Intra-patient Inter-metastatic Genetic Heterogeneity in Colorectal Cancer as a Key Determinant of Survival after Curative Liver Resection.

Chromosomal instability is a well-defined hallmark of tumor aggressiveness and metastatic progression in colorectal cancer. The magnitude of genetic heterogeneity among distinct liver metastases from the same patient at the copy number level, as well as its relationship with chemotherapy exposure and patient outcome, remains unknown. We performed high-resolution DNA copy number analyses of 134 liver metastatic deposits from 45 colorectal cancer patients to assess: (i) intra-patient inter-metastatic genetic heterogeneity using a heterogeneity score based on pair-wise genetic distances among tumor deposits; and (ii) genomic complexity, defined as the proportion of the genome harboring aberrant DNA copy numbers. Results were analyzed in relation to the patients' clinical course; previous chemotherapy exposure and outcome after surgical resection of liver metastases. We observed substantial variation in the level of intra-patient inter-metastatic heterogeneity. Heterogeneity was not associated with the number of metastatic lesions or their genomic complexity. In metachronous disease, heterogeneity was higher in patients previously exposed to chemotherapy. Importantly, intra-patient inter-metastatic heterogeneity was a strong prognostic determinant, stronger than known clinicopathological prognostic parameters. Patients with a low level of heterogeneity (below the median level) had a three-year progression-free and overall survival rate of 23% and 66% respectively, versus 5% and 18% for patients with a high level (hazard ratio0.4, 95% confidence interval 0.2-0.8, P = 0.01; and hazard ratio0.3,95% confidence interval 0.1-0.7, P = 0.007). A low patient-wise level of genomic complexity (below 25%) was also a favorable prognostic factor; however, the prognostic association of intra-patient heterogeneity was independent of genomic complexity in multivariable analyses. In conclusion, intra-patient inter-metastatic genetic heterogeneity is a pronounced feature of metastatic colorectal cancer, and the strong prognostic association reinforces its clinical relevance and places it as a key feature to be explored in future patient cohorts.

Single-session alcohol sclerotherapy of symptomatic liver cysts using 10-20 min of ethanol exposure: no recurrence at 2-16 years of follow-up.

PURPOSE: To assess long-term results after single-session alcohol sclerotherapy of symptomatic benign liver cysts performed with maximum 20 min of exposure to alcohol. METHODS: We included 47 patients aged 32-88 years (42 women, 5 men) with 51 benign non-parasitic liver cysts that were exposed to ethanol for 7-20 min in a single sclerotherapy session and were followed for at least 24 months. Each cyst was emptied before injecting ethanol (10% of cyst volume, but maximum 100 mL) into it. The patient rotated from side to side to facilitate contact between ethanol and the whole cyst wall. Pre-treatment cyst volume was defined as the volume of aspirated cyst fluid after complete emptying of the cyst. Follow-up cyst volume was estimated based on computed tomography images. RESULTS: Cyst volumes were 30-4900 (median 520) mL at pre-treatment and 0-230 (median 1) mL at 24-193 (median 56) months follow-up, a reduction of 83-100% (median 99.7%). No cyst required repeated treatment during the follow-up. Median volume reduction was 99.7% at median 49 months of follow-up for 35 cysts exposed to ethanol for 7-10 min vs. 99.6% at median 75 months of follow-up for 16 cysts exposed for 20 min (p = 0.83, Mann-Whitney test). Ethanol intoxication occurred in one patient. There were no other complications except for pain. CONCLUSION: Long-term results of single-session alcohol sclerotherapy performed with maximum 20 min of exposure to ethanol were satisfactory with no sign of recurrence of cyst fluid.

Impact of KRAS, BRAF, PIK3CA, TP53 status and intraindividual mutation heterogeneity on outcome after liver resection for colorectal cancer metastases.

We determined prognostic impact of KRAS, BRAF, PIK3CA and TP53 mutation status and mutation heterogeneity among 164 colorectal cancer (CRC) patients undergoing liver resections for metastatic disease. Mutation status was determined by Sanger sequencing of a total of 422 metastatic deposits. In univariate analysis, KRAS (33.5%), BRAF (6.1%) and PIK3CA (13.4%) mutations each predicted reduced median time to relapse (TTR) (7 vs. 22, 3 vs. 16 and 4 vs. 17 months; p < 0.001, 0.002 and 0.023, respectively). KRAS and BRAF mutations also predicted a reduced median disease-specific survival (DSS) (29 vs. 51 and 16 vs. 49 months; p <0.001 and 0.008, respectively). No effect of TP53 (60.4%) mutation status was observed. Postoperative, but not preoperative chemotherapy improved both TTR and DSS (p < 0.001 for both) with no interaction with gene mutation status. Among 94 patients harboring two or more metastatic deposits, 13 revealed mutation heterogeneity across metastatic deposits for at least one gene. Mutation heterogeneity predicted reduced median DSS compared to homogeneous mutations (18 vs. 37 months; p = 0.011 for all genes; 16 vs. 26 months; p < 0.001 analyzing BRAF or KRAS mutations separately). In multivariate analyses, KRAS or BRAF mutations consistently predicted poor TRR and DSS. Mutation heterogeneity robustly predicted DSS but not TTR, while postoperative chemotherapy improved both TTR and DSS. Our findings indicate that BRAF and KRAS mutations as well as mutation heterogeneity predict poor outcome in CRC patients subsequent to liver resections and might help guide treatment decisions.

Predictive factors for time to recurrence, treatment and post-recurrence survival in patients with initially resected colorectal liver metastases.

BACKGROUND: Despite progress in resection for colorectal liver metastases (CLM), the majority of patients experience recurrence. We aimed to evaluate factors influencing time to recurrence (TTR), treatment and post-recurrence survival (PRS) related to site of recurrence. METHODS: This is a retrospective population-based cohort study (1998-2012) of consecutive patients without extrahepatic disease treated with resection for CLM in a referral centre. RESULTS: A total of 311 patients underwent resection for CLM. After a median follow-up of 4.2 years (range 1.2-15.2), 209 (67.4 %) patients developed recurrence, hepatic 90, extrahepatic 59 and both 60. Median TTR was 14.0 months, and 5-year recurrence-free status was 25.7 %. Five- and 10-year overall survival (OS) was 38.8 and 22.0 %, respectively. Median OS was 45 months. A multivariate analysis displayed synchronous disease (hazard ratio (HR) 1.50), American Society of Anaesthesiologists (ASA) score (HR 1.40), increasing number (HR 1.24) and size of metastases (HR 1.08) to shorten TTR (all p < 0.05). Perioperative chemotherapy (n = 59) increased overall TTR (HR 0.63) and overall survival (OS; HR 0.55). Hepatic TTR was correlated to synchronous disease (HR 2.07), number of lesions (HR 1.20), R1 resection (HR 2.00) and ASA score (HR 1.69), whereas extrahepatic TTR was correlated to N stage of the primary (HR 1.79), number (HR 1.27) and size of metastases (HR 1.16). Single-site recurrence was most common (135 of 209, 64.5 %), while 58 patients had double- and 16 triple-site relapses. Median PRS was 24.3 months. There was a difference in median PRS (months) according to site of relapse: liver 30.5, lung 32.3, abdominal 22.0, liver and lung 14.3, others 14.8 (p = 0.002). Repeated liver resections were performed in n = 57 patients resulting in 40.6 months median OS and 36.8 % 5-year OS. CONCLUSIONS: An adverse overall TTR was correlated to number and size of metastases, ASA score and synchronous disease. Perioperative chemotherapy increased TTR and OS after surgery for CLM. Patients with solitary post-resection relapse in the liver or lungs had the potential for longevity due to multimodal treatment.

Performance comparison of three BRAF V600E detection methods in malignant melanoma and colorectal cancer specimens.

Personalized cancer care requires reliable biomarkers. While the BRAF V600E mutation is implemented in the clinic, no method for its detection has so far been established as reference. We aimed to perform a comprehensive comparison of three methods currently being used for V600E detection in clinical samples. We analysed genomic DNA from 127 malignant melanomas (77 patients) and 389 tumours from 141 colorectal cancer patients (383 liver metastases and 6 primary tumours) by Sanger sequencing and a single probe-based high-resolution melting assay (LightMix). Formalin-fixed paraffin-embedded (FFPE) tissue from a subset of these lesions (n = 77 and 304, respectively) was analysed by immunohistochemistry (IHC) using the V600E-specific antibody VE1. In a dilution series of V600E-mutated DNA in wild-type DNA, the detection limit for the LightMix assay was 1:1000 mutated alleles while it was 1:10 for Sanger sequencing. In line with this, we detected 15 additional mutated melanoma samples and two additional mutated metastatic colorectal cancer samples by the LightMix assay compared to Sanger sequencing. For the melanoma samples, we observed high concordance between DNA-based methods and analysis by IHC. However, in colorectal samples, IHC performed poorly with 12 samples being scored as V600E positive exclusively by IHC and nine samples being scored as V600E negative exclusively by IHC. In conclusion, the VE1 antibody is not recommendable for clinical tests of colorectal cancer samples. For melanoma samples, IHC may be useful as a screening tool guiding further analytical approaches.

Surgery for colorectal liver metastases: the impact of resection margins on recurrence and overall survival.

BACKGROUND: Several reports have presented conflicting results regarding the association between resection margins (RMs) and outcome after surgery for colorectal liver metastases (CLM), especially in the era of modern chemotherapy. The purpose of this study was to evaluate the impact of RMs on overall survival (OS), time to recurrence (TTR) and local recurrence (LR) status, particularly for patients treated with preoperative chemotherapy. METHODS: A combined retrospective (1998 to 2008) and prospective (2008 to 2010) cohort study of consecutive patients with CLM without extrahepatic disease treated with primary resection at a medium volume centre. RESULTS: A total of 253 patients with known R status and 242 patients with defined margin width were included in the study. Patients were stratified according to margin width; A: R1, <1 mm (n=48, 19%), B: 1 to 4 mm (n=77), C: 5 to 9 mm (n=46) and D: ≥10 mm (n=71). Median time to recurrence was 12.8 months, and after five years 21.5% had no recurrence. LR (inclusive combined recurrence in other hepatic sites or extrahepatic) occurred in 40 (16.5%) cases, most frequently seen with RMs below 5 mm. Five-year OS was 42.5% in R0 and 16.1% in R1 resections (P=0.011). Patients were also stratified according to preoperative chemotherapy (n=88), and the difference in five-year OS between R0 (45.1%) and R1 (14.7%) was maintained (P=0.037). By multiple Cox regression analysis R1 resections tended to an adverse outcome (P=0.067), also when adjusting for preoperative chemotherapy (P=0.081). CONCLUSIONS: R1 resections for colorectal liver metastases predict adverse outcome. RMs below 5 mm increased the risk for LR and shortened the time to recurrence. Preoperative chemotherapy did not alter an adverse outcome in R1 vs. R0 patients.

Survival and an overview of decision-making in patients with cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma is rare, accounting for approximately 3% of all gastrointestinal cancers. This study aimed to identify the survival rate among surgically treated and palliated patients, and secondly to identify parameters that could predict a curative resection. METHODS: A total of 121 patients, 55 men and 66 women, median age 70 years (range 31-91), who had been treated for cholangiocarcinoma in the period of 1990-2005 were evaluated retrospectively. RESULTS: Curative resection was performed in 40 patients (33%), whereas 81 received palliative treatment (67%). 16% (19 of 121) of the patients had an explorative laparotomy without tumour resection. Age above 65 years (OR 3.4; 95% CI 1.4-8.4; P=0.008), weight loss (OR 8.5; 95% CI 1.5-46; P=0.01) or tumour location (The resection rate of hilar cholangiocarcinoma was lower than that of intrapancreatic cancer.) (OR 2.7; 95% CI 1.7-4.5; P=0.001) predicted palliative treatment. The adjusted 5-year survival rate of patients who received tumour resection and palliative treatment was 30% and 1.2 %, respectively (P<0.001). The survival rate of patients who were subjected to hepatectomy (70%) was better than that of patients who had a local or distal resection (20%) (P=0.02). CONCLUSIONS: In few patients with a resectable cholangiocarcinoma, an explorative laparotomy is often necessary to evaluate resectability. However, long-term survival is significantly better in patients who received radical surgical resection.

Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial.

OBJECTIVE: The aim of this trial was to investigate whether a routine of allowing normal food at will increases morbidity after major upper gastrointestinal (GI) surgery. SUMMARY BACKGROUND DATA: Nil-by-mouth with enteral tube feeding is widely practiced for several days after major upper GI surgery. After other abdominal operations, normal food at will has been shown to be safe and to improve gut function. METHODS: Patients were randomly assigned to a routine of nil-by-mouth and enteral tube feeding by needle-catheter jejunostomy (ETF group) or normal food at will from the first day after major upper GI surgery. Primary end point was rate of major complications and death. Secondary outcomes were minor complications and adverse events, bowel function, and length of stay. All patients were invited to a follow-up at 8 weeks after discharge from the hospital. RESULTS: Four hundred fifty-three patients who underwent major open upper GI surgery in 5 centers were enrolled between 2001 and 2006. Four hundred forty-seven patients were correctly randomized. Of 227 patients 76 (33.5%) had major complications in the ETF group compared with 62 (28.2%) of 220 patients allowed normal food at will (P = 0.26, 95% CI for the difference in rate from -3.3 to 13.9). In the ETF group, 36 (15.9%) patients were reoperated compared with 29 (13.2%) in the group allowed normal food at will (P = 0.50) and 30-day mortality was 10 (4.4%) of 227 and 11 (5.0%) of 220 patients, respectively (P = 0.83). Time to resumed bowel function was significantly in favor of allowing normal food at will (P = 0.01), as were the total number of major complications, length of stay, and rate of postdischarge complications. CONCLUSIONS: Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding.

[Surgical treatment of liver metastases from colorectal cancer]. / Kirurgisk behandling av levermetastaser fra kolorektal kreft.

BACKGROUND: The liver is the most common location for metastases from colorectal cancer. Current treatment options (i.e. neo-adjuvant chemotherapy, pre-operative portal vein embolization), IMPROVED OPERATIVE TECHNIQUES: and combinations of modalities and have rendered more patients eligible for liver surgery. MATERIAL AND METHODS: Literature from 1996 to July 2007 was retrieved from Pubmed using the search terms "liver metastases", "liver resection", "colorectal cancer", "randomized controlled trial", "systematic review" and "meta-analysis". RESULTS: No randomized controlled trials were identified that compared liver resection with non-surgical treatment of these patients. Except for a few systematic review articles, the scientific basis for resection of liver metastases from colorectal cancer consists mainly of retrospective studies from single institutions. Median survival for patients with colorectal liver metastases is about 20 months; a five-year survival of 30-50% is reported in resected patients. Patients with non-resectable disease rarely survive for five years. 30-40% of the resected patients have post-operative complications (mostly minor) and postoperative mortality is 3-5%. INTERPRETATION: Surgical treatment of liver metastases is established practice. Patients with colorectal liver metastases should be referred to a multidisciplinary team for appropriate evaluation. Neoadjuvant treatment and multimodal approaches may increase the proportion of patients with resectable liver metastases, and better preoperative imaging may help to more carefully select patients who can benefit from this treatment.

[Treatment of patients with gastrointestinal stromal tumour with imatinib mesylate]. / Behandling med imatinibmesylat av pasienter med gastrointestinal stromal tumor.

BACKGROUND: Gastrointestinal stromal tumour (GIST) is the most frequent mesenchymal tumour type of the digestive tract. Between 30 and 40% of patients have high-risk, malignant GIST with poor prognosis after surgery. Imatinib mesylate is a recently introduced KIT tyrosine kinase inhibitor with effect on metastatic GIST. We report our experience with imatinib mesylate in the treatment of GIST. MATERIAL AND METHODS: Nine patients diagnosed with GIST have received imatinib mesylate since August 2001. Eight patients had metastatic disease, one patient received adjuvant treatment. The patients were evaluated according to standard protocols for clinical performance, effect of treatment, and adverse effects. Tumour tissue was analysed for mutational status in KIT and PDGFRA. RESULTS: All patients with metastatic disease had palliative benefit; three had partial response and the remaining stable disease. The single patient receiving adjuvant treatment had no sign of recurrence. Side effects were mainly mild diarrhoea, nausea and vomiting. Seven patients had mutations in KIT exon 11, one in KIT exon 9, and one in PDGFRA exon 12. INTERPRETATION: The results demonstrate that imatinib mesylate is an effective drug that can stabilise and reduce disease in patients with advanced GIST.

Single-session alcohol sclerotherapy in symptomatic benign hepatic cysts performed with a time of exposure to alcohol of 10 min: initial results.

The aim of this study was to evaluate the 1-year results of single-session sclerotherapy of symptomatic benign non-parasitic liver cysts performed with maximum 10 min time of ethanol exposure. During the period 1995-1999, 15 symptomatic liver cysts in nine patients--eight women and one man--were treated with 10 min time of exposure to ethanol. Ultrasound-guided puncture combined with fluoroscopy was used for catheter placement. Alcohol sclerotherapy was performed with a maximum volume of ethanol 96% of 10% of the cyst volume, never exceeding 100 ml. At follow-up the patients were examined with liver function tests, ultrasound or CT examination, clinical examination, and interview by a gastrointestinal surgeon. Ten cysts in seven patients (six women and one man; age range 44-61 years, median age 58 years), who had a follow-up of at least 1 year, were included. The original cyst volumes were 30-4110 ml (median 392 ml). After a follow-up period of 12-47 months (median 23 months), cyst volumes were 0-523 ml (median 21.5 ml) with a reduction of the median cyst volume by 95% ( p<0,005). All patients experienced relief of their clinical symptoms. Except for pain, no complications were observed. Sclerotherapy using only one session and maximum 10 min time of exposure to ethanol represents an effective treatment of symptomatic liver cysts.