Natasha S. Becker

Shifting trends in liver-directed management of patients with colorectal liver metastasis: A population-based analysis

BACKGROUND We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM). METHODS Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined. RESULTS Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05). CONCLUSION Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.

Global graying, colorectal cancer and liver metastasis: New implications for surgical management

Aging of the population - global graying - is occurring rapidly, with significant effects on epidemiology, treatment and outcomes for cancer patients. In colorectal cancer, outcomes for the elderly are worse than those for younger patients, partially driven by treatment disparities between the two groups. Nonetheless, standard-of-care treatment for the elderly results in equivalent long-term outcomes to those observed in the younger population; and available data support the use of aggressive surgery and adjuvant therapies in well-selected patients. Data evaluating epidemiology, treatment patterns and outcomes in elderly patients with colorectal cancer liver metastasis are lacking. Liver resection offers the only curative approach, but it is rarely offered to older adults. Current data support the use of hepatectomy for well-selected elderly colorectal cancer patients with liver metastasis; however, this and other evolving therapies need to be assessed in the elderly to better define their role, indications, safety and outcomes.

Analysis of recent pediatric orthotopic liver transplantation outcomes indicates that allograft type is no longer a predictor of survivals.

Two strategies to increase the donor allograft pool for pediatric orthotopic liver transplantation (OLT) are deceased donor segmental liver transplantation (DDSLT) and living donor liver transplantation (LDLT). The purpose of this study is to evaluate outcomes after use of these alternative allograft types. Data on all OLT recipients between February 2002 and December 2004 less than 12 years of age were obtained from the United Network for Organ Sharing database. The impact of allograft type on posttransplant survivals was assessed. The number of recipients was 1260. Of these, 52% underwent whole liver transplantation (WLT), 33% underwent DDSLT, and 15% underwent LDLT. There was no difference in retransplantation rates. Immediate posttransplant survivals differed, with WLT patients having improved 30‐day patient survivals compared to DDSLT and LDLT patients (P = 0.004). Although unadjusted 1‐year patient survivals were better for WLT versus DDSLT (P = 0.01), after risk adjustment, 1‐year patient survivals for WLT (94%), DDSLT (91%), and LDLT (93%) were similar (P values > 0.05). Unadjusted allograft survivals were better for WLT and LDLT in comparison with DDSLT (P = 0.009 and 0.018, respectively); however, after adjustment, these differences became nonsignificant (all P values > 0.05). For patients ≤ 2 years of age (n = 833), the adjusted 1‐year patient and allograft survivals were also similar (all P values > 0.05). In conclusion, in the current era of pediatric liver transplantation, WLT recipients have better immediate postoperative survivals. By 1 year, adjusted patient and allograft survivals are similar, regardless of the allograft type. Liver Transpl 14:1125–1132, 2008.

Use of Administrative Data to Identify Colorectal Liver Metastasis

BACKGROUND The ability to identify patients with colorectal cancer (CRC) liver metastasis (LM) using administrative data is unknown. The goals of this study were to evaluate whether administrative data can accurately identify patients with CRCLM and to develop a diagnostic algorithm capable of identifying such patients. MATERIALS AND METHODS A retrospective cohort study was conducted to validate the diagnostic and procedural codes found in administrative databases of the Veterans Administration (VA) system. CRC patients evaluated at a major VA center were identified (1997-2008, n = 1671) and classified as having liver-specific ICD-9 and/or CPT codes. The presence of CRCLM was verified by primary chart abstraction in the study sample. Contingency tables were created and the positive predictive value (PPV) for CRCLM was calculated for each candidate administrative code. A multivariate logistic-regression model was used to identify independent predictors (codes) of CRCLM, which were used to develop a diagnostic algorithm. Validity of the algorithm was determined by discrimination (c-statistic) of the model and PPV of the algorithm. RESULTS Multivariate logistic regression identified ICD-9 diagnosis codes 155.2 (OR 9.7 [95% CI 2.5-38.4]) and 197.7 (84.6 [52.9-135.3]), and procedure code 50.22 (5.9 [1.3-25.5]) as independent predictors of CRCLM diagnosis. The models discrimination was 0.89. The diagnostic algorithm, defined as the presence of any of these codes, had a PPV of 87%. CONCLUSIONS VA administrative databases reliably identify patients with CRCLM. This diagnostic algorithm is highly predictive of CRCLM diagnosis and can be used for research studies evaluating population-level features of this disease within the VA system.