Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite.

OBJECTIVES: In two-stage hepatectomy for bilateral liver metastases, patient dropout between stages is a major issue. We recently proposed a novel approach of fast-track two-staged hepatectomy (FT-TSH), in which patients undergo concurrent first-stage hepatectomy (FSH) with portal vein embolization (PVE) in a hybrid interventional radiology surgical suite. However, its efficacy remains unclear. METHODS: Patients with bilateral liver metastases scheduled for FT-TSH at MD Anderson Cancer Center between October 2017 and December 2020 were included on a prospective registry. The effectiveness and feasibility were evaluated. RESULTS: Nineteen patients were scheduled for FT-TSH. Primary site of tumor was colon/rectum in 18 patients and ovary in one patient. Median number of tumors was 10 and median size of largest tumor before surgery was 2.4 cm. Two (11%) patients did not undergo PVE and seventeen patients (89%) completed FSH + PVE. None of the patients had a major complication (Clavien-Dindo grade ≥ III) after FSH + PVE. Median kinetic growth rate after FSH + PVE was 2.9%/week (range 0.8-5.6). Twelve patients (71%) among the seventeen who underwent FSH + PVE proceeded to second-stage hepatectomy, and ten patients (59%) finally completed second-stage hepatectomy. Median interval between stages was 5.6 weeks (4.0-20.1). One patient (10%) had a major morbidity after SSH, and there was no 90-day mortality. CONCLUSIONS: FT-TSH is safe and allows for short intervals between hepatectomy stages while achieving favorable liver hypertrophy. Further investigation is needed to evaluate the true efficacy of FT-TSH.

Simultaneous Sigmoid Colectomy, Bilobar Liver Resection and Lung Metastasectomy via a Transdiaphragmatic Approach for Stage IV Colonic Adenocarcinoma.

BACKGROUND: Current evidence supports the curative resection of colorectal cancer and synchronous liver and lung metastases in selected patients.1,2 This video shows simultaneous left colectomy, bilobar liver resection, and lung metastasectomy via a transdiaphragmatic approach for stage IV colorectal cancer.3 PATIENT: A 57-year-old man with a stage IV colonic adenocarcinoma was considered for simultaneous resection of primary, liver, and lung metastases without thoracic incision. The tumor mutational status was KRAS, NRAS, and BRAF wild-type, and the patient underwent preoperative chemotherapy. TECHNIQUE: After performing a midline laparotomy, atypical liver resection of segments 8/4a was performed under the guidance of intraoperative ultrasonography and intermittent Pringle maneuver using the two-surgeon's technique. A small capsular lesion in segment 3 also was intraoperatively detected and resected. Lung metastasectomy of the right lower lobe was performed via a transdiaphragmatic approach using an endoscopic stapler. Sigmoid colectomy with transanal circular-stapled anastomosis was performed. Duration of surgery and blood loss were 358 min and 400 ml, respectively. Histopathological examination showed metastatic colonic adenocarcinoma with negative surgical margins and final stage was T3N2aM1b. The patient was discharged on postoperative day 6 without complication. He was alive and free of disease at 90-day follow-up. CONCLUSIONS: Simultaneous colon, liver, and lung resection via a transdiaphragmatic approach is a feasible and safe surgical strategy in selected patients with peripheral lung metastases and favorable tumor biology.4 This surgical strategy avoids thoracic incision, multiple operations, and may reduce the healthcare costs and the recovery time to early implement postoperative therapy.

Interactions of multiple gene alterations in colorectal liver metastases.

The advancements in next generation sequencing have expanded the information available in clinical practice. Alterations of TP53, APC, RAS, PIK3CA, and SMAD4 are present in more than 10% of patients with colorectal liver metastases (CLM). Of these genes, TP53, RAS and SMAD4 were associated with worse survival in patients undergoing CLM resection. Testing multiple gene alterations provides a more precise prognosis for patients undergoing CLM resection and may be useful for better clinical decision making.

Long-term outcomes in patients undergoing resection, ablation, and trans-arterial chemoembolization of hepatocellular carcinoma in the United States: a national cancer database analysis.

In the United States, hepatocellular carcinoma (HCC) incidence rates were approximately three times higher in over 30 years. To investigate the long-term outcomes of patients who underwent resection, ablation, and trans-arterial chemoembolization (TACE) of HCC, we analyzed the National Cancer Data Base (NCDB), which is a nationwide oncology outcomes database and covers approximately 70% of new cancer cases in the United States. A total of 56,512 patients with HCC in the NCDB during 2004-2013 were retrospectively analyzed. Results showed that liver resection (48.5%) and ablation (57.0%) were performed more frequently than TACE (31.5%) in patients with AJCC stage I HCC. The 5-year overall survival (OS) was significantly higher in patients undergoing resection (52.4%) than in patients undergoing ablation (40.5%; P < 0.001) and patients undergoing TACE (36.1%; P < 0.001). For patients with AJCC stage I, the 5-year OS of patients undergoing resection (51.6%; P < 0.001) and patients undergoing ablation (51.1%, P = 0.005) remains significantly better than patients undergoing TACE (40.0%). However, the 5-year OS did not differ significantly between patients undergoing resection and patients undergoing ablation (P = 0.486). Additionally, the findings of our study confirm that the sub-stratification of T1 category by HCC diameter in the AJCC staging eighth edition (i.e., T1a, HCC diameter ≤ 2 cm and T1b, HCC diameter > 2 cm) is valid, with a 5-year OS of 54.1% and 50.4%, respectively (P = 0.031).