Surgical Resection Of Liver Metastases Research Articles

A prognostic indicator for the resection of liver metastasis of colorectal cancer

We investigated the predictive indicator for a good prognosis of surgical resection for liver metastasis of colorectal cancer. Between 1990 and 2009 at our institute, 117 patients underwent 132 hepatic resections for liver metastasis of colorectal cancer. The clinical, pathological, and outcome parameters affecting their prognoses were analyzed. The extent of the liver metastases was subdivided according to the Japanese Classification of Colorectal Carcinoma (JCCRC), and the patients were classified into different grades based on the JCCRC classification and the status of the nodal involvement of the primary tumor. The median survival time (MST) of the 117 patients was 58 months, and the actuarial survival rates at 1, 3, and 5 years were 92.3, 60.0, and 46.1 %, respectively. A multivariate analysis revealed that the JCCRC Grade classification was an independent prognostic indicator (Grade A vs. B vs. C: MST, 72 vs. 41 vs. 23 months; 5-year survival, 59.0 vs. 38.6 vs. 0 %: p < 0.0001). Our findings indicate that the JCCRC Grade classification for liver metastasis of colorectal cancer is a significant prognostic indicator and may be useful for making decisions regarding the treatment of liver metastasis.

Surgical resection of liver metastases and survival outcomes in real-life for metastatic colorectal cancer (mCRC) patients treated in front-line with cetuximab (CTX): The EREBUS cohort.

e14514 Background: CTX has demonstrated improved survival outcomes and resection rate in unresectable mCRC patients (pts) but little data is available from real-life use. Methods: EREBUS is a French multicentre (n=65) cohort that included pts with unresectable mCRC and wt KRAS initiating 1st-line CTX in 2009 and 2010, and followed 12 months. An expert committee validated baseline resectability and resection results. Resection rates and survival outcomes were described according to metastases site: liver-only, liver-not exclusively, other. Results: 389 pts were included: 37.8% liver-only metastases, 38.3% liver-not exclusively, 23.9% other. Baseline characteristics of the cohort: median age 64 yrs, 67.4% male, 77.9% ECOG=0-1, 55.5% primary tumor resection, 53% single metastatic site. Combined chemotherapy regimen were with irinotecan (56.6%) or oxaliplatin (38.2%). Median duration of CTX use was 4.8 months. 97 pts (24.9%, 95%CI: 20.6-29.2) had metastases resection; rates for liver-only: 36.7% (28.9-44.5), liver-not exclusively: 20.8% (14.3-27.3), other: 12.9% (6.9-21.5). Among them, 51.5% had radical resection with R0+/-radiofrequency (liver-only: 61.1% and liver-not exclusively: 32.3%), 11.3% R1+/-radiofrequency (liver-only: 16.7% and liver-not exclusively: 3.2%) and 9.4% missing metastases, 27.3%R2. 52.6% had post-operative complications (20.6% infection, 8.2% thromboembolic event, 8.2% other cardiovascular event, 3.1% death). Median PFS for the cohort was 9.7 months (8.6-10.5). In multivariate Cox analysis progression was independently associated with metastases site, liver-only: HR=1.93 (1.36-2.74), liver-not exclusively: HR=1.46 (1.06-2.02). The 1-yr OS probability was 71.3% (66.4-75.6) without any site difference. In Cox analysis, death was less likely in responders with or without metastases surgery: HR=0.26 (0.08-0.90) and HR=0.37 (0.21-0.63). Conclusions: This cohort shows that 1st-line CTX in wt KRAS mCRC allows a high proportion of metastases resection, particularly in liver-only. It also provides data on rarely studied mCRC pts (liver-not exclusively and other metastases).

Evaluation of a Multimodality MR/US Coregistration System for Investigation of Hepatic Metastases from Colorectal Cancer

PurposeTo evaluate a magnetic resonance (MR)/ultrasound (US) coregistration system with US used in follow-up diagnostic studies of lesions originally identified by MR imaging. Materials and MethodsA single-center prospective study enrolled 21 consecutive patients (age, 64.0 y±7.5; eight men [age, 63.0 y±7.1] and 13 women [age, 65.0 y±7.3]) evaluated for potential surgical resection of liver metastases. Each patient underwent same-day MR examination and two US examinations: one regular and one with the MR/US coregistration system. Target lesions were identified on MR imaging, and US was used in follow-up diagnostic studies of lesions originally identified by MR imaging. During US, two outcome measures (target localization success and target localization time) were collected. Ratios of lesions found per patient were compared with a paired Wilcoxon test, and a Student t test was used to compare target localization time. ResultsRatios of lesions found per patient with the coregistered system (93.7%) and conventional US (73.3%) were statistically different (P =.003). Lesions found by the coregistration system but not conventional US were statistically smaller than those found by both systems (6.1 mm±4.0 vs 15.6 mm±9.8; P<.0006). There was no statistical difference in target localization time for detection of lesions found by coregistered (100 s±89) and conventional US (108 s±86; P = .78). ConclusionsThe MR/US coregistration system increases the number of lesions detected with US versus standard US alone. This may prove beneficial in surgical and nonsurgical management of patients with focal liver lesions.

Management of potentially resectable colorectal cancer liver metastases

Colorectal cancer is a very common malignancy worldwide and development of liver metastases, both synchronous or metachronous, is a common event. Of all patients with metastatic colorectal cancer, up to 77% have a liver-only disease and approximately 10%-20% of patients with colorectal liver metastases are considered resectable at the time of diagnosis. Surgical resection of liver metastases remains the best treatment option and it is associated with a survival plateau and a 20%-25% of long-term survivors. Perioperative chemotherapy for resectable liver metastases may improve resecability of liver metastases and disease free survival, but its impact on overall survival is still unclear and more studies are needed. Moreover, preoperative chemotherapy can increase postoperative complications. Further studies are needed to define the role of adjuvant chemotherapy after a R0 resection of liver metastases and to define the criteria for a better selection of patients candidate to hepatectomy. New strategies such as targeted therapies are emerging with promising results. Optimal management requires a multidisciplinary approach, local and systemic, but it is a still pending question. Colorectal liver metastases represent a major challenge for oncologists and surgeons. In this review will be analyzed available data about assessment and management of the patients with potentially resectable colorectal liver metastases.

Determining timing of hepatectomy for colorectal cancer with distant metastasis according to imaging-based tumor shrinkage ratio.

Background: The optimal timing of surgical resection of liver metastasis remains controversial, and guidelines regarding the upper limits of operative indications have not yet been defined. Surgical indication for metastasis from colorectal cancer (CLM) based on results of preoperative chemotherapy and RNF8 was investigated. Methods: Differences in CLM size on CT were evaluated as shrinkage rate/day by dividing tumor shrinkage rates by the interval in days between CT. Levels of RNF8 of resected colorectal cancer and CLM frozen specimen were detected. Results: When the cut line for shrinkage rate at 12 weeks was set at 0.35%, disease-free survival was significantly better in patients with a shrinkage rate >0.35% vs. ≤0.35% (p=0.003). RNF8 expression was significantly higher in Tis (p=0.001). In liver metastasis, RNF8 expression level was significantly lower in patients with partial response to FOLFOX than with stable disease, (p=0.017). Conclusions: A strategy of FOLFOX administration for 12 weeks to patients with low RNF8 expression and hepatectomy planned after 4 weeks rest may be accepted as the best therapeutic option for treating CLM.

Impact of 18F-FDG PET/CT on therapeutic decisions in patients with colorectal cancer and liver metastases

ObjectivesSurgical resection and radio-frequency ablation (RFA) are standard therapeutic procedures for colorectal metastases confined to the liver. The presence of extrahepatic disease has a significant effect on the management of these patients. The goal of this study is to assess the value of positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (18F-FDG PET/CT) in the decision making whether to perform RFA or surgical resection of liver metastases in patients with metastatic colorectal cancer. Material and methodsThirty-five consecutive patients (23 men, 12 women; age range: 46–78 years) with colorectal carcinoma and liver metastases were prospectively enrolled. Nineteen of them were considered candidates for surgical resection and 16 for RFA. All underwent 18F-FDG PET/CT, helical computed tomography of the chest and abdomen and, some of them, magnetic resonance imaging of the abdomen. The 18F-FDG PET/CT studies were performed within 4 weeks from conventional imaging, and additional findings were later confirmed or not, either by histology or follow up. ResultsIn the surgical candidate group, 18F-FDG PET/CT detected extrahepatic disease, missed by conventional imaging, in 9/19 patients (47.3%). These findings directly altered the management in 7 patients (36.8%). In the group of RFA candidates, 18F-FDG PET/CT detected additional extrahepatic disease in 4/16 patients (25%) and directly altered management in all of them. Overall, in 11/35 patients (31.4%), 18F-FDG PET/CT detected extrahepatic metastatic disease. ConclusionIn patients with colorectal cancer and liver metastases, 18F-FDG PET/CT provides relevant additional information that has significant impact on management.

P-0057 Capecitabine, Epirubicin and Oxaliplatin (Eox Regimen) in Liver Metastasis from Gastric Adenocarcinoma (Lmga)

IntroductionLiver metastasis from gastric cancers may be synchronous or occur later, after the gastrectomy. They are often diffuse and associated with advanced disease, conducting the patient to a palliative treatment. However, these metastases can be isolated and resectable, which must lead to discuss a surgical treatment. Indeed, analysis of the literature shows that surgical resection of liver metastases may be in curative intent in selected cases, since the survival after resection is about 30% at 5 years. The prognostic factors are related to stage of gastric tumor, the uniqueness of the metastasis, its size and the achievement of full resection. If chemotherapy is the reference in the metastatic gastric cancer, in resectable metastasis cases, chemotherapy combined with surgery should be discussed on a case by case because there is so far no data available on its usefulness and its nature, given the lack of therapeutic trials in this rare situation. MethodsThe aim of this prospective analysis is to evaluate the efficacy and safety of EOX in LMGA after 4 cycles. Inclusion criteria were histologically proven gastric carcinoma, no prior chemotherapy (adjuvant chemotherapy allowed if more than 6 month before), no other serious concomitant illness ECOG PS<2, adequate renal and liver function, good marrow reserve. Treatment regimen: oxaliplatin 130 mg/m2 d1, epirubicin 60mg/m2 d1 and capecitabine 500 – 625 mg/m2 twice daily for 21 days (d1=d21). ResultsFrom 01/2010 to 12/2011, 65 patients (M/F=35/30) were enrolled with advanced or metastatic gastric cancer in this study 25 have a liver metastasis. Of 25 enrolled patients, 24 were evaluable for efficacy and 25 for toxicity. A median of 6 cycles (range 1-10) was administered. The overall response rate was 50%, and diseases control rate is 75% including 3 complete responses, 9 partial responses, 6 stable diseases, and 6 progressions. Median progression-free survival was 5.8 months and median overall survival was 10.4 months. Grade 3-4 neutropenia and anemia were observed in 2.5 and 0.3% of patients, respectively. Grade 3-4 non hematological toxicities included alopecia (4.1%), nausea (8.3%), vomiting (2.2%), diarrhea (1.1%), hand-foot syndrome (0.3%) and mucositis (0.9%). ConclusionIn our experience, the EOX regimen was highly effective, well tolerated and conveniently delivered as first-line chemotherapy for LMGA.

Gadoxetic acid-enhanced 3.0 T MR imaging versus multidetector-row CT in the detection of colorectal metastases in fatty liver using intraoperative ultrasound and histopathology as a standard of reference

ObjectiveTo compare the diagnostic value of gadoxetic acid-enhanced MRI at 3.0 T with 64-row MDCT in the detection of colorectal liver metastases in diffuse fatty infiltration of the liver after neoadjuvant chemotherapy. MethodsTwenty-three patients with colorectal liver metastases and at moderate to severe steatosis (25–90%) underwent prospectively preoperative tri-phasic MDCT (Somatom Sensation 64, Siemens) and gadoxetic acid-enhanced MRI (3-T Magnetom Trio, Siemens). All patients underwent surgical resection of liver metastases. Intraoperative ultrasound (IOUS) was carried out, which served as the standard of reference, together with histopathology. ResultsOverall, 68 metastases (range, 0.4–6 cm; 31/68 metastases [46%] ≤ 1 cm) were found at histology. MDCT detected 49/68 lesions (72%), and MRI 66/68 (97%, p < 0.001). For lesions ≤1 cm, MDCT detected only 13/31 (41.9%) and MRI 29/31 (93%, p < 0.001). Eight false-positive lesions were detected by MDCT, seven small lesions by MRI. There was no statistically significant difference between the two modalities in the detection of lesions >1 cm (p = 0.250). IOUS detected all metastases and revealed two false-positive diagnoses. ConclusionGadoxetic acid-enhanced 3.0 T MRI is superior to 64-row MDCT in detecting colorectal liver metastases ≤1 cm during preoperative staging in patients with liver steatosis. A combination of MRI and IOUS may further improve the outcome of surgical treatment.

Surgical resection and peri-operative chemotherapy for colorectal cancer (CRC) liver metastases in routine clinical practice: A population-based outcomes study.

3632 Background: Resection of liver metastases combined with peri-operative chemotherapy is an important treatment option for patients with advanced CRC. Most of the literature describes outcomes achieved in highly selected patients treated at a few high volume institutions. Here we report the results of a population-based study of the management and outcome of all patients who underwent resection of CRC liver metastases in Ontario, Canada. Methods: All cases of CRC in Ontario who underwent surgical resection of liver metastases in 1994-2009 were identified using the population-based Ontario Cancer Registry (OCR). The OCR captures diagnostic and demographic information on ~98% of all incident cancer cases in Ontario. We linked electronic records of treatment to the OCR to identify surgery, neoadjuvant (NACT) and adjuvant chemotherapy (ACT). We describe time trends in treatment and survival using 3 study periods: 1994-1999, 2000-2004, 2005-2009. Results: During 1994-2009, 2717 patients underwent resection of CRC liver metastases in Ontario; mean age was 65 years and 61% were male. From 1994-2009 there was a 103% increase in the number of patients undergoing resection of liver metastases (117/year to 237/year) while incident cases of CRC during this time increased by 31% (5285/year to 6956/year). Use of NACT increased over the study period: 94-99, 11% (78/700); 00-04, 15% (124/830); 05-09, 36%; (424/1187), (p&lt;0.001). Use of ACT also increased: 94-99, 38% (263/700); 00-04, 40% (335/830); 05-09, 45% (532/1187), (p=0.006). In 2005-2009 there was substantial variation across geographic regions in use of NACT (range 19% to 46%, p=0.029) and ACT (range 31% to 56%, p=0.015). Five year overall survival during the 3 study periods was 36% (95%CI 32-39%), 40% (95%CI 36-43%), and 47% (95%CI 43-51%) (p&lt;0.001). Conclusions: Resection of CRC liver metastases in routine practice in the general population of Ontario is associated with survival outcomes that are comparable to those reported in case series from leading comprehensive cancer centres. Survival improved over the study period despite a greater proportion of patients with CRC undergoing liver resection.

Gastric perforation following stereotactic body radiation therapy of hepatic metastasis from colon cancer

Surgical resection of liver metastases from colon cancer is a safe and effective therapy, yielding a 5-year survival rate of 35%-40%.1 For patients who are medically inoperable or who decline surgery, nonsurgical methods such as radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT) have been employed. SBRT treatment of liver metastases from colon cancer has been in general clinical use only over the last 5-6 years. While there have been published reports on efficacy and technique from some large centers,2-4 clinical experience with SBRT has been limited. In this paper, we report a significant and life-threatening complication related to the SBRT of a hepatic metastasis.

Surgical Resection of Solitary Metastatic Liver Tumor Arising From Lung Cancer: A Case Series

Resectability of hepatic metastases which have developed from lung cancer is limited and only a few reports have been published. We report two cases of a surgical resection of liver metastases arising from lung cancer. A 77-year-old male underwent a lower left lobectomy to treat a primary large cell lung carcinoma. Eight months later, abdominal computed tomography revealed a slightly enhanced heterogeneous tumor measuring 50 mm in diameter in the right liver, segment 8. We performed a hepatic anterior sectionectomy. The pathological findings were similar to those of the primary carcinoma. After six months, there was no evidence of a recurring lesion. A 65-year-old female underwent an upper right lobectomy to treat a primary adenocarcinoma. Twenty months later, abdominal computed tomography revealed a heterogeneous tumor measuring 20 mm in diameter in the right liver, segment 7. We performed a hepatic posterior sectionectomy. The pathological findings were similar to those of the primary lung carcinoma. After twenty months, the patient died from an unresectable recurrent carcinoma in the lung and brain. No recurrence was detected in the liver. We recommend that surgical resection be considered for solitary metastatic liver tumors which develop from lung cancer.

Adjuvant Chemotherapy With or Without Pelvic Radiotherapy After Simultaneous Surgical Resection of Rectal Cancer With Liver Metastases: Analysis of Prognosis and Patterns of Recurrence

To investigate the outcomes of adjuvant chemotherapy (CT) or chemoradiotherapy (CRT) after simultaneous surgical resection in rectal cancer patients with liver metastases (LM). One hundred and eight patients receiving total mesorectal excision for rectal cancer and surgical resection for LM were reviewed. Forty-eight patients received adjuvant CRT, and 60 were administered CT alone. Recurrence patterns and prognosis were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were compared between the CRT and CT groups. The inverse probability of the treatment-weighted (IPTW) method based on the propensity score was used to adjust for selection bias between the two groups. At a median follow-up period of 47.7 months, 77 (71.3%) patients had developed recurrences. The majority of recurrences (68.8%) occurred in distant organs. By contrast, the local recurrence rate was only 4.7%. Median DFS and OS were not significantly different between the CRT and CT groups. After applying the IPTW method, we observed no significant differences in terms of DFS (hazard ratio [HR], 1.347; 95% confidence interval [CI], 0.759-2.392; p = 0.309) and OS (HR, 1.413; CI, 0.752-2.653; p = 0.282). Multivariate analyses showed that unilobar distribution of LM and normal preoperative carcinoembryonic antigen level (<6 mg/mL) were significantly associated with longer DFS and OS. The local recurrence rate after simultaneous resection of rectal cancer with LM was relatively low. DFS and OS rates were not different between the adjuvant CRT and CT groups. Adjuvant CRT may have a limited role in this setting. Further prospective randomized studies are required to evaluate optimal adjuvant treatment in these patients.

An update on chemotherapy of colorectal liver metastases

Surgical resection of liver metastases of colorectal cancer greatly improves the clinical outcome of patients with advanced disease. Developments in chemotherapeutic agents and strategies bring hope of a cure to patients with initially unresectable colorectal liver metastases (CLM). Perioperative chemotherapy significantly improves the survival time of patients who receive curative-intent hepatectomy. Even for unresectable CLM, recent studies demonstrated that active preoperative chemotherapy could achieve shrinkage of liver metastasis and thus render some for resection. Furthermore, an increase in tumor resection rate and prolonged survival time among patients with CLM has been observed following the application of monoclonal antibodies in recent years. However, the value of chemotherapy via hepatic arterial infusion is still unclear. More trials should be conducted in patients with CLM in order to improve survival.

6077 POSTER Surgical Resection of Liver Metastases From Colorectal Carcinoma -Survival According to Radical Liver Resection and to Prognostic Factors

6077 POSTER Surgical Resection of Liver Metastases From Colorectal Carcinoma -Survival According to Radical Liver Resection and to Prognostic Factors

Surgical resection of liver metastasis of breast cancer: A multidisciplinary approach—Study case-control.

e11086 Background: In patients with metastatic breast cancer, only the appearance of metastases in the liver occurs in 10% of cases. Unlike colorectal cancer, liver resection is rarely given and its place remains to be defined. The aim of this retrospective study was to compare the survival of two populations with resectable liver metastases (LM) treated for one only medically and for the other surgically preceded by a medical treatment. Methods: From 1988 to 2007, among 100 patients operated of liver metastases of breast cancer at the Curie Institute, 51 were included in this case-control study. Only a positive bone scan was authorized as other metastatic localization. Operated patients received chemotherapy and/or hormonal therapy before surgery and had to be either stabilized or in response. These patients were matched to 51 patients treated only medically. All patients had to have a performance status of 0-1 and the LM should be R0 resected (no residual microscopically desease) with less than 4 metastases. The matching criteria were: patient age, year of diagnosis of breast cancer, time to onset between breast cancer and metastasis, histological type, stage, and status of hormone receptors of breast cancer. The pairing was done 1/1/. Results: In univariate analysis, survival was better in the 2 populations if patients were N -, had no bone metastases or were operated. In multivariate analysis only the liver resection was prognostic. In a Cox model adjusted for paired data yields a RR. = 3.18 (p <0.0001) in favor of surgical treatment. Conclusions: In a selected population, hepatic resection of metastases of breast cancer is a real benefit in terms of survival.

Adjuvant radioimmunotherapy after radiofrequency ablation of colorectal liver metastases in an experimental model

PurposeRadiofrequency ablation (RFA) has shown to improve survival in patients not eligible for surgical resection of colorectal liver metastases. However, recurrences after RFA are a major problem. Adjuvant radioimmunotherapy (RIT) after surgical resection of liver metastases has shown to improve survival. The aim of the present study was to test the hypothesis that adjuvant RIT might be an effective way to prevent recurrent liver metastases after RFA in an experimental model. MethodsTumours in the liver were induced by intrahepatic injection of 300 000 CC531 cells in male Wag/Rij rats (n = 60). Ten days later, the intrahepatic tumours were treated with RFA. Adjuvant RIT (177Lu-labelled monoclonal antibody MG1 at 300 MBq/kg) was administered intravenously either at the day of RFA (day 10) or 7 days later. Control rats received no treatment. Primary endpoint was survival. ResultsAdministration of 177Lu-MG1 resulted in a transient decrease in body weight, compared to no adjuvant treatment. However, no other signs of clinical discomfort were registered. Log rank test showed that the survival curves of the groups treated with RIT, either at day 10 or day 17, did not differ significantly from the survival curve of the rats that did not receive adjuvant treatment (P = 0.902). ConclusionThis study shows that adjuvant RIT does not increase survival after RFA of colorectal liver metastases in rats.

Preoperative detection of colorectal liver metastases in fatty liver: MDCT or MRI?

Objective To compare the diagnostic value of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the preoperative detection of colorectal liver metastases in diffuse fatty infiltration of the liver, associated with neoadjuvant chemotherapy. Materials and methods Twenty preoperative tri-phasic MDCT (4–64-row, Siemens) and dynamic contrast-enhanced MRI (1.5 T or 3.0 T, Siemens) examinations of patients with colorectal cancer and liver metastases in diffuse steatosis were retrospectively evaluated. All patients underwent surgical resection for liver metastases (time interval 1–60 days). The amount of fatty infiltration of the liver was determined histopathologically by semi-quantitative percent-wise estimation and ranged from 25 to 75%. Results Overall, 51 metastases were found by histopathology of the resected liver segments/lobes. The size of the metastases ranged from 0.4 to 13 cm, with 18 (35%) being up to 1 cm in diameter. In the overall rating, MDCT detected 33/51 lesions (65%), and MRI 45/51 (88%). For lesions up to 1 cm, MDCT detected only 2/18 (11%) and MRI 12/18 (66%). One false positive lesion was detected by MDCT. Statistical analysis showed that MRI is markedly superior to MDCT, with a statistically significant difference ( p < .001), particularly for the detection of small lesions (≤1 cm; p < .004). There was no significant difference between the two modalities in the detection of lesions > 1 cm. Conclusion For the detection of colorectal liver metastases after neoadjuvant chemotherapy and consecutive diffuse fatty infiltration of the liver, MRI is superior to MDCT, especially for the detection of small lesions.

The Role of Chemotherapy in Managing Patients With Resectable Liver Metastases

Colorectal cancer metastatic to the liver is a common oncologic problem, and carefully selected patients can be successfully treated with surgical resection of liver metastases. Perioperative chemotherapy has been shown to increase progression-free survival in patients with resectable liver metastases and can currently be considered a standard therapy for eligible patients. Preoperative chemotherapy can downstage unresectable liver metastases and allow a complete resection. More aggressive chemotherapy as well has the incorporation of targeted agents such as cetuximab and bevacizumab into modern chemotherapy regimens has resulted in higher response rates, which may translate into improved survival. Preoperative chemotherapy can increase postoperative complications after hepatic resection, and the decision to use such therapy should be made in a multidisciplinary setting.

9317 Ipilimumab re-induction after progression in patients with advanced melanoma enrolled in Phase II clinical trials

Uveal melanomas have a significant predilection for metastasis to the liver: up to 50% of patients will develop metastases, the liver is the sole or dominant site in more than 80% of them. Microscopic complete (R0) surgical resection of liver metastases improves survival to 22 months in very high selected patients. Despite aggressive therapy, survival is poor, the 1-year survival rate is 10%. Prognostic factors from the primary include tumor diameter and thickness, anterior location, extraocular extension, epithelioid cell type, monosomy 3 and gene expression profile. Early identification of a high-risk group of patients might allow early detection of metastases, and increase R0 liver surgery. We began in October 2006 an intensive follow-up prospective study to detect early minimal lesions with liver MRI in asymptomatic high risk patients. High-risk was defined by thickness >8mm or diameter >15mm, or extrascleral extension, or monosomy 3. Primary objective was to increase R0 liver resection rate from 10 to 30% (a risk = 0.04 and b risk = 0.05); secondary objectives were overall survival, metastasisfree survival, predictive value of MRI and liver functional tests (LFT’s). After treatment of the primary, patients undergo liver MRI and serum samples/6 months, LFTs/3 months. MRI screening consists in T1, T2, T1 dynamic series with gadolinium injection and LFT’s in total bilirubin, ALAT/ASAT, Alkaline phosphatase, GGT, LDH. MRI suspect abnormalities lead to surgical procedure. Information document is sent to radiologists, MRI central review is conducted by Institut Curie radiologists. From Oct 2006 to March 2009, 85 patients were enrolled, median age 60 (32−83), sex ratio M39/F46. The median uveal tumor diameter was 19mm (11−26), median thickness 11.6mm (2.7−17), with retinal detachment in 65 patients, and extraocular spread in 7. Local primary treatment consisted in proton beam therapy in 9 patients, enucleation in 76. Secondary enucleation was performed in 5 cases (2 for local relapse). The histological cell type was epithelioid in 18 cases, fusiform in 17, mixed in 41. Monosomy 3 (FISH) was present in 41/58 analysed enucleations. With a median follow up of 15 months, the metastasis-free survival is 72%. 2 Patients underwent enucleation for local relapse. 24 patients developed metastasis, 2/11 operated patients had R0 liver surgery (18%). To date, 6 patients died (5 from metastasis, 1 myocardial infarction) and 17 patients are alive with metastasis. MRI and LFT’s screening analysis will be presented with an updated follow up in the 85 available patients.

Chest Computed Tomography Screening in Colorectal Cancer Patients

We read with interest the article ‘‘Clinical usefulness of chest radiography in detection of pulmonary metastases after curative resection for colorectal cancer’’ that was published in the July 2007 issue of World Journal of Surgery [1]. In a retrospective analysis of patients after curative resection for colorectal cancer, the authors showed that the sensitivity of abdominal computed tomography (CT) with lower thorax images was superior to chest radiography for lung metastasis detection. They concluded that elevating the upper level of the scan during abdominal CT or performing chest CT could result in higher detection of lung metastases. As Lee et al. noted, reports evaluating CT versus radiography for detecting pulmonary metastases in the context of colorectal cancer have been few and somewhat inconsistent [2, 3]. In our center, we did a prospective study in a selected subset of 96 patients undergoing preoperative evaluation for liver metastases resection, 90% of which were from colorectal cancer, with intrapatient comparison of chest radiography and whole-chest CT for the detection of lung metastases. Neoplastic confirmation of lung lesions was done either by lung biopsy or evidence of growth on follow-up. Lung metastases were present in 13 patients (13.5%). Chest CT was more sensitive than radiography and alone prevented unnecessary liver surgery in three patients (3.1%) in whom chest radiography was normal. Four other chest CT-positive/chest radiography-negative patients were not operated on based on the nonresectability of liver lesions demonstrated by abdominal CT. In six patients, lung metastases were demonstrated by both chest CT and radiography. Incidental CT visualization of indeterminate small lung nodules (too small for characterization with biopsy or positron emission tomography) remains a potential drawback of routine chest CT for colorectal cancer in a small number of patients. Those patients require follow-up chest CT [4]. Since our prospective study, we have included chest CT in the preoperative evaluation of our patients for colorectal liver metastases resection. This is especially valuable with the wider indications of surgical resection of liver metastases allowed by the use of improved combination chemotherapy regimens [5].