomes. This is the first study to evaluate the postoperative outcomes, and short- and long-term survival rates after a robotic hepatectomy for five major malignant disease processes. MethodsA prospectively collected database of patients who underwent a robotic hepatectomy for malignant disease was reviewed. Pathologies included colorectal liver metastases (CLM), hepatocellular carcinoma (HCC), Klatskin tumor, intrahepatic cholangiocarcinoma (IHCC), and gallbladder cancer (GC). Data are presented as median (mean ​± ​standard deviation) for illustrative purposes. ResultsOf the 210 consecutive patients who underwent robotic hepatectomy for malignant disease, 75 (35 ​%) had CLM, 69 (33 ​%) had HCC, 27 (13 ​%) had Klatskin tumor, 20 (10 ​%) had IHCC, and 19 (9 ​%) had GC. Patients were 66 (65 ​± ​12.4) years old with a BMI of 29 (29 ​± ​6.5) kg/m2. R0 resection was achieved in 91 ​%, and 65 ​% underwent a major hepatectomy. Postoperative major complication rate was 6 ​%, length of stay was four (5 ​± ​4.3) days, and 30-day readmission rate was 17 ​%. Survival at 1, 3, and 5-years were 93 ​%/75 ​%/72 ​% for CLM, 84 ​%/71 ​%/64 ​% for HCC, 73 ​%/55 ​%/55 ​% for Klatskin tumor, 80 ​%/69 ​%/69 ​% for IHCC, 79 ​%/65 ​%/65 ​% for GC. ConclusionThis study suggests a favorable 5-year overall survival benefit with use of the robotic platform in hepatic resection for colorectal metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, Klatskin tumor, and gallbladder cancer. The robotic platform facilitates fine dissection in complex hepatobiliary operations, with a high rate of R0 resections and excellent perioperative clinical outcomes.

False positive PET-CT imaging after application of fibrin-based sponge at the site of previous hepatic resection for colo-rectal metastasis: A short series

Surgical resection is the treatment of choice with curative intent for colorectal liver metastasis. Preoperative accurate radiological staging is key for optimal treatment. Fluorine-18 fluorodeoxyglucose PET-CT (PETCT) is effective for this purpose. We present 4 cases of patients with history of hepatectomy for colorectal liver metastasis. In all patients, during the procedure, we used fibrin-based sponge to achieve optimal haemostasis of the parenchymal transection surface. During the oncologic follow-up, a suspicion of disease recurrence justified a staging PET-CT that revealed pathologic metabolic activity on sites of previous liver resection, highly suspicious of tumour recurrence. The delay between hepatectomy and PET-CT for recurrence ranged from 5 to 12 months. In all cases, a new surgical exploration was performed after neoadjuvant chemotherapy, and PET-CT positive sites of previous liver resection were removed. Definitive histological diagnosis showed inflammatory granuloma or fibrous tissue.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort.

Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments. We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012. To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive. Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.

Missing Liver Metastases in colorectal cancer as a clinical challenge. Single centre experience

Background: Chemotherapy regimens have changed the current scenario of CRC LM, making some difficult to identify through classic radiological techniques. Missing Metastases (MM) arise as a clinical challenge for the surgeon. Methods: The aim of this study was to identify “Missing Metastases”, defined as lesions on baseline imaging that were not identifiable on pre-operative MRI. Retrospective review of hepatic resections for colorectal metastases between 01/2014 and 12/2016 was performed to evaluate the rate of complete radiological and pathologic response. Results: In the 2 year period we performed liver resection (LR) in 172 patients, of which 13 presented MM. The total number of MM identify on baseline imaging for these patients was 51. At surgical pathology 6 of 16 lesions resected demonstrated viable tumor. Twenty two of 35 lesions left in situ presented a sustained clinical response, meanwhile 13 of 35 relapsed in the same location. Conclusion: Despite disappearance on MRI imaging, pathology exam showed viable tumor in 37% of resected LM. On the other hand, in patients with MM left in situ, more than the third part relapse during the first year. New radiological techniques such as Fusion CEUS-CT and Fiducial markers could help the surgeon to identify the original location and perform a complete resection.

Liver resection for colorectal hepatic metastases after systemic chemotherapy and selective internal radiation therapy with Yttrium-90 Microspheres (SIRT): the current world experience

Liver resection for colorectal hepatic metastases after systemic chemotherapy and selective internal radiation therapy with Yttrium-90 Microspheres (SIRT): the current world experience

Impact of Surgical Margin Width on Recurrence and Overall Survival Following R0 Hepatic Resection of Colorectal Metastases: A Systematic Review and Meta-analysis.

To examine the impact of surgical margin width on survival following R0 hepatic resection for colorectal metastases (CRLM). Although negative resection margin is considered of paramount importance for the prognosis of patients with colorectal liver metastases, optimal resection margin width remains controversial. Eligible studies examining the association between margin status after R0 hepatic resection for CRLM and survival, including overall survival (OS) and disease-free survival (DFS) were sought using the Medline, Cochrane, and EMBASE databases. Random-effects models were used for the calculation of pooled relative risks (RRs) with their 95% confidence intervals (95% CIs). Thirty-four studies were deemed eligible for inclusion representing a cohort of 11,147 hepatic resections. Wider resection margin (>1 vs <1 cm) was significantly associated with improved OS at 3 years (pooled RR = 0.86, 95% CI: 0.79-0.95), 5 years (pooled RR = 0.91, 95% CI: 0.85-0.97), and 10 years (pooled RR = 0.94, 95% CI: 0.88-1.00). Similarly, DFS was positively associated with >1 cm resection margin at 3, 5, and 10 years. Interestingly, >1 mm (vs <1 mm) resection margin was significantly associated with improved OS at all-time points. Meta-regression analyses did not reveal any significant modifying role of the study features under investigation, such as the administration of neoadjuvant/adjuvant therapy. Importantly, our findings suggest that while a >1 mm margin is associated with better prognosis than a submillimeter margin, achieving a margin >1 cm may result in even better oncologic outcomes and should be considered if possible.

A randomized phase II study of perioperative chemotherapy plus bevacizumab versus postoperative chemotherapy plus bevacizumab inpatients with upfront resectable hepatic colorectal metastases (APPROACH).

3528Background: Whether patients with resectable colorectal cancer liver metastases (CRLM) gain a survival benefit or not from neoadjuvant chemotherapy remains controversial. The addition of bevaci...

The Effect of Regional Anesthesia on Oncologic Outcomes after Resection of Colorectal Hepatic Metastases

The Effect of Regional Anesthesia on Oncologic Outcomes after Resection of Colorectal Hepatic Metastases

Surgical Margin in Hepatic Resections for Colorectal Metastasis: Should We Care?

Many studies seek to define the appropriate margin width necessary to confer the best survival advantage following hepatic resection for colorectal metastatic disease. The ability to achieve at least a 1-cm tumor-free margin has historically represented one of the strongest prognostic factors determining overall outcomes and has been a necessary condition for resectability. With the advent of modern chemotherapy, the importance of surgical margin width is increasingly questioned and our understanding of its impact is evolving concomitantly to the improvement and the widespread use of more effective systemic chemotherapeutic agents. Although achieving a microscopic margin-negative resection (R0) remains the goal of surgical resection, specific tumor biology factors should be consider in deciding on the appropriate margin width. In this review, we summarize the most recent evidence regarding the importance of the surgical margin in hepatic resection for colorectal metastasis in the era of modern chemotherapy.

Resection of hepatic colorectal metastases: Moving from a low volume to high volume unit

Resection of hepatic colorectal metastases: Moving from a low volume to high volume unit

Colorectal liver metastases: disappearing lesions in the era of Eovist hepatobiliary magnetic resonance imaging

BackgroundHepatobiliary contrast enhanced MRI is known to be the most sensitive imaging modality for detection of colorectal hepatic metastasis. To date no study has investigated the rate of disappearing lesions with gadoxetic acid MR (Eovist/Primovist), or characterized the pathologic response of lesions which disappear on gadoxetic acid MR. MethodsRetrospective review of hepatic resections for colorectal metastases between 01/2008 and 01/2014 was performed to evaluated the rate of disappearance of lesions on gadoxetic acid MR and the rate of complete pathologic response in the lesions that disappear. “Disappearing lesions” were lesions on baseline imaging that were not identifiable on pre-operative Eovist MRI. Complete pathologic response was defined as no viable tumor on pathology or by lack of recurrence within 1 year. ResultsIn 23 patients, 200 colorectal metastases were identified on baseline imaging. On pre-operative Eovist MR 77 of the 200 lesions (38.5%) were “disappearing” lesions. At surgical pathology or 1 year follow-up imaging, 42 of 77 lesions (55%) demonstrated viable tumor (21) or recurrence (21). Thirty of 77 lesions (39%) were nonviable at pathology (10) or without evidence of recurrence at 1 year (20). 5 lesions were indeterminate. DiscussionDespite disappearance on Eovist MR imaging (the most sensitive available imaging modality), 38.5% of all colorectal metastases disappeared and of those, 55% were viable.

Impact of obesity on postoperative outcome of hepatic resection for colorectal metastases

Outcomes in obese patients who underwent liver resection have been analyzed, but series are heterogeneous and data are controversial. The aim of this study was to analyze short-outcome in obese patients undergone hepatectomy for colorectal metastases. A retrospective analysis on 1,021 consecutive hepatectomies between January 2000 and April 2014 for colorectal metastases was carried out. World Health Organization Classification of obesity (body mass index >30 kg/m(2)) was used to identify 140 obese patients. Outcomes were compared among obese and nonobese patients. Obese patients were mainly male (78%) and were associated more frequently with hypertension (51% vs 29%, P < .001), ischemic heart disease (9% vs 3%, P = .007), and diabetes (23% vs 10%, P < .001) compared with nonobese patients. Approximately 30% of patients underwent major hepatectomy in the 2 groups. Associated resections were performed in 36% of obese and 37% of nonobese patients. Median parenchymal transection time (80 ± 64 minutes vs 70 ± 50 minutes, P = .013) and blood loss (300 ± 420 vs 200 ± 282, P = .001) were greater in obese patients. Postoperative mortality was nil in obese patients and 0.6% in nonobese patients. Overall morbidity was greater in obese patients (41% vs 31%, P = .012) mainly related to pulmonary complications (16% vs 9%, P = .012). Reinterventions were more frequent in obese patients (3.6% vs 1.2%, P = .004). Median hospital stay was comparable. At pathologic examination, hepatic steatosis was greater in obese (69% vs 43%, P < .001). At multivariate analysis, age >65 years (odds ratio [OR] 1.43, 95% confidence interval [95% CI] 1.09-1.88), obesity (OR 1.64, 95% CI 1.13-2.38), major hepatectomies (OR 1.65, 95% CI 1.31-2.33), and associated resections (OR 1.67, I95% CI 1.27-2.20) were independent predictors of overall morbidity (P < .001). Among obese patients, there was a positive correlation between age and severity of complications (R = 0.173, P = .041). Obese patients undergoing hepatectomy for colorectal metastases should be approached with caution because of an increased risk of postoperative morbidity.

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

Kok, N. F. M. MD, PhD; Grünhagen, D. J. MD, PhD; Ayez, N. MD; Verhoef, C. MD, PhD Author Information

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

The validity of the KRAS mutation as a predictor of recurrence-free survival (RFS) or overall survival (OS) is unclear. The current study investigated whether the presence of the KRAS mutation decreased RFS or OS in patients with colorectal cancer who underwent liver resection. Patients with resected colorectal liver metastases who received adjuvant hepatic arterial infusion plus systemic therapy and for whom KRAS data was available were evaluated. Correlation between KRAS and clinical factors was done using the Fisher exact test. Kaplan-Meier methods were used to estimate the median RFS and OS. A total of 169 patients were evaluated, 118 of whom had KRAS wild-type (WT) and 51 had KRAS mutated (MUT) tumors. The 3-year RFS rate was 46% for patients with KRAS WT (95% confidence interval [95% CI], 35%-56%) and 30% (95% CI, 16%-44%) for patients with KRAS MUT (P =.005). The 3-year OS rate was 95% (95% CI, 87%-98%) and 81% (95% CI, 62%-95%), respectively, for patients with KRAS WT and KRAS MUT (P =.07). On multivariate analysis, KRAS remained a significant predictor of RFS (hazard ratio, 1.9). The 3-year cumulative recurrence rate by site of metastases was as follows: 2% versus 13.4% for bone (P≤.01), 2% versus 14.5% for brain (P =.05), 33.2% versus 58% for lung (P≤.01), and 30% versus 47% for liver (P =.10) in patients with KRAS WT versus KRAS MUT. In the current study, among patients with resected colorectal liver metastases who were treated with adjuvant hepatic arterial infusion plus systemic therapy, patients with KRAS MUT were found to have a significantly worse 3-year RFS (30%) compared with KRAS WT (46%) p=.005. The cumulative incidence of bone, brain, and lung metastases was significantly higher for patients with KRAS MUT compared with those with KRAS WT.

Simultaneous versus staged hepatic resection for colorectal metastases with an intact primary cancer

Currently, there are approximately 103,170 new cases of colon cancer and 40,290 new cases of rectal cancer diagnosed yearly. Approximately 51,690 deaths occur from colorectal cancers annually. Colon and rectal cancer combined are the fourth most common cancer diagnosis and second most common cause of cancer mortality. While the incidence and mortality are decreasing, about half of all patients will develop metastatic disease. Of these patients, 80e90% develops unresectable liver metastases, which include 20e34% who have synchronous hepatic metastases. Recently published, Fahy presented that there are at least 13 different treatment algorithms for synchronous colon cancer with liver metastases [1]. Certainly, this makes it nearly impossible for physicians to rely on any “standard of care” or “standard approach” for these patients. One constant remains, however; treatment recommendations and decisions should be made in the setting of a multidisciplinary team including an experienced hepatobiliary surgeon. This article is not meant to give a comprehensive review of all the possible algorithms, but aims to discuss the timing of surgical resection of the primary cancer and the metastatic disease. Numerous retrospective articles have been published over the previous 10e15 years looking at surgical outcomes when comparing patients who have synchronous resection of colorectal liver metastases, to patients who have staged resections. The data suggests that a synchronous resection is just as safe as a two-staged approach, i.e. there is no difference in mortality or

Repeated Resection of Colorectal Liver Metastases

The expansion of resection of colorectal hepatic metastases over the past two decades has been accompanied by a concomitant expansion of nonresectional options to treat patients with liver-only colorectal metastases. Comparative outcomes for different therapeutic strategies are largely unavailable or incomplete. Without sufficient equipoise to randomize the disparate population of patients with hepatic recurrence to all available therapeutic options, we will likely need to individualize our treatment strategies without the use of randomized trials. Clarifying the role of repeated hepatectomy for patients with recurrent disease requires knowledge of the outcomes, limitations, and alternatives for repeated resection of colorectal metastases. In this review, consideration of the published experience with hepatic re-resection can help define the boundaries and expectations for patient selection and outcomes.

Hepatic resection for colorectal metastases

The liver represents a common site for metastasis in colorectal cancer. Improvements in patient selection and surgical techniques has resulted in improved outcomes following hepatic metastasectomy with large series reporting 5- and 10-year overall survival rates of 40% and 20%, respectively. In recent years, criteria for resectability has expanded with the use of forced liver hypertrophy and staged resection. The role of perioperative chemotherapy remains controversial with a slight increase in survival and operative morbidity.

Comparative analysis of the incidence of surgical site infections in patients with liver resection for colorectal hepatic metastases after neoadjuvant chemotherapy

BackgroundThe aim of this study was to identify the incidence of surgical site infections (SSIs) and postoperative complications, as defined by the Clavien–Dindo classification, after hepatic resection for metastatic colorectal cancer in patients with and without associated neoadjuvant chemotherapy. MethodsA total of 181 patients were studied retrospectively. Patients were divided into two groups: the first group comprised patients with associated neoadjuvant chemotherapeutic treatment for liver metastases with a latency time <8 wk and the second group comprised patients without associated neoadjuvant chemotherapy. ResultsVariables of duration of liver surgery, length of total hospital stay, and length of postoperative hospital stay seem to be correlated with SSIs and postoperative complications, P < 0.005 and P < 0.0001, respectively. Duration of surgery is a risk factor for SSIs, with an odds ratio of 1.15, and for complications according to the Clavien–Dindo classification, with an odds ratio of 1.35. ConclusionsNeoadjuvant chemotherapy was not a significant risk factor for SSIs, whereas the total length of hospital stay, length of postoperative hospital stay, and duration of surgery were independent predictors of SSIs and complications according to the Clavien–Dindo classification.

Systemic Therapy for Patients with Resectable Hepatic Colorectal Metastases: Improving Patient Selection

The past three decades have seen great changes in the management of hepatic colorectal cancer metastases. While resection remains firmly established as the most effective therapy for selected patients, the emergence of more effective chemotherapeutic agents has been a practice changing development and has considerably altered the therapeutic approach to patients with this disease. In the palliative setting, the power of contemporary systemic agents is clear, with superior tumor response rates and prolonged survival well documented. Indeed, this greater efficacy translates into conversion to resectability in a significant proportion of patients with advanced, initially unresectable disease, a feature of systemic therapy only rarely seen in the past. There is thus little doubt that contemporary systemic chemotherapeutic agents, with their greater antitumor activity and ability to bring more patients to resection, have greatly improved long-term outcome in patients with advanced disease. As a result, there is a perception that advances in chemotherapy offer a similar benefit when used in the adjuvant or perioperative setting. Supporting this is a large body of retrospective data that suggests significantly better posthepatectomy survival over time. In the era before contemporary systemic agents, 5-year survival rates of 25– 40 % were reported routinely following hepatic resection. By contrast, several studies have demonstrated significantly greater 5-year survival rates for patients treated more contemporaneously. Of note, these analyses typically show improvements in overall survival over time, whereas changes in disease-free survival rates have been much less impressive. On the surface, these data would implicate a major contribution from systemic therapy in leading to better outcomes in patients in patients with resectable disease; however, prospective data do not reflect the same level of benefit seen in patients with advanced disease. In fact, the results of multiple prospective randomized trials examining adjuvant or perioperative chemotherapy after potentially curative hepatic resection have shown no improvement in overall survival. In two trials of adjuvant 5-FU after hepatic resection, a combined analysis of 302 randomized patients was unable to demonstrate significant improvements in recurrence-free or overall survival. Furthermore, a study of adjuvant FOLFIRI compared with 5-FU after hepatic resection in 306 patients showed absolutely no difference in recurrence free or overall survival. The most notable adjuvant trial, the EORTC study led by Nordlinger, randomized 364 patients to perioperative FOLFOX or observation following complete resection of four or fewer liver metastases, and showed a marginal benefit in progression free survival at 3 years (7 %, p = 0.058); this improved to 9 % (p = 0.025) when the analysis was restricted to resected patients. An updated analysis showed no improvement in overall survival. These seemingly discordant results between outcomes in the adjuvant and palliative settings are disappointing and somewhat surprising, particularly those reported in the EORTC study, which compared current, standard agents to a ‘‘no chemotherapy’’ group. Although many oncologists point to these data as justification for the routine use of adjuvant or perioperative systemic chemotherapy after potentially curative resection of colorectal liver metastases, the benefit, if present at all, is likely to be small, and the weight of published evidence does not necessarily support this approach. The reasons that these studies do not show a clear benefit of systemic therapy are unclear, but failure to account fully for the heterogeneity of patients with hepatic Society of Surgical Oncology 2013

The results of surgery for colorectal hepatic metastases following expansion of the indications in 2005

Safety and survival were investigated in patients treated according to expanded surgical indications for colorectal hepatic metastases. A retrospective analysis of all consecutive patients who underwent resection of colorectal hepatic metastases at Zhongshan Hospital from 2000 to 2010 was conducted. The patients were divided into two groups based on a change in the surgical indications introduced in 2005. Patients in Group I underwent hepatic surgery between 2000 and 2004 and those in Group II between 2005 and 2010. The clinicopathological data and survival rates of both groups were analysed. There were 530 patients who underwent hepatic surgery between 2000 and 2010. After the expansion of surgical indications, the rate of surgical resection rose from 25.1 to 35.1% (P<0.05). There was no significant difference in perioperative mortality (2.2% vs 0.9%) or morbidity (20.9% vs 29.8%). Recurrence occurred in 27.5% and 36.7% in Groups I and II, respectively, and 5-year overall survival was 43% and 49%, respectively (not significant). Expanding the indications for surgical resection of hepatic metastases increased the resection rate but had no significant effect on survival.