Two decades of experience with hepatic cryotherapy for advanced colorectal metastases.

INTRODUCTION: Only 15% of patients with colorectal liver metastases (CLM) are candidates for curative hepatectomy at time of diagnosis, limited by anatomical location and tumor burden. Ablative therapies may extend this. This study reports a single institution's long-term experience with hepatic cryotherapy for advanced CLM. METHODS: Between April 1990 and June 2009, 304 patients were curatively treated with cryotherapy. Survival was estimated by Kaplan-Meier method. Prognostic factors for survivals were determined by using univariate and multivariate analyses. RESULTS: A total of 293 patients were included into analysis. The median number of lesions treated per patient was three (range, 1-13). The median overall survival was 29 (range, 3-220) months. The 1-, 3-, 5-, and 10-year survivals were 87%, 41.8%, 24.2%, and 13.3%, respectively. A total of 161 patients developed intrahepatic recurrences: cryosite (23%); edge recurrence (14%); and within the liver remnant (78%). The median disease-free survival (DFS) was 9 (range, 1-220) months. The 1-, 3-, 5-, and 10-year DFS rates were 37.9%, 17.2%, 13.4%, and 10.8%, respectively. Univariate analysis identified four factors that significantly affect survival: node-positive primary tumor (p=0.001), preoperative CEA level (p<0.001), number of lesions (p<0.001), and use of neoadjuvant chemotherapy (p<0.001). However, only primary tumor nodal status was independently prognostic (hazards ratio=2.023; 95% confidence interval, 1.444-2.835; p<0.001). CONCLUSIONS: Hepatic cryotherapy seems to be a safe and effective ablative technique for the treatment of colorectal liver metastases and may offer long-term survival in otherwise unresectable disease.

Prognostic determinants for survival after resection/ablation of a large hepatocellular carcinoma.

BACKGROUND: Liver resection of large hepatocellular carcinomas (HCC), measuring at least 10 cm remains a controversial debate. Multiple studies on HCCs treated with surgical resection and/or ablation had shown variable results with 5-year survival rates ranging from 0% to 54.0%. The aim of this study was to evaluate the survival of patients with HCCs measuring at least 10 cm and to identify the potential prognostic variables affecting the outcome. METHODS: Retrospective analysis was performed on the prospectively updated HCC database. A total of 44 patients with tumours measuring 10 cm or more were 'curatively' treated with surgical resection with or without ablation. Patient demographics, clinical, surgical, pathology and survival data were collected and analysed. RESULTS: Thirty-one patients received surgical resection alone. Thirteen other patients were treated with a combination of surgical resection and ablation. The median follow-up duration was 14.5 months. The overall median survival at 1, 3 and 5 years were 66.4%, 38.1% and 27.8%, respectively. The median time to tumour recurrence was 10.7 months and the 1, 3 and 5-year disease-free survival were 49.6%, 23.9% and 19.1%, respectively. Univariate analysis demonstrated cirrhosis, microvascular invasion, poor tumour differentiation and ethnicity to adversely affect survival. For overall survival, only cirrhosis, poor tumour differentiation and ethnicity were significant on multivariate analysis. Portal vein tumour thrombus, microvascular invasion and ethnicity were identified on univariate analysis to significantly affect disease-free survival. CONCLUSION: Surgical treatment offers good survival to patients with large HCCs (> or = 10 cm). Both cirrhosis and poor tumour differentiation are independent variables prognostic of adverse survival.

Significance of lymph node metastasis in patients with colorectal cancer peritoneal carcinomatosis.

BACKGROUND: Lymph node metastasis is common in patients with colorectal cancer. Its significance in patients at the time of primary colorectal surgery and later in patients who develop colorectal cancer peritoneal carcinomatosis (CRPC) is unknown. Lymphatic metastasis reflects a systemic spread of cancer and its implication on patients who undergo cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) for carcinomatosis needs to be studied. METHODS: Patients with CRPC underwent CRS and PIC according to a standardized treatment protocol in our institution. Pathology reports from the primary colorectal surgery and at the time of treatment for CRPC was retrospectively retrieved and appraised. Comparison of survival outcomes using the log-rank test was performed for patients with and without lymphatic metastasis. RESULTS: Sixty patients were treated for CRPC with CRS and PIC. At the time of colorectal surgery, patients with lymph node involvement had similar survival outcomes compared with patients without lymph node involvement (median survival: 31 months, 36 months; p = 0.9). However, when they subsequently develop peritoneal carcinomatosis and underwent treatment with CRS and PIC, patients with lymph node involvement did significantly worse (median survival: 20 months, 38 months; p = 0.003). CONCLUSIONS: The results of our study suggest that lymph node metastasis in patients with CRPC is an indicator of a poor prognosis and requires further investigation and recognition.

Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution.

BACKGROUND: Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has been recognized as a treatment option for pseudomyxoma peritonei. This study reports the survival outcomes, clinicopathological prognostic factors, and a learning curve from a single institution's experience. METHODS: Patients with pseudomyxoma peritonei underwent CRS and PIC, which was comprised of hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC), according to a standardized treatment protocol in our institution. Clinicopathological factors were analyzed to determine their prognostic value for survival using univariate and multivariate analysis. Time period comparison was performed to study the effect of a learning curve. RESULTS: A total of 106 patients (43 men and 63 women) were treated. The mortality rate was 3% and severe morbidity rate was 49%. The median follow-up was 23 (range, 0-140) months. The overall median survival was 104 months with a 5-year survival rate of 75%. The progression-free survival was 40 months with a 1-year progression-free survival rate of 71%. Factors influencing survival include histopathological type of tumor, use of both HIPEC and EPIC, peritoneal cancer index, completeness of cytoreduction, and severe morbidity. The results demonstrate a learning curve where patients with a higher peritoneal cancer index (PCI) were treated, reduced amount of blood products required, more patients undergoing HIPEC and the combined HIPEC and EPIC, more redo-procedures performed, and a longer progression-free survival. CONCLUSIONS: This report demonstrates long-term survival outcomes, acceptable perioperative outcomes, and a learning curve associated with the treatment of patients with pseudomyxoma peritonei.