Although the presence of synchronous colorectal liver metastases (CRLM) represents an important prognostic factor for recurrence-free survival (RFS) and overall survival (OS), the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer (CRC), until either six or 12 months after the time of diagnosis, according to the author of each study. Simultaneous approaches to treat CRC and CRLM seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter hospital length of stay, and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged, and both performance status and the presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time.
The presence of synchronous colorectal liver metastases represents an important prognostic factor for recurrence-free survival and overall survival, the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer, and until either six or 12 months after the time of diagnosis, according to the authors of the studies.
Simultaneous approaches to treat colorectal cancer and colorectal liver metastases seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter length of stay and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and colorectal liver metastases, whether simultaneously or staged, and both performance status and presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time
Although the presence of synchronous colorectal liver metastases (CRLM) represents an important prognostic factor for recurrence-free survival (RFS) and overall survival (OS), the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer (CRC), until either six or 12 months after the time of diagnosis, according to the author of each study. Simultaneous approaches to treat CRC and CRLM seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter hospital length of stay, and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged, and both performance status and the presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time.
Solid pseudopapillary tumor of the pancreas has been frequently reported in the past two decades. Surgery remains the treatment of choice, with the liver being the most frequent site of metastases.
The study aimed to present an option of surgical treatment for an 18-year-old female patient with a solid lesion in the body and tail of the pancreas associated with metastatic lesions in both hepatic lobes.
Two surgical procedures were scheduled. In the first procedure, body-caudal pancreatectomy with splenectomy was performed, associated with the resection of three lesions of the liver's left lobe. A right hepatectomy was performed 6 months later, progressing without complications.
The patient continues without clinical complaints on the last return, and abdominal magnetic resonance performed 28 months after the second procedure does not show liver or abdominal cavity lesions.
The knowledge on the biological behavior of tumors, evolution, and recurrence risks allows the indication of more rational surgical techniques that best benefit patients.
Deaths related to colorectal cancer are generally associated with its metastases that affect the liver (50%) through the hematogenous route. Approximately 20-25% of these patients already have synchronous metastases in the liver at the time of primary tumor diagnosis. In others, liver metastases will occur during the course of the disease and are called metachronous. Metachronous metastases are believed to have a better prognosis; however, 20-25% of metastatic cases can be resected during the course of the disease. There is a lack of consensus on the diagnostic time interval for metastases to be considered metachronous in the consulted literature. Surgical treatment of metastases and lymph nodes is indicated, and extrahepatic neoplastic disease must be carefully evaluated. Liver transplantation can benefit the patient, should be evaluated, and is indicated in some special situations.
Liver metastases from melanomas, sarcomas, and renal tumors are less frequent. Treatment and prognosis will depend on whether they are isolated or multiple, size and location, the presence or absence of extrahepatic neoplastic disease, age, stage of the initial disease, initial treatments instituted, time of evolution, and clinical condition of the patient. Recently, a high number of oncological therapies including monotherapy or in combination, neoadjuvants or adjuvants, and immuno-oncological treatments have been developed and tested, increasing disease-free time and survival.
Complete removal of metastatic disease and maintenance of an adequate liver remnant remains the only treatment option with curative intent concerning colorectal liver metastases. Surgery impacts on the long-term prognosis and complications adversely affect oncological results. The actual morbidity involving this scenario is debatable and estimated to be ranging from 15% to 50%. Postoperative complications eventually lead to an increase in both mortality rates and tumor recurrence. Biliary fistula and liver failure are the leading complications following liver resection to metastatic colorectal cancer. Prophylactic drainage does not prevent fistulas or hemorrhage. Drainage along with endoscopic intervention and/or surgery may be necessary for grade B and C fistulas. Liver failure is a potentially lethal complication with few therapeutic options. Patient selection and preoperative care are crucial for its prevention.
In patients with synchronic liver colorectal metastasis, resection of the primary tumor and liver metastases is the only potentially curative strategy. In such cases, there is no consensus on whether resection of the primary tumor and metastases should be performed simultaneously or whether a staged approach should be performed (resection of the primary tumor and after, hepatectomy, or hepatectomy first). Patients with no bowel occlusion and with extensive liver disease are advised neoadjuvant oncological therapy. Similarly, various strategies such as portal vein embolization, liver deprivation, two-staged hepatectomy, and associating liver partition and portal vein ligation are available for patients who do not have a sufficient future liver remnant (generally 30-40% of the total). Therefore, a multidisciplinary approach is required for the treatment of these patients.
The development of surgical techniques, chemotherapy, biological agents, and multidisciplinary approaches have made patients with unresectable colorectal liver metastases eligible for surgery. Many strategies have been developed to allow patients for surgical resection (percutaneous portal vein embolization, liver venous deprivation, parenchyma-sparing liver surgery, reverse strategy, associating liver partition and portal vein ligation for staged hepatectomy, and liver transplantation), the only form of disease control and curative treatment.
Surgery after neoadjuvant chemotherapy (CT) improves the prognosis of colorectal liver metastases (CRLM).
The aim of this study was to evaluate the predictive factors of the histological response of CRLM after neoadjuvant treatment.
A retrospective monocentric study including patients with CRLM operated after neoadjuvant treatment. Assessment of histological response was based on the Rubbia-Brandt tumor regression grading score. The scores were grouped into two types of response: Response Group (R) and No Response Group (NR).
The study included 77 patients (mean age=56 years, sex ratio=1.57). Node metastases were noticed in 62% of cases. Synchronous liver metastasis was present in 42 cases (55%) and metachronous liver metastasis in 45%. Neoadjuvant treatment consisted of CT only in 52 patients (68%) and CT with targeted therapy in 25 patients (32%). Chemo-induced lesions were present in 44 patients (57%). Histological response was presented (Group R) in 36 cases (47%) and absent (Group NR) in 41 cases (53%). The overall survival of our patients was 32 months. For Group R, survival was significantly greater (p=0.001). The predictive factors of histological response identified were delay in the onset of liver metastasis greater than 14 months (p=0.027) and neoadjuvant treatment combining CT and targeted therapy (p=0.031). In multivariate analysis, the type of neoadjuvant treatment (p=0.035) was an independent predictive factor of histological response.
Predictive factors of histological response would allow us to identify patients who would benefit most from neoadjuvant treatment. These patients with CRLM onset of more than 14 months and treated with CT combined with targeted therapy would be the best candidates for a neoadjuvant CT strategy followed by surgical resection.
Lymph node status is vital for gastric cancer (GC) prognosis, but the conventional pN stage may be limited by variations in lymphadenectomy and stage migration. The N-Ratio, which assesses the ratio of metastatic to resected lymph nodes, emerges as a promising prognostic tool.
To assess N-Ratios prognostic value in GC, particularly in patients with <25 resected lymph nodes.
Patients who underwent gastrectomy with curative intent for GC were retrospectively evaluated. The N-Ratio categories were determined using the ROC curve method, and the area under the curve (AUC) was used as a measure of performance in predicting recurrence/death.
A total of 561 GC patients were included in the study, 57% had pN+ status, and 17.5% had <25 resected lymph nodes. N-Ratio, with a mean of 0.12, predicted survival with 74% accuracy (AUC=0.74; 95%CI 0.70–0.78, p<0.001). N-Ratio categories included: N-Ratio 0 (43%); N-Ratio 1 (12.3%); N-Ratio 2 (31.6%); and N-Ratio 3 (13.2%). Disease-free survival (DFS) varied among all N-Ratio groups, with N-Ratio 3 showing worse survival than pN3 cases (DFS=21.8 vs. 11 months, p=0.022, p<0.05). In cases with <25 resected lymph nodes, DFS was not significantly worse in N-Ratio 0 (68.8 vs. 81.9%, p=0.061, p>0.05) and N-Ratio 1 (66.2 vs. 50%, p=0.504, p>0.05) groups. The DFS of N-Ratio-0 cases with <25 lymph nodes was similar to N-Ratio 1 cases.
N-Ratio influenced survival in GC patients, especially in advanced lymph node disease (N-Ratio 3). Considering that N-Ratio does not impact pN0 cases, individualized prognosis assessment is essential for patients with <25 resected lymph nodes.
Desenvolvido por Surya MKT