Resection of Hepatic Metastases from Colorectal Cancer Biologic Perspectives

Department of Surgery, New England Deaconess Hospital, Harvard Medical School, Boston, Massachusetts 02215.
Annals of Surgery (Impact Factor: 8.33). 09/1989; 210(2):127-38. DOI: 10.1097/00000658-198908000-00001
Source: PubMed


During the past decade the results of slightly fewer than 1000 resections of liver metastases from colorectal carcinoma have been analyzed, retrospectively reanalyzed, and reviewed. The following are confirmed conclusions: major liver resection can be performed safely (less than a 5% operative mortality rate); 20% to 25% of these patients are cured; no other regional therapy options have any curative potential. The following caveats are also obvious: most patients who are operated on are not cured; although predictors have been proposed to select patients most likely to benefit from surgery, none is discriminating in and of itself; most therapy questions in this group of patients have not been addressed in any formal way; surgery for isolated regionally recurrent colon and rectum carcinoma remains an important stopgap only until effective systemic therapy is discovered. This review of our own and other single and multi-institutional prospective and retrospective data will be framed by the following questions. (1) Does resection of liver metastases cure patients or simply select those who would have survived in the long-term without any therapy? (2) In the absence of any formalized, properly designed trial, how can one judge the benefit of resection? (3) Why do metastases recur only in the liver? (4) What new therapies should focus on the predominant secondary failure sites in the majority of patients who do not benefit from hepatic metastasis resection?

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    • "In this setting, targeted local therapies have procured significant long-term survival. Systematic reviews of the resection of hepatic metastases showed a 5 year survival of 25e30% [4] [5]. Similarly, a multinational registry of 5206 patients undergoing surgical resection of lung metastases showed a 5 year survival rate of 36%, with the median survival being 35 months [6]. "
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    ABSTRACT: To compare outcomes of single-fraction and multi-fraction stereotactic ablative body radiotherapy (SABR) for pulmonary metastases. A retrospective review from two academic institutions of patients with one to three pulmonary metastases staged with (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scans. For single-fraction SABR, 26Gy was prescribed for peripheral targets and 18Gy for central targets. In the multi-fraction cohort, 48Gy/4 or 50Gy/5 was prescribed for peripheral targets and 50Gy/5 was prescribed for central targets. Three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans were delivered using heterogeneity corrections. Conformity indices at an intermediate dose (R50%) and at a high dose (R100%) were used to assess a relationship with the planning target volume (PTV). Overall survival, local and distant progression and toxicity rates were analysed from the date of treatment completion. Between February 2010 and June 2013, 65 patients with 85 pulmonary metastases were reviewed. The median follow-up was 2.1 years. Metastases most commonly originated from colorectal cancer (31%), followed by non-small cell lung cancer (25%). 3D-CRT was used in 52 targets, IMRT in 21 and VMAT in 12. 3D-CRT showed a lower median R50% (P = 0.01), but a higher median R100% than IMRT/VMAT (P = 0.04). The R50% index was inversely correlated to the PTV with all techniques (P = 0.01). Overall survival at 1 and 2 years in all patients was 93% (95% confidence interval 87-100%) and 71% (95% confidence interval 58-86%), respectively. The 2 year freedom from local and distant progression was 93% (95% confidence interval 86-100%) and 38% (95% confidence interval 27-55%), respectively. There were no significant differences between overall survival (P = 0 .14), time to distant progression (P = 0.06) or toxicity rates (P = 0.75) between single- and multi-fraction cohorts. We report comparable local control, overall survival and toxicity rates between single-fraction and multi-fraction SABR treatments in patients with FDG-PET-staged pulmonary oligometastases. We propose a guideline for R50% conformity incorporating 3D-CRT/IMRT/VMAT techniques with heterogeneity corrected planning algorithms. Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
    Clinical Oncology 02/2015; 27(6). DOI:10.1016/j.clon.2015.01.004 · 3.40 Impact Factor
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    • "Colorectal cancer (CRC) is one of the most common cancers occurring worldwide and the second leading cause of cancer-related deaths in Europe and the United States [1,2]. Approximately 50% of CRC patients will experience metastases [3], and patients with stage IV disease were deemed incurable, previously. However, if patients with colorectal liver metastases treated with extirpative surgery and proper chemotherapy, 5-year survival rates would reach up to 58% in the recent reports [4-6]. "
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    ABSTRACT: This study evaluated the efficacy of neoadjuvant chemotherapy combining 5-flurouracil/folinic acid with irinotecan (FOLFIRI) in colorectal multiple liver metastases regardless of resectability. Forty-four patients with multiple (at least two) colorectal liver metastases were enrolled at seven tertiary referral hospitals between May 2007 and September 2010. All patients received the FOLFIRI chemotherapeutic regimen. Response to chemotherapy was assessed after three cycles (6 weeks) and once more after six cycles (12 weeks) of treatment. Objective response was noted in 27 patients (61.4%) and 4 patients (9.1%) had progressive disease. Of 44 patients, 10 patients (22.7%) underwent curative surgery (R0 resection) and 34 patients did not receive R0 resection. Grades 3 to 4 hematological toxicity was noted in 12 patients (27.3%) and grades 3 to 4 nonhematologic toxicity was identified in 5 patients (11.4%). FOLFIRI chemotherapy as a neoadjuvant chemotherapy for multiple colorectal liver metastases regardless of resectability demonstrated the possibility of R0 resection, high rate of objective response, and tolerable toxicities in this study.
    Journal of the Korean Surgical Society 10/2013; 85(4):154-160. DOI:10.4174/jkss.2013.85.4.154 · 0.73 Impact Factor
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    • "Metastatic disease accounts for the majority of malignant lesions in the liver. Often, the presence of liver metastases is the main determinant of survival and guides the therapeutic strategy, particularly in patients with colorectal cancer [16, 17]. "
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    ABSTRACT: Positron emission tomography (PET) is widely available and its application with 2-[(18)F] fluoro-2-deoxy-D-glucose ((18)F-FDG) in oncology has become one of the standard imaging modalities in diagnosing and staging of tumors, and monitoring the therapeutic efficacy in hepatic malignancies. Recently, investigators have measured glucose utilization in liver tumors using (18)F-FDG and positron emission tomography/computer tomography (PET/CT) in order to establish a diagnosis of tumors, assess their biologic characteristics and predict therapeutic effects on hepatic malignancies. The PET/CT with (18)F-FDG may further enhance the hepatic malignancy diagnostic algorithm by accurate diagnosis, staging, restaging and evaluating its biological characteristics, which can benefit the patients suffering from primary and metastatic hepatic tumors such as hepatocellular carcinoma (HCC), cholangiocarcinoma (CCC), and metastatic liver tumor.
    Journal of Gastroenterology 03/2013; 49(1). DOI:10.1007/s00535-013-0790-5 · 4.52 Impact Factor
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