Total tumour volume as a prognostic factor in patients with resectable colorectal cancer liver metastases.

BACKGROUND: Although total tumour volume (TTV) may have prognostic value for hepatic resection in certain solid cancers, its importance in colorectal liver metastases (CRLM) remains unexplored. This study investigated its prognostic value in patients with resectable CRLM. METHOD: This was a retrospective review of patients who underwent hepatic resection for CRLM between 2008 and 2017 in a single institution. TTV was measured from CT images using three-dimensional construction software; cut-off values were determined using receiver operating characteristic (ROC) curve analyses. Potential prognostic factors, overall survival (OS) and recurrence-free survival (RFS) were determined using multivariable and Kaplan-Meier analyses. RESULTS: Some 94 patients were included. TTV cut-off values for OS and RFS were 100 and 10 ml respectively. Right colonic primary tumours, primary lymph node metastasis and bilobar liver metastasis were included in the multivariable analysis of OS; a TTV of 100 ml or above was independently associated with poorer OS (hazard ratio (HR) 6·34, 95 per cent c.i. 2·08 to 17·90; P = 0·002). Right colonic primary tumours and primary lymph node metastasis were included in the RFS analysis; a TTV of 10 ml or more independently predicted poorer RFS (HR 1·90, 1·12 to 3·57; P = 0·017). The 5-year OS rate for a TTV of 100 ml or more was 41 per cent, compared with 67 per cent for a TTV below 100 ml (P = 0·006). Corresponding RFS rates with TTV of 10 ml or more, or less than 10 ml, were 14 and 58 per cent respectively (P = 0·009). A TTV of at least 100 ml conferred a higher rate of unresectable initial recurrences (12 of 15, 80 per cent) after initial hepatic resection. CONCLUSION: TTV was associated with RFS and OS after initial hepatic resection for CRLM; TTV of 100 ml or above was associated with a higher rate of unresectable recurrence.

ANTECEDENTES: Aunque el volumen total del tumor (total tumour volume, TTV) puede tener valor pronóstico tras la resección hepática (hepatic resection, HR) en algunas neoplasias sólidas, no se conoce su importancia en las metástasis hepáticas de cáncer colorrectal (colorectal liver metastases, CRLMs). Este estudio analizó el valor pronóstico del TTV en pacientes con CRLMs resecables. MÉTODOS: Revisión retrospectiva de pacientes a los que se realizó una HR por CRLMs entre 2008 y 2017 en un solo centro. El TTV se estimó a partir de imágenes de tomografía computarizada utilizando un programa de reconstrucción 3D; se determinaron los valores de corte mediante un análisis de las características operativas del receptor. Se identificaron los posibles factores pronósticos y se calcularon la supervivencia global (overall survival, OS) y la supervivencia libre de recidiva (recurence-free survival, RFS) mediante análisis multivariados y de Kaplan-Meier. RESULTADOS: Se incluyeron 94 pacientes. Los valores de corte del TTV para la OS y la RFS fueron de 100 mL y 10 mL, respectivamente. En el análisis multivariable para la OS, se incluyeron los tumores del colon derecho, las metástasis linfáticas primarias y la metástasis hepática bilobar; un TTV ≥ 100 mL se asoció de forma independiente con una peor OS (cociente de riesgos instantáneos, hazard ratio, HR, 6,34, i.c. del 95% 2,08-17,9; P = 0,002). En el anáisis para la RFS, se incluyeron tumores primarios de colon derecho y las metástasis linfáticas primarias; un TTV ≥ 10 mL predijo de forma independiente una peor RFS (HR 1,90, i.c. del 95% 1,12-3,57; P = 0,017). Las tasas de OS a los 5 años con TTVs ≥ 100 mL versus < 100 mL fueron del 41% versus 67% (P = 0,006); las tasas de RFS respecto a TTVs ≥ 10 mL versus < 10 mL fueron del 14% versus 58% (P = 0,009). Un TTV ≥ 100 mL conllevó una tasa más elevada (80%) de recidivas no resecables después de la HR inicial. CONCLUSIÓN: El TTV se asoció con la RFS y la OS tras la HR por CRLMs; unos valores ≥ 100 mL conllevan una tasa más elevada de recidiva irresecable.

Right portal vein embolization with absolute ethanol in major hepatic resection for hepatobiliary malignancy.

BACKGROUND: This study aimed to evaluate the safety and efficacy of preoperative right portal vein embolization (PVE) with absolute ethanol in patients with hepatobiliary malignancies. METHODS: PVE was performed via a percutaneous transhepatic ipsilateral approach, and the right portal branch was embolized with absolute ethanol. Technical success and complications following PVE, and changes in liver enzyme levels were evaluated. Changes in future liver remnant (FLR) and FLR/total functional liver volume ratio were calculated. Complications following hepatic resection were assessed. RESULTS: A total of 83 patients with hepatobiliary malignancies (53 men, 30 women; mean age 68 years) underwent right PVE. Tumour types were hilar cholangiocarcinoma (37), liver metastases (14), gallbladder cancer (13), intrahepatic cholangiocellular carcinoma (10) and hepatocellular carcinoma (HCC) (9). PVE was performed successfully in all patients. Four patients (5 per cent) developed complications following PVE (liver abscess 2, left portal vein thrombosis 1, pseudoaneurysm 1), but this did not preclude hepatic resection. Liver enzyme levels rose transiently after PVE. The mean FLR and FLR/total functional liver volume increased after PVE (from 366 to 513 cm(3) and from 31 to 43 per cent respectively; both P < 0·001). Changes in the FLR and FLR/total functional liver volume ratio were comparable between patients with HCC and those with other malignancies (42 and 44 per cent, and 12 and 12 per cent, respectively). Sixty-nine of 83 patients underwent hepatic resection at a median of 25 days after PVE, with no postoperative mortality. CONCLUSION: Preoperative right PVE with absolute ethanol is safe and effective for induction of selective hepatic hypertrophy in patients with hepatobiliary malignancy.

Evaluation of several saccharides as osmotic agent for peritoneal dialysate.

OBJECTIVE: The carbonyl group of glucose reacts non-enzymatically with the amino group of protein to form advanced glycosylation end-products (AGEs). AGEs are found in the peritoneum of continuous ambulatory peritoneal dialysis patients, and this AGE formation is suspected to be one of the causes of impaired peritoneal function. In order to control AGE formation in the peritoneum, AGE formation and ultrafiltration in rats were examined with peritoneal dialysates using as osmotic agents saccharides that lack a carbonyl group, the saccharic acid lactobionate [molecular weight (MW) 358.30], the sugar alcohol maltitol (MW 344.32), and the nonreducing sugar nistose (MW 666.58). DESIGN: Bovine serum albumin (BSA) (25 mg/mL) was incubated with 18, 36, and 72 mg/mL maltitol, lactobionate, nistose, and glucose at 37 degrees C. After 3 or 6 weeks, amounts of furosine and N-(carboxymethyl) lysine were measured. A 20-mL intraperitoneal injection of a lactate-based dialysate (osmotic pressure 388 mOsm/kg) containing 4.34% maltitol, 4.52% lactobionate, or 8.4% nistose was given to Sprague-Dawley rats and, after 2, 4, or 6 hours, the quantity of effluent and levels of urea nitrogen and creatinine in the effluent and in serum were measured. RESULTS: No increases in furosine or N-(carboxymethyl) lysine were seen with maltitol, lactobionate, or nistose after 3 and 6 weeks of incubation with BSA; AGE formation was not observed. In the study in rats, the quantity of abdominal fluid after a 6-hour dwell was nistose > lactobionate > maltitol > glucose. No differences in dialysate-to-plasma ratios for urea nitrogen or creatinine were seen in any group. CONCLUSIONS: AGE formation in peritoneal tissue might be controlled by using saccharides with a modified carbonyl group as osmotic agents for peritoneal dialysates. Nistose is considered to yield the most efficient dialysis.

Minimizing the drainage period for continuous ambulatory peritoneal dialysis.

OBJECTIVES: To examine features of drainage flow and to determine whether the drainage period could be safely reduced in continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Open nonrandomized prospective study in CAPD patients. SETTING: The kidney center in a tertiary care university hospital. PATIENTS: Fourteen CAPD patients with good catheter function. INTERVENTIONS: Drainage flow pattern was studied using a 2-L dialysate. The drainage period was reduced from 28 minutes (mean) to 10 minutes throughout a short-term, 2-month study period and a long-term, 6-month study period for 10 patients. MAIN OUTCOME MEASURES: Ultrafiltration volume, body weight, and peritoneal clearance. RESULTS: A kinetics analysis of the drainage period and volume indicated a positive linear correlation with two different slopes: one for rapid drainage for the first 5-7 minutes and one for subsequent slow drainage. The effluent exceeded 80% in the former period. Ultrafiltration volume and body weight showed no change due to the reduction. Improved peritoneal clearance of small molecular substances could not be confirmed despite a 5% increase in the effective dialysis period. Nearly all patients were satisfied with the reduction and desired its continuation. CONCLUSIONS: Ten minutes is a sufficient drainage period for most CAPD patients with a 2-L dialysate volume. This may possibly allow an increase in daily activities and an effective peritoneal membrane dialysate contact period.