Francis Chu

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: A consensus statement

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin : a consensus statement

Hepatic resection for metastatic breast cancer: A systematic review

BACKGROUND Systemic chemotherapy is the mainstay of treatment for metastatic breast cancer with the role of surgery being strictly limited for palliation of metastatic complications or locoregional relapse. An increasing number of studies examining the role of therapeutic hepatic metastasectomy show encouraging survival results. A systematic review was undertaken to define its safety, efficacy and to identify prognostic factors associated with survival. METHODS Electronic search of the MEDLINE and PubMed databases (January 2000-January 2011) to identify studies reporting outcomes of hepatectomy for breast cancer liver metastases (BCLM) with hepatectomy was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Safety and clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. RESULTS Nineteen studies were examined. This comprised of 553 patients. Hepatectomy for BCLM was performed at a rate of 1.8 (range, 0.7-7.7) cases per year in reported series. The median time to liver metastases occurred at a median of 40 (range, 23-77) months. The median mortality and complication rate were 0% (range, 0-6%) and 21% (range, 0-44%), respectively. The median overall survival was 40 (range, 15-74) months and median 5-year survival rate was 40% (range, 21-80%). Potential prognostic factors associated with a poorer overall survival include a positive liver surgical margin and hormone refractory disease. CONCLUSION Hepatectomy is rarely performed for BCLM but the studies described in this review indicate consistent results with superior 5-year survival for selected patients with isolated liver metastases and in those with well controlled minimal extrahepatic disease. To evaluate its efficacy and control for selection bias, a randomised trial of standard chemotherapy with or without hepatectomy for BCLM is warranted.

Systematic review of neoadjuvant transarterial chemoembolization for resectable hepatocellular carcinoma.

Resection of hepatocellular carcinoma (HCC) offers the only hope for cure. However, in patients undergoing resection, recurrences, in particular, intrahepatic recurrence are common. The effectiveness of transarterial chemoembolization (TACE) as a neoadjuvant therapy for unresectable HCC was exploited by numerous liver units and employed preoperatively in the setting of resectable HCC with an aim to prevent recurrence and prolong survival. A systematic literature search of databases (Medline and PubMed) to identify published studies of TACE administered preoperatively as a neoadjuvant treatment for resectable HCC was undertaken. A systematic review by tabulation of the results was performed with disease‐free survival (DFS) as the primary endpoint. Overall survival (OS), rate of pathological response, impact on surgical morbidity and mortality and pattern of recurrences were secondary endpoints of this review. Eighteen studies; three randomized trials and 15 observational studies were evaluated. This comprised of 3927 patients, of which, 1293 underwent neoadjuvant TACE. The median DFS in the TACE and non‐TACE group ranged from 10 to 46 and 8 to 52 months, respectively, with 67% of studies reporting similar DFS between groups despite higher extent of tumour necrosis from the resected specimens indicating a higher rate of pathological response (partial TACE 27–72% vs. non‐TACE 23–52%; complete TACE 0–28% vs. non‐TACE zero), with no difference in surgical morbidity and mortality outcome. No conclusion could be drawn with respect to OS. Both randomized and non‐randomized trials suggest the use of TACE preoperatively as a neoadjuvant treatment in resectable HCC is a safe and efficacious procedure with high rates of pathological responses. However, it does not appear to improve DFS.

Surgical resection of hepatic metastases from neuroendocrine neoplasms: A systematic review

BACKGROUND Neuroendocrine tumours (NET) most commonly metastasize to the liver. Hepatic resection of NET hepatic metastases (NETHM) has been shown to improve symptomology and survival. METHODS A systematic review of clinical studies before September 2010 was performed to examine the efficacy of hepatic resection for NETHM. As a secondary end-point, the impact of treatment on safety and symptomology were determined and prognostic variables were identified. The quality of each study was also assessed using predefined criteria incorporating 9 characteristics. Clinical outcome was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS Twenty-nine included reported survival outcomes with a median 3-, 5- and 10-year overall survival of 83% (range, 63-100%), 70.5% (range, 31-100%), and 42% (range, 0-100%), respectively. The median progression-free survival (PFS) was 21 months (range, 13-46 months) and median 1-,3-,5- and 10-year PFS of 63% (range, 50-80 %), 32% (range, 24-69%), 29% (range, 6-66%) and 1% (range, 0-11%), respectively. Poor histologic grade, extra-hepatic disease and a macroscopically incomplete resection were associated with a poor prognosis. Studies reported a median rate of symptomatic relief from surgery in 95% of patients (range, 50-100%). CONCLUSION Hepatic resection for NETHM provides symptomatic benefit and is associated with favourable survival outcomes although the majority of patients invariably develop disease progression.

Improved outcomes after aggressive surgical resection of hilar cholangiocarcinoma: a critical analysis of recurrence and survival

BACKGROUND Hilar cholangiocarcinoma (HC) is invariably fatal without surgical intervention. The primary aim of the current study was to report overall survival and recurrence-free survival outcomes after surgical resection of HC. METHODS Between December 1992 and December 2009, 85 patients were evaluated; of these, 42 patients underwent potentially curative surgery. These patients are the principal subjects of this study. Patients were assessed monthly for the first 3 months and then at 6-month intervals after treatment. Recurrence-free survival and overall survival were determined; 18 clinicopathologic and treatment-related factors associated with recurrence-free survival and overall survival were evaluated through univariate and multivariate analyses. RESULTS No patient was lost to follow-up evaluation. The median follow-up period was 20 months (range, 0-106 mo). The median recurrence-free survival and overall survival after resection was 15 and 28 months, respectively. The 5-year survival rate was 24%. Two factors were associated with overall survival: histologic grade (P = .002) and margin status (P = .033). Only histologic grade (P = .029) was associated with recurrence-free survival. CONCLUSIONS Surgical resection is an efficacious treatment for HC. Patient selection based on identified prognostic factors can improve treatment outcomes.

Synchronous resection of colorectal primary cancer and liver metastases.

BackgroundPatients with synchronous colorectal liver metastases are thought to have a less favorable prognosis than those with colorectal cancer alone. Surgical treatment options are controversial, be it synchronous resection or staged resection. This study compared the clinical, perioperative, disease-free survival (DFS), and overall survival (OS) results of patients undergoing synchronous resection versus staged resection.MethodsAn observational cohort study of 103 patients with synchronous colorectal liver metastases was performed. All data were collected prospectively. Clinical, perioperative, DFS, and OS results of patients undergoing synchronous resection (group I, n = 73) and staged resection (group II, n = 30) were compared.ResultsMore patients in group I had poorly differentiated colorectal cancer, bilobar liver metastases, more than three liver metastases, ≤4 cm liver metastases, and shorter hospital stays than patients in group II. There were no significant statistically differences in DFS and OS between the two groups. The median DFS of groups I and II were 28 and 26 months, respectively (p = 0.585). The median OS of groups I and II were 37 and 36 months, respectively (p = 0.900).ConclusionsSynchronous resection achieved DFSs and OSs similar to those seen after staged resection while avoiding a second major operation.

Hepatectomy and resection of concomitant extrahepatic disease for colorectal liver metastases--a systematic review.

BACKGROUND Recent data suggest that hepatectomy for patients with colorectal liver metastases (CLM) with concomitant extrahepatic disease (EHD) achieve encouraging survival result. The authors examine the clinical efficacy of this treatment approach through a systematic review of the published literature. METHODS Electronic search of the MEDLINE and PubMed databases (January 2000 to January 2011) to identify studies reporting outcomes of hepatectomy for CLM with resection of EHD was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. RESULTS Twenty-two studies were examined. This comprised 1142 patients. The median disease-free survival was 12 (range, 4-22) months, median overall survival was 30 (range, 14-44) months and median 5-year survival rate was 19% (range, 0-42%). Median 5-year survival of patients with R0 hepatectomy with resection of EHD was 25% (range, 19-36%). Survival based on site of EHD include lung; median survival (M/S) was 41 (range, 32-46) months, porto-caval lymph node; M/S was 25 (range, 19-48) months, peritoneal metastases; M/S was 25 (range, 18-32) months. CONCLUSION In the era of effective systemic therapies, surgical resection of CLM and concomitant EHD in carefully selected patients may achieve survival results superior to non-surgically treated patients. This treatment strategy may be considered appropriate especially when a R0 hepatectomy and complete resection of EHD may be achieved.

Viewing metastatic colorectal cancer as a curable chronic disease.

Improved survival of colorectal cancer has been made over the last 3 decades; reasons may be attributed to early detection through screening, and better treatment options. Advancements in modern systemic chemotherapy for colorectal cancer include oxaliplatin-based and irinotecan-based combination and the introduction of biological agents such as bevacizumab and cetuximab. Systemic therapies need to be used in patients with high risk stage II and stage III colorectal cancer and in patients with metastatic disease. Evidence for liver resection and ablation, pulmonary metastasectomy and/or radiofrequency ablation, and cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for metastasis to sites of the liver, lung, and peritoneum respectively are well established. The biggest challenge is to select the right patients for metastasectomy and to pursue metastatic disease as a chronic disease to ensure appropriate personalized therapy, pursue second-line therapies or repeat surgeries, and minimize toxicities of therapies.

Summary outcomes of two-stage resection for advanced colorectal liver metastases.

Surgical resection is associated with improved long‐term survival in patients with colorectal liver metastases (CLM). However, majority of patients have unresectable bilobar advanced liver metastases. Two‐stage resection (TSR) allows selected patients to achieve complete resection when combined with chemotherapy and interventional radiological procedures.Background Surgical resection is associated with improved long-term survival in patients with colorectal liver metastases (CLM). However, majority of patients have unresectable bilobar advanced liver metastases. Two-stage resection (TSR) allows selected patients to achieve complete resection when combined with chemotherapy and interventional radiological procedures. Methods Electronic search of the MEDLINE and PubMed databases (January 2000–October 2011) to identify studies examining the outcomes of the surgical approach of TSR of advanced CLM was undertaken. Results Twelve studies were examined. This comprised 488 patients. A median of 77% (range: 64–100%) of planned patients completed TSR. The most common reason for failure was due to disease progression observed in a median of 100% (range: 56–100%) of patients. Second-stage resection appeared to be more morbid compared to first-stage resection with higher complication rates (33% vs. 14%) and requiring more blood transfusions (3 U vs. 1 U). Completed TSR achieved a median survival of 37 (range: 18–66) months, median 3-year survival rate of 60% (range: 45–84%), and median 5-year survival rate of 48% (range: 32–70%). In patients who failed TSR, the median survival was 16 (range: 10–29) months. Conclusion In carefully selected candidates with advanced bilobar CLM, the TSR approach achieves long-term survival in patients who would otherwise be considered for palliative chemotherapy only. Despite failing to complete TSR, patients had an encouraging survival outcome that appeared to compare favorably over palliative chemotherapy alone. J. Surg. Oncol. 2013;107:211–216.

Predictors of cure after hepatic resection of colorectal liver metastases: an analysis of actual 5- and 10-year survivors.

Hepatic resection of colorectal liver metastases (CLM) is now regarded the standard of care. Evaluation of true long‐term suvivors will demonstrate the curative potential of this therapy with cure being defined as actual 10‐year survival versus a satisfactory oncological outcome of 5‐year survival. Limited data exists on outcomes of patients beyond 5 years. Studying the rates of cure and predictive factors for cure are essential to define the true benefit of this therapy.