Surgical Treatment Of Colorectal Liver Metastases Research Articles

Association of modified textbook outcome and overall survival after surgery for colorectal liver metastases: A nationwide analysis

BackgroundTextbook outcome (TO) represents a multidimensional quality measurement, encompassing the desirable short-term outcomes following surgery. This study aimed to investigate whether achieving TO after resection of colorectal liver metastases (CRLM) surgery is related to better overall survival (OS) in a national cohort. MethodData was retrieved from the Dutch Hepato Biliary Audit. A modified definition of TO (mTO) was used because readmissions were only recorded from 2019. mTO was achieved when no severe postoperative complications, mortality, prolonged length of hospital stay, occurred and when adequate surgical resection margins were obtained. To compare outcomes of patients with and without mTO and reduce baseline differences between both groups propensity score matching (PSM) was used for patients operated on between 2014 and 2018. ResultsOut of 6525 eligible patients, 81 % achieved mTO. For the cohort between 2014 and 2018, those achieving mTO had a 5-year OS of 46.7 % (CI 44.8–48.6) while non-mTO patients had a 5-year OS of 33.7 % (CI 29.8–38.2), p < 0.001. Not achieving mTO was associated with a worse OS (aHR 1.34 (95 % CI 1.17–1.53), p < 0.001. Median follow-up was 76 months., PSM assigned 519 patients to each group. In the PSM cohort patients achieving mTO, 5-year OS was 43.6 % (95 % CI 39.2–48.5) compared to 36.4 % (95 % CI 31.9–41.2) in patients who did not achieve mTO, p = 0.006. ConclusionAchieving mTO is associated with improved long-term survival. This emphasizes the importance of optimising perioperative care and reducing postoperative complications in surgical treatment of CRLM.

Effect of KRAS Mutational Status on Surgical Outcomes for Colorectal Liver Metastases: Results from the Colorectal Liver Operative Metastasis International Collaborative

Introduction: Laterality of colorectal cancers appears to affect outcomes after surgical treatment for Colorectal Liver Metastases (CLM). KRAS mutations are thought to play a role. We hypothesized a differential effect of primary tumor laterality on long-term outcomes after surgical treatment of CLM, and that KRAS mutations influence this effect.

The Disease-Free Interval Between Resection of Primary Colorectal Malignancy and the Detection of Hepatic Metastases Predicts Disease Recurrence But Not Overall Survival

IntroductionThe disease-free interval (DFI) between resection of primary colorectal cancer (CRC) and diagnosis of liver metastases is considered an important prognostic indicator; however, recent analyses in metastatic CRC found limited evidence to support this notion.ObjectiveThe current study aims to determine the prognostic value of the DFI in patients with resectable colorectal liver metastases (CRLM).MethodsPatients undergoing first surgical treatment of CRLM at three academic centers in The Netherlands were eligible for inclusion. The DFI was defined as the time between resection of CRC and detection of CRLM. Baseline characteristics and Kaplan–Meier survival estimates were stratified by DFI. Cox regression analyses were performed for overall (OS) and disease-free survival (DFS), with the DFI entered as a continuous measure using a restricted cubic spline function with three knots.ResultsIn total, 1374 patients were included. Patients with a shorter DFI more often had lymph node involvement of the primary, more frequently received neoadjuvant chemotherapy for CRLM, and had higher number of CRLM at diagnosis. The DFI significantly contributed to DFS prediction (p =0.002), but not for predicting OS (p =0.169). Point estimates of the hazard ratio (95% confidence interval) for a DFI of 0 versus 12 months and 0 versus 24 months were 1.284 (1.114–1.480) and 1.444 (1.180–1.766), respectively, for DFS, and 1.111 (0.928–1.330) and 1.202 (0.933–1.550), respectively, for OS.ConclusionThe DFI is of prognostic value for predicting disease recurrence following surgical treatment of CRLM, but not for predicting OS outcomes.

Portal Vein Occlusion Prior to Extensive Resection in Colorectal Liver Metastasis: A Necessity Rather than an Option!

Preoperative portal vein occlusion (PVO) of one liver lobe is regularly used for inducing liver hypertrophy of the contralateral lobe to prevent postoperative liver failure in patients with an anticipated insufficient future liver remnant (FLR) following resection. A similar rate of hypertrophy of the liver parenchyma with preserved portal flow can be obtained either by percutaneous portal embolization using several agents or by portal vein ligation. This strategy of preoperatively manipulating the liver volume has been acclaimed as a major step in liver surgery, paving the way for extensive resection for initially unresectable tumors. It has been clearly shown that chemotherapy of colorectal liver metastases (CRLM) can provide significant downstaging of liver disease enabling curative rescue resection and translating into an improved long-term survival. Over the last decade, both PVO and chemotherapy have dramatically widened the scope of surgical resection of CRLM. Several institutions involved in the surgical treatment of CRLM have claimed that preoperative PVO has increased the number of candidates for complete tumor resection. The hypertrophy of the FLR allows the safety of major resection. In the present issue, the article by Pamecha et al. tends to dampen the early enthusiasm regarding PVO for CLRM. This well-written article, which compares the surgical outcomes of two groups of patients operated for CRLM with or without portal vein embolization (PVE), highlights the unfavorable effects of PVE. Firstly, one-third of the patients were nonoperable after PVE because of rapid progression of disease, and secondly the long-term survival for patients resected after PVE was less favorable than for the group who underwent immediate surgery. A legitimate concern is whether the stimulus for liver regeneration induced by PVO might enhance tumor growth. As reported in a recent review of this journal, experimental studies have shown that hepatectomy or portal ligation in rats induced tumor growth and in some clinical studies, after PVO, the growth rate of liver metastasis seems to be more rapid than that of the liver parenchyma including a higher proliferative activity of intrahepatic metastasis possibly induced by hyper arterializations. Although these studies clearly demonstrate that tumor progression after PVO is possible, we believe that it is not yet time to consider a restriction of preoperative modulation of the liver parenchyma by PVO. Percutaneous embolization is a safe procedure that could reduce intrahepatic recurrence rate after right hepatectomy for unilobar CRLM. Several series have shown that in patients with extensive CRLM who would otherwise be unresectable, PVO followed by surgery offers a significant benefit with a 5-year survival up to 40%. In these studies the evidence of direct stimulation of tumor growth by PVE is circumstantial, and the rate of unresectability after PVE due to intrahepatic and/or extrahepatic tumor progression is regularly around 25%, which is not very different from the results of Pamecha et al. The main problem raised by this article is the indication of PVO and its association with chemotherapy before a major liver resection. The indication of PVO should depend on several factors including the extent and expected difficulties of resection, the status of nontumorous liver parenchyma, and the exact quantification of sufficient minimal functional hepatic volume. We have clearly demonstrated that a right hepatectomy, which is the main procedure performed after PVO, can be safely performed in patients with normal parenchyma. Therefore, except in patients with a FLR less than 25% of the total volume and Society of Surgical Oncology 2009

R1 Resection by Necessity for Colorectal Liver Metastases

To compare long-term outcome of R0 (negative margins) and R1 (positive margins) liver resections for colorectal liver metastases (CLM) treated by an aggressive approach combining chemotherapy and repeat surgery. Complete macroscopic resection with negative margins is the gold standard recommendation in the surgical treatment of CLM. However, due to vascular proximity or multinodularity, complete macroscopic resection can sometimes only be performed through R1 resection. Increasingly efficient chemotherapy may have changed long-term outcome after R1 resection. All resected CLM patients (R0 or R1) at our institution between 1990 and 2006 were prospectively evaluated. Exclusion criteria were: macroscopic incomplete (R2) resection, use of local treatment modalities, and presence of extrahepatic disease. We aimed to resect all identified metastases with negative margins. However, when safe margins could not be obtained, resection was still performed provided complete macroscopic tumor removal. Overall survival (OS) and disease-free survival were compared between groups, and prognostic factors were identified. Of 840 patients, 436 (52%) were eligible for the study, 234 (28%) of whom underwent R0 resection, and 202 (24%) underwent R1 resection. Number and size of CLM were higher, and distribution was more often bilateral in the R1 group. After a mean follow-up of 40 months, 5-year OS was 61% and 57% for R0 and R1 patients (P = 0.27). Five-year disease-free survival was 29% in the R0 group versus 20% in the R1 group (P = 0.12). In the R1 group, intrahepatic (but not surgical margin) recurrences were more often observed (28% vs. 17%; P = 0.004). Preoperative carcinoembryonic antigen level > or =10 ng/mL and major hepatectomy, but not R1 resection, were independent predictors of poor OS. Size > or =30 mm, bilateral distribution, and intraoperative blood transfusions independently predicted positive surgical margins. Despite a higher recurrence rate, the contraindication of R1 resection should be revisited in the current era of effective chemotherapy because survival is similar to that of R0 resection.