Combined Ablation and Resection (CARe) as an Effective Parenchymal Sparing Treatment for Extensive Colorectal Liver Metastases

Abstract

BackgroundCombined intra-operative ablation and resection (CARe) is proposed to treat extensive colorectal liver metastases (CLM). This multicenter study was conducted to evaluate overall survival (OS), local recurrence-free survival (LRFS), hepatic recurrence-free survival (HRFS) and progression-free survival (PFS), to identify factors associated with survival, and to report complications.Materials and MethodsFour centers combined retropectively their clinical experiences regarding CLM treated by CARe. CLM characteristics, pre- and post-operative chemotherapy regimens, surgical procedures, complications and survivals were analyzed.ResultsOf the 288 patients who received CARe, 210 (73%) had synchronous and 255 (88%) had bilateral CLM. Twenty-two patients (8%) had extrahepatic disease. Median follow-up was 3.17 years (95%CI 2.83–4.08). Median OS was 3.33 years (95%CI 3.08–4.17) and 5-year OS was 37% (95%CI 29–45). One- and 5-year LRFS from ablated lesions were 87.9% (95%CI 83.3–91.2) and 78.0% (95%CI 71–83), respectively. Median HRFS and PFS were 14 months (95%CI 11–18) and 9 months (95%CI 8–11), respectively. One hundred patients experienced complications: 29 grade I, 68 grade II–III–IV, and three deaths. In the multivariate models adjusted for center, the occurrence of complications was confirmed as a major independent factor associated with 3-year OS (HR 1.80; P = 0.008). Five-year OS was 25.6% (95%CI 14.9–37.6) for patients with complications and 45% (95%CI 33.3–53.4) for patients without.ConclusionsRecent strategies facing advanced CLM include non-anatomic resections, portal-induced hypertrophy of the future remnant liver and aggressive medical preoperative treatments. CARe has the qualities of an approach that allows effective tumor clearance while maintaining good tolerance for the patient.

Laparoscopic parenchyma-sparing liver resection for colorectal metastases

“…In the study published in 2014, Evrard et al 50 combined PSLR with RFA in 288 patients, five-year overall survival was 37%, compared to 39% for the 18 patients that underwent resection combined with local ablation in our study. These outcomes demonstrate that multiple simultaneous LPSLRs are feasible and may be preferred over single major resection in a substantial portion of patients.…”

Colorectal cancer

“…The 5-year overall survival rate in this group is about 20% 209,210 , an impressive figure for metastatic disease. One clinical trial has used a perioperative FOLFOX protocol in this group of patients and showed an improvement in PFS, but no significant difference in overall survival compared with surgery alone 201 .…”

Prospective phase II trial of combination hepatic artery infusion and systemic chemotherapy for unresectable colorectal liver metastases: Long term results and curative potential

“…,51 However, the improved response among patients with KRAS WT tumors indicates a potential predictive biomarker role for KRAS when evaluating patients for combination HAI and SYS chemotherapy.Additional methods to increase conversion to resectability can be used in conjunction with HAI and SYS chemotherapy. We employed surgical techniques such as intraoperative ablation and two-stage liver resections to achieve complete resection in patients with complex, bilobar metastases [52][53][54][55][56]. PVE can also performed for patients who are deemed unresectable due to lack of sufficient volume in the future liver remnant; however, PVE does not address the issue of irresectability due to excessive tumor burden or unfavorable tumor location relative to major vessels or biliary structures 57.…”