Percutaneous cryosurgery for the treatment of hepatic colorectal metastases

AIM:To determine the safety and efficacy of efficacy of percutaneous cryosurgery for treatment of patients with hepatic colorectal metastases. METHODS: Three hundred and twenty-six patients with non-resectable hepatic colorectal metastases underwent percutaneous cryosurgery under the guidance of ultrasound or CT. Follow-up was 1 mo after cryosurgery and then every 4 mo thereafter by assessment of tumor markers, liver ultrasonography, and abdominal CT. For lesions suspicious of recurrence, a liver biopsy was performed and subsequent repeat cryosurgery was given if histology was positive for cancer. RESULTS: All patients underwent a total of 526 procedures of cryosurgery. There were 151 patients who underwent repeat procedures of cryosurgery for recurrent tumors in the liver and extrahepatic places. At 3 mo after cryosurgery, carcinoembryonic antigen (CEA) levels in 197 (77.5%) patients who had elevated markers before cryosurgery decreased to normal range. Among 280 patients who received CT following-up, cryotreated lesions showed complete response (CR) in 41 patients (14.6%), partial response (PR) in 115 patients (41.1%), stable disease (SD) in 68 patients (24.3%) and progressive disease (PD) in 56 patients (20%). The recurrence rate was 47.2% during a median follow-up of 32 mo (range, 7-61). Sixty one percent of the recurrences were seen in liver only and 13.9% in liver and extrahepatic areas. The recurrence rate at cryotreated site was only 6.4% for all cases. During a median follow-up of 36 mo (7-62 mo), the median survival of all patient was 29 mo (range 3-62 mo). Overall survival was 78%, 62%, 41%, 34% and 23% at 1, 2, 3, 4 and 5 years, respectively, after the treatment. Patients with tumor size less than 3 cm, tumor in right lobe of liver, lower CEA levels (< 100 ng/dL) and post- cryosurgery TACE had higher survival rate. There wasno significant difference in terms of survival based on the number of tumors, pre-cryosurgery chemotherapy and the timing of the development of metastases (synchronous vs metachronous). Patients who underwent 2-3 procedures of cryosurgery had increased survival compared to patients who received cryosurgery once only. There was no intra-cryosurgery mortality. Main adverse effects, such as hepatic bleeding, cryoshock, biliary fistula, liver failure, renal insufficiency and liver abscess were only observed in 0.3%-1.5% of patients. CONCLUSION:Percutaneous cryosurgery was a safe modality for hepatic colorectal metastases. Rather than an alternative to resection, this technique should be regarded as a complement to hepatectomy and as an additional means of achieving tumor eradication when total excision is not possible.

Tumour response following preoperative chemotherapy is affected by body mass index in patients with colorectal liver metastases

BACKGROUND Colorectal cancer is the third most prevalent malignancy globally and ranks second in cancer-related mortality,with the liver being the primary organ of metastasis.Preoperative chemotherapy is widely recommended for initially or potentially resectable colorectal liver metastases(CRLMs).Tumour pathological response serves as the most important and intuitive indicator for assessing the efficacy of chemotherapy.However,the postoperative pathological results reveal that a considerable number of patients exhibit a poor response to preoperative chemotherapy.Body mass index(BMI)is one of the factors affecting the tumori-genesis and progression of colorectal cancer as well as prognosis after various antitumour therapies.Several studies have indicated that overweight and obese patients with metastatic colorectal cancer experience worse prognoses than those with normal weight,particularly when receiving first-line chemotherapy regimens in combination with bevacizumab.AIM To explore the predictive value of BMI regarding the pathologic response following preoperative chemotherapy for CRLMs.METHODS A retrospective analysis was performed in 126 consecutive patients with CRLM who underwent hepatectomy following preoperative chemotherapy at four different hospitals from October 2019 to July 2023.Univariate and multivariate logistic regression models were applied to analyse potential predictors of tumour pathological response.The Kaplan-Meier method with log rank test was used to compare progression-free survival(PFS)between patients with high and low BMI.BMI<24.0 kg/m^(2) was defined as low BMI,and tumour regression grade 1-2 was defined as complete tumour response.RESULTS Low BMI was observed in 74(58.7%)patients and complete tumour response was found in 27(21.4%)patients.The rate of complete tumour response was significantly higher in patients with low BMI(29.7%vs 9.6%,P=0.007).Multivariate analysis revealed that low BMI[odds ratio(OR)=4.56,95%confidence interval(CI):1.42-14.63,P=0.011],targeted therapy with bevacizumab(OR=3.02,95%CI:1.10-8.33,P=0.033),preoperative carcinoembryonic antigen level<10 ng/mL(OR=3.84,95%CI:1.19-12.44,P=0.025)and severe sinusoidal dilatation(OR=0.17,95%CI:0.03-0.90,P=0.037)were independent predictive factors for complete tumour response.The low BMI group exhibited a significantly longer median PFS than the high BMI group(10.7 mo vs 4.7 mo,P=0.011).CONCLUSION In CRLM patients receiving preoperative chemotherapy,a low BMI may be associated with better tumour response and longer PFS.

Multidisciplinary discussion and management of synchronous colorectal liver metastases: A single center study in China

BACKGROUND The multidisciplinary team(MDT)has been carried out in many large hospitals now.However,given the costs of time and money and with little strong evidence of MDT effectiveness being reported,critiques of MDTs persist.AIM To evaluate the effects of MDTs on patients with synchronous colorectal liver metastases and share our opinion on management of synchronous colorectal liver metastases.METHODS In this study we collected clinical data of patients with synchronous colorectal liver metastases from February 2014 to February 2017 in the Chinese People’s Liberation Army General Hospital and subsequently divided them into an MDT+group and an MDT-group.In total,93 patients in MDT+group and 169 patients in MDT-group were included totally.RESULTS Statistical increases in the rate of chest computed tomography examination(P=0.001),abdomen magnetic resonance imaging examination(P=0.000),and preoperative image staging(P=0.0000)were observed in patients in MDT+group.Additionally,the proportion of patients receiving chemotherapy(P=0.019)and curative resection(P=0.042)was also higher in MDT+group.Multivariable analysis showed that the population of patients assessed by MDT meetings had higher 1-year[hazard ratio(HR)=0.608,95%confidence interval(CI):0.398-0.931,P=0.022]and 5-year(HR=0.694,95%CI:0.515-0.937,P=0.017)overall survival.CONCLUSION These results proved that MDT management did bring patients with synchronous colorectal liver metastases more opportunities for comprehensive examination and treatment,resulting in better outcomes.

Liver transplantation as an alternative for the treatment of non-resectable liver colorectal cancer: Advancing the therapeutic algorithm

Colorectal cancer is a leading cause of cancerrelated mortality,with nearly half of the affected patients developing liver metastases.For three decades,liver resection(LR)has been the primary curative strategy,yet its applicability is limited to about 20%of cases.Liver transplantation(LT)for unresectable metastases was attempted unsuccessfully in the 1990s,with high rates of perioperative death and recurrence.There is now more interest in this strategy due to improvements in systemic therapies and surgical techniques.A significant study conducted by the Oslo group showed that patients receiving liver transplants had a 60%chance of survival after five years.Significantly better results have been achieved by using advanced imaging for risk stratification and further refining selection criteria,especially in the Norvegian SECA trials.This review carefully charts the development and history of LT as a treatment option for colorectal cancer liver metastases.The revolutionary path from the early days of exploratory surgery to the current situation of cautious optimism is traced,highlighting the critical clinical developments and improved patient selection standards that have made LT a potentially curative treatment for such challenging very well selected cases.

Role of advanced imaging techniques in the evaluation of oncological therapies in patients with colorectal liver metastases

In patients with colorectal liver metastasis(CRLMs)unsuitable for surgery,oncological treatments,such as chemotherapy and targeted agents,can be performed.Cross-sectional imaging[computed tomography(CT),magnetic resonance imaging(MRI),18-fluorodexoyglucose positron emission tomography with CT/MRI]evaluates the response of CRLMs to therapy,using post-treatment lesion shrinkage as a qualitative imaging parameter.This point is critical because the risk of toxicity induced by oncological treatments is not always balanced by an effective response to them.Consequently,there is a pressing need to define biomarkers that can predict treatment responses and estimate the likelihood of drug resistance in individual patients.Advanced quantitative imaging(diffusionweighted imaging,perfusion imaging,molecular imaging)allows the in vivo evaluation of specific biological tissue features described as quantitative parameters.Furthermore,radiomics can represent large amounts of numerical and statistical information buried inside cross-sectional images as quantitative parameters.As a result,parametric analysis(PA)translates the numerical data contained in the voxels of each image into quantitative parameters representative of peculiar neoplastic features such as perfusion,structural heterogeneity,cellularity,oxygenation,and glucose consumption.PA could be a potentially useful imaging marker for predicting CRLMs treatment response.This review describes the role of PA applied to cross-sectional imaging in predicting the response to oncological therapies in patients with CRLMs.

Pyroptosis:A promising biomarker for predicting colorectal cancer prognosis and enhancing immunotherapy efficacy

In this editorial,we comment on the article by Zhu et al published in the recent issue of the World Journal of Clinical Oncology.We focus specifically on the characteristics and mechanisms of pyroptosis and the impact of changes in the tumor immune microenvironment(TIME)on cancer prognosis.Pyroptosis is a distinct form of programmed cell death;its occurrence can change the TIME and regulate the growth and spread of tumors and therefore is significantly correlated with cancer prognosis.Previous research has demonstrated that pyroptosis-related genes can be used in prognostic models for various types of cancer.These models enhance the mechanistic understanding of tumor evolution and serve as valuable guides for clinical treatment decision-making.Nevertheless,further studies are required to thoroughly understand the function of pyroptosis within the TIME and to assess its mode of action.Such studies should reveal new tumor therapeutic targets and more successful tumor immunotherapy strategies.

Chemokine expression in hepatocellular carcinoma versus colorectal liver metastases

AIM： To evaluate and compare the expression profiles of CXCL12 （SDF-1）, CCL19 （MIP-3β）, CCL20 （MIP-3a） and CCL21 （6Ckine, Exodus2） and their receptors on RNA and protein levels in hepatocellular carcinoma （HCC） versus colorectal liver metastases （CRLM） and to elucidate their impact on the carcinogenesis and progression of malignant liver diseases. METHODS： Chemokine expression was analyzed by RT-PCR and ELISA in 11 cases of HCC specimens and in 23 cases of CRLM and corresponding adjacent nontumorous liver tissues, respectively. Expressions of their receptors CXCR4, CCR6 and CCR7 were analyzed by RT- PCR and Western blot analysis in the same cases of HCC and CRLM. RESULTS： Significant up-regulation for CCL20/CCR6 was detected in both cancer types. Moreover, CCL20 demonstrated significant overexpression in CRLM in relation to the HCC tissues. Being significantly up-regulated only in CRLM, CXCR4 displayed an aberrant expression pattern with respect to the HCC tissues. CONCLUSION： Correlation of CXCR4 expression with CRLM suggests CXCR4 as a potential predictive factor for CRLM. High level expression of CCL20 and its receptor CCR6 in HCC and CRLM with marked up-regulation of CCL20 in CRLM in relation to HCC tissues indicates involvement of the CCL20/CCR6 ligand-receptor pair in the carcinogenesis and progression of hepatic malignancies.

Colorectal cancer with liver metastases:Neoadjuvant chemotherapy,surgical resection first or palliation alone?

Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for &#x0003e; 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.

Role of associating liver partition and portal vein ligation for staged hepatectomy in colorectal liver metastases:A review

Colorectal cancer is the third most common cancer in the Western world. Approximately half of patients will develop liver metastases, which is the most common cause of death. The only potentially curative treatment is surgical resection. However, many patients retain a to small future liver remnant(FLR) to allow for resection directly. There are therefore strategies todecrease the tumor with neoadjuvant chemotherapy and to increase the FLR. An accepted strategy to increase the FLR is portal vein occlusion(PVO). A concern with this strategy is that a large proportion of patients will never be operated because of progression during the interval between PVO and resection. ALPPS(associating liver partition and portal vein ligation for staged hepatectomy) is a new procedure with a high resection rate. A concern with this approach is the rather high frequency of complications and high mortality, compared to PVO. In this review, it is shown that with ALPPS the resection rate was 97.1% for CRLM and the mortality rate for all diagnoses was 9.6%. The mortality rate was likely lower for patients with CRLM, but some data were lacking in the reports. Due to the novelty of ALPPS, the indications and technique are not yet established but there are arguments for ALPPS in the context of CRLM and a small FLR.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver,with five-year survival rates up to 58% in selected cases.However,only a minority are resectable at the time of diagnosis.Continuous research in this field aims at increasing the percentage of patients eligible for resection,refining the indications and contraindications for surgery,and improving overall survival.The use of surgical innovations,such as staged resection,portal vein embolization,and repeat resection has allowed higher resection rates in patients with bilobar disease.The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection.Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates.Current management of colorectal liver metastases requires a multidisciplinary approach,which should be individualized in each case.

Contrast-enhanced intraoperative ultrasonography equipped with late Kupffer-phase image obtained by sonazoid in patients with colorectal liver metastases

AIM: To find occult metastases during hepatectomy in patients with colorectal cancer liver metastases (CRCLM), contrast-enhanced intraoperative ultrasonography (CE-IOUS) was performed using a new microbubble agent, sonazoid, which provides a parenchyma-specific contrast image based on its accumulation in the Kupffer cells. METHODS: Eight patients with CRCLM underwent CE- IOUS using sonazoid before hepatectomy. The liver was investigated during a late Kupffer-phase imaging, which is a valuable characteristic of sonazoid. RESULTS: CE-IOUS using sonazoid provided the early vascular- and sinusoidal-phase images for 10 min followed by the late Kupffer-phase image up to 30 min after the injection of sonazoid. IOUS did not provide new findings of metastatic lesion in the 8 patients. However, during the late Kupffer-phase image of sonazoid, a metastatic lesion was newly found in two of the 8 patients. These newly detected lesions were removed by an additional hepatectomy and histopathologically diagnosed as a metastasis. CONCLUSION: CE-IOUS using sonazoid can allow surgeons to investigate the whole liver with enough time and to find new metastases intraoperatively.

Surgical approaches of resectable synchronous colorectal liver metastases:Timing considerations

AIM: To compare the safety and efficacy of simultaneous versus two stage resection of primary colorectal tumors and liver metastases. METHODS: From January 1996 to May 2004, 103 colorectal tumor patients presented with synchronous liver metastases. Twenty five underwent simultaneous colorectal and liver surgery and 78 underwent liver surgery 1-3 mo after primary colorectal tumor resection. Data were retrospectively analyzed to assess and compare the morbidity and mortality between the surgical strategies. The two groups were comparable regarding the age and sex distribution, the types of liver resection and stage of primary tumors, as well as the number and size of liver metastases. RESULTS: In two-stage procedures more transfusions were required (4 ± 1.5 vs 2 ± 1.8, pRBCs, P < 0.05). Chest infection was increased after the two-stage approach (26% vs 17%, P < 0.05). The two-stage procedure was also associated with longer hospitalization (20 ± 8 vs 12 ± 6 d, P < 0.05). Five year survival in both groups was similar (28% vs 31%). No hospital mortality occurred in our series. CONCLUSION: Synchronous colorectal liver metastases can be safely treated simultaneously with the primary tumor. Liver resection should be prioritized over colon resection. It is advisable that complex liver resections with marginal liver residual volume should be dealt with at a later stage.

Effect of preoperative FOLFOX chemotherapy on CCL20/CCR6 expression in colorectal liver metastases

AIM： To evaluate the influence of preoperative FOLFOX chemotherapy on CCL20/CCR6 expression in liver metastases of stage IV colorectal cancer （CRC） patients.（/7 = 53） and in patients who did not receive FOLFOX chemotherapy prior to liver surgery （n = 29）. RESULTS： Of the 53 patients who received FOLFOX, time to liver surgery was n〈 1 mo in 14 patients, 〈 1 year in 22 patients and 〉 1 year in 17 patients, respectively. In addition, we investigated the proliferation rate of CRC cells in liver metastases in the different patient groups. Both CCL20 and CCR6 mRNA and protein ex- pression levels were significantly increased in patients who received preoperative FOLFOX chemotherapy ~〈 12 mo before liver surgery （P 〈 0.001） in comparison to patients who did not undergo FOLFOX treatment. Further, proliferation of CRLM cells as measured by Ki-67 was increased in patients who underwent FOLFOX treat- ment. CCL20 and CCR6 expression levels were significantly increased in CRLM patients who had undergone preoperative FOLFOX chemotherapy. CONCLUSION： This chemokine/receptor up-regulation could lead to increased proliferation/migration through an autocrine mechanism which might be used by surviving metastatic cells to escape cell death caused by FOLFOX.

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases:Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate.Staged approach,with initial colorectal resection followed by liver resection(LR),or even the reverse,liver-first approach in specific situations,is traditionally preferred.Simultaneous resections,however,represent an appealing strategy,because may have perioperative risks comparable to staged resections in appropriately selected patients,while avoiding a second surgical procedure.In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases,simultaneous major hepatectomies may determine worse perioperative outcomes,so that parenchymal-sparing LR should represent the most appropriate option whenever feasible.Mini-invasive colorectal surgery has experienced rapid spread in the last decades,while laparoscopic LR has progressed much slower,and is usually reserved for limited tumours in favourable locations.Moreover,mini-invasive parenchymal-sparing LR is more complex,especially for larger or multiple tumours in difficult locations.It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise,at least for more complex procedures.This review aims to critically analyze the current status and future perspectives of simultaneous resections,and the present role of the available miniinvasive techniques.

Neoadjuvant chemotherapy for colorectal liver metastases:A contemporary review of the literature

Colorectal carcinoma(CRC)is one of the leading causes of cancer-related deaths worldwide,and up to 50%of patients with CRC develop colorectal liver metastases(CRLM).For these patients,surgical resection remains the only opportunity for cure and long-term survival.Over the past few decades,outcomes of patients with metastatic CRC have improved significantly due to advances in systemic therapy,as well as improvements in operative technique and perioperative care.Chemotherapy in the modern era of oxaliplatin-and irinotecancontaining regimens has been augmented by the introduction of targeted biologics and immunotherapeutic agents.The increasing efficacy of contemporary systemic therapies has led to an expansion in the proportion of patients eligible for curative-intent surgery.Consequently,the use of neoadjuvant strategies is becoming progressively more established.For patients with CRLM,the primary advantage of neoadjuvant chemotherapy(NCT)is the potential to down-stage metastatic disease in order to facilitate hepatic resection.On the other hand,the routine use of NCT for patients with resectable metastases remains controversial,especially given the potential risk of inducing chemotherapy-associated liver injury prior to hepatectomy.Current guidelines recommend upfront surgery in patients with initially resectable disease and low operative risk,reserving NCT for patients with borderline resectable or unresectable disease and high operative risk.Patients undergoing NCT require close monitoring for tumor response and conversion of CRLM to resectability.In light of the growing number of treatment options available to patients with metastatic CRC,it is generally agreed that these patients are best served at tertiary centers with an expert multidisciplinary team.

Neoadjuvant chemotherapy for patients with resectable colorectal cancer liver metastases: A systematic review and meta-analysis

BACKGROUND In recent years,neoadjuvant chemotherapy(NAC)has been increasingly used in patients with resectable colorectal liver metastases.However,the efficacy and safety of NAC in the treatment of resectable colorectal liver metastases(CRLM)are still controversial.AIM To assess the efficacy and application value of NAC in patients with resectable CRLM.METHODS We searched PubMed,Embase,Web of Science,and the Cochrane Library from inception to December 2020 to collect clinical studies comparing NAC with non-NAC.Data processing and statistical analyses were performed using Stata V.15.0 and Review Manager 5.0 software.RESULTS In total,32 studies involving 11236 patients were included in this analysis.We divided the patients into two groups,the NAC group(that received neoadjuvant chemotherapy)and the non-NAC group(that received no neoadjuvant chemotherapy).The meta-analysis outcome showed a statistically significant difference in the 5-year overall survival and 5-year disease-free survival between the two groups.The hazard ratio(HR)and 95%confidence interval(CI)were HR=0.49,95%CI:0.39-0.61,P=0.000 and HR=0.4895%CI:0.36-0.63,P=0.000.The duration of surgery in the NAC group was longer than that of the non-NAC group[standardized mean difference(SMD)=0.41,95%CI:0.01-0.82,P=0.044)].The meta-analysis showed that the number of liver metastases in the NAC group was significantly higher than that in the non-NAC group(SMD=0.73,95%CI:0.02-1.43,P=0.043).The lymph node metastasis in the NAC group was significantly higher than that in the non-NAC group(SMD=1.24,95%CI:1.07-1.43,P=0.004).CONCLUSION We found that NAC could improve the long-term prognosis of patients with resectable CRLM.At the same time,the NAC group did not increase the risk of any adverse event compared to the non-NAC group.

Computer planned, image-guided combined resection and ablation for bilobar colorectal liver metastases

For patients with extensive bilobar colorectal liver metastases (CRLM), initial surgery may not be feasible and a multimodal approach including microwave ablation (MWA) provides the only chance for prolonged survival. Intraoperative navigation systems may improve the accuracy of ablation and surgical resection of so-called &#x0201c;vanishing lesions&#x0201d;, ultimately improving patient outcome. Clinical application of intraoperative navigated liver surgery is illustrated in a patient undergoing combined resection/MWA for multiple, synchronous, bilobar CRLM. Regular follow-up with computed tomography (CT) allowed for temporal development of the ablation zones. Of the ten lesions detected in a preoperative CT scan, the largest lesion was resected and the others were ablated using an intraoperative navigation system. Twelve months post-surgery a new lesion (Seg IVa) was detected and treated by trans-arterial embolization. Nineteen months post-surgery new liver and lung metastases were detected and a palliative chemotherapy started. The patient passed away four years after initial diagnosis. For patients with extensive CRLM not treatable by standard surgery, navigated MWA/resection may provide excellent tumor control, improving longer-term survival. Intraoperative navigation systems provide precise, real-time information to the surgeon, aiding the decision-making process and substantially improving the accuracy of both ablation and resection. Regular follow-ups including 3D modeling allow for early discrimination between ablation zones and recurrent tumor lesions.

Portal thrombosis and steatosis after preoperative chemotherapy with FOLFIRI-bevacizumab for colorectal liver metastases

In order to discuss the role of preoperative chemo- therapy for colorectal liver metastases, which is used frequently before hepatic resection, even in patients with resectable disease at presentation, we herein report the development of two complications, partial portal vein thrombosis and hepatic steatosis with Iobular inflammation, during the course of preoperative chemotherapy with FOLFIRI plus bevacizumab for colorectal liver metastases, which recognition led to timely discontinuation of chemotherapy as well as a change in the surgical strategy to resect the tumors and the damaged liver through advanced techniques. We conclude that duration of treatment and drug doses and combinations may impact the development of chemotherapy-induced liver injury. Surgeons and medical oncologists must work together to devise safe, rational, and oncologically appropriate treatments for patients with multiple colorectal liver metastases, and to improve the understanding of the pathogenesis of chemotherapyinduced liver injury.

Surgical dilemmas in the management of colorectal liver metastases: the role of timing

Colorectal cancer(CRC) is an emerging health problem in the Western World both for its raising tendency as well as for its metastatic potential. Almost half of the patients with CRC will develop liver metastases during the course of their disease. The liver surgeon dealing with colorectal liver metastases faces several surgical dilemmas especially in the setting of the timing of operation. Synchronous resectable metastases should be treated prior or after induction chemotherapy? Furthermore in the case of synchronous colorectal liver metastases which organ should we first deal with, the liver or the colon? All these questions are set in the editorial and impulse for further investigation is put focusing on multidisciplinary approach and individualization of treatment modalities.

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer(CRC)is a common malignancy of the digestive system.Colorectal liver cancer metastasis(CRLM)occurs in approximately 50%of the patients and is the main cause of CRC mortality.Surgical resection is currently the most effective treatment for CRLM.However,given that the remnant liver volume after resection should be adequate,only a few patients are suitable for radical resection.Since Dr.Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)for CRLM in 2012,ALPPS has received considerable attention and has continually evolved in recent years.This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy,pointing to its favorable postoperative outcomes.We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed.Finally,further directions in both basic and clinical research regarding ALPPS have been proposed.Although ALPPS surgery is a difficult and high-risk technique,it is still worth exploration by experienced surgeons.