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.

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.

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.

Laparoscopic liver resection for colorectal liver metastases—shortand long-term outcomes:A systematic review

BACKGROUND For well-selected patients and procedures,laparoscopic liver resection(LLR)has become the gold standard for the treatment of colorectal liver metastases(CRLM)when performed in specialized centers.However,little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.AIM To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.METHODS A systematic search was performed in PubMed,EMBASE,Web of Science and the Cochrane Library using the keywords“colorectal liver metastases”,“laparoscopy”,“liver resection”,“prognostic factors”,“outcomes”and“survival”.Only publications written in English and published until December 2019 were included.Furthermore,abstracts of which no accompanying full text was published,reviews,case reports,letters,protocols,comments,surveys and animal studies were excluded.All search results were saved to Endnote Online and imported in Rayyan for systematic selection.Data of interest were extracted from the included publications and tabulated for qualitative analysis.RESULTS Out of 1064 articles retrieved by means of a systematic and grey literature search,77 were included for qualitative analysis.Seventy-two research papers provided data concerning outcomes of LLR for CRLM.Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes.Qualitative analysis of the collected data showed that LLR for CRLM is safe,feasible and provides oncological efficiency.Multiple research groups have reported on the short-term advantages of LLR compared to open procedures.The obtained results accounted for minor LLR,as well as major LLR,simultaneous laparoscopic colorectal and liver resection,LLR of posterosuperior segments,twostage hepatectomy and repeat LLR for CRLM.Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.CONCLUSION In experienced hands,LLR for CRLM provides good short-and long-term outcomes,independent of the complexity of the procedure.

Role of liver transplantation in the management of colorectal liver metastases:Challenges and opportunities

The liver is the most common site of colorectal cancer metastasis.Complete resection of the metastatic tumor is currently the only treatment modality available with a potential for cure.However,only 20%of colorectal liver metastases(CRLM)are considered resectable at the time of presentation.Liver transplantation(LT)has been proposed as an alternative oncologic treatment for patients with unresectable CRLM.This review summarizes the published experiences of LT in the setting of unresectable CRLM from the previous decades and discusses the challenges and future horizons in the field.Contemporary experiences that come mostly from countries with broader access to liver grafts are also explored and their promising findings in terms of overall survival(OS)and disease-free survival(DFS)are outlined along with their study design and methods.The rationale of establishing specific patient selection criteria and the dilemmas around immunosuppressive regimens in patients undergoing LT for CRLM are also highlighted.Additionally,this review describes the findings of studies comparing LT vs chemotherapy alone and LT vs portal vein embolization plus resection for CRLM in terms of OS and DFS.Last but not least,we present current perspectives and ongoing prospective trials that try to elucidate the role of LT for CRLM.

Liver transplantation benefits selected patients with hilar cholangiocarcinoma and colorectal liver metastases

Hilarcholangiocarcinoma(HCCA)isanaggressivemalignancy with a dismal prognosis. The 5-year survival rate has been reported to range from 39%to 50%if an R0 resection is obtained [1]. Approximately 25%patients with early stage HCCA of all cases can be treated with radical surgical resection [2], while most patients do not have a chance to receive a surgical procedure due to the advanced stage at the time of diagnosis. The poor prognosis is gen-

Is precision medicine for colorectal liver metastases still a utopia?New perspectives by modern biomarkers,radiomics,and artificial intelligence

The management of patients with liver metastases from colorectal cancer is still debated.Several therapeutic options and treatment strategies are available for an extremely heterogeneous clinical scenario.Adequate prediction of patients’outcomes and of the effectiveness of chemotherapy and loco-regional treatments are crucial to reach a precision medicine approach.This has been an unmet need for a long time,but recent studies have opened new perspectives.New morphological biomarkers have been identified.The dynamic evaluation of the metastases across a time interval,with or without chemotherapy,provided a reliable assessment of the tumor biology.Genetics have been explored and,thanks to their strong association with prognosis,have the potential to drive treatment planning.The liver-tumor interface has been identified as one of the main determinants of tumor progression,and its components,in particular the immune infiltrate,are the focus of major research.Image mining and analyses provided new insights on tumor biology and are expected to have a relevant impact on clinical practice.Artificial intelligence is a further step forward.The present paper depicts the evolution of clinical decision-making for patients affected by colorectal liver metastases,facing modern biomarkers and innovative opportunities that will characterize the evolution of clinical research and practice in the next few years.

Two-stage hepatectomy with radioembolization for bilateral colorectal liver metastases:A case report

BACKGROUND Two-stage hepatectomy(TSH)is a well-established surgical technique,used to treat bilateral colorectal liver metastases(CRLM)with a small future liver remnant(FLR).However,in classical TSH,drop-out is reported to be around 25%-40%,due to insufficient FLR increase or progression of disease.Trans-arterial radioembolization(TARE)has been described to control locally tumor growth of liver malignancies such as hepatocellular carcinoma,but it has been also reported to induce a certain degree of contralateral liver hypertrophy,even if at a lower rate compared to portal vein embolization or ligation.CASE SUMMARY Herein we report the case of a 75-year-old female patient,where TSH and TARE were combined to treat bilateral CRLM.According to computed tomography(CT)-scan,the patient had a hepatic lesion in segment VI-VII and two other confluent lesions in segment II-III.Therefore,one-stage posterior right sectionectomy plus left lateral sectionectomy(LLS)was planned.The liver volumetry estimated a FLR of 38%(segments I-IV-V-VIII).However,due to a more than initially planned,extended right resection,simultaneous LLS was not performed and the patient underwent selective TARE to segments II-III after the first surgery.The CT-scan performed after TARE showed a reduction of the treated lesion and a FLR increase of 55%.Carcinoembryonic antigen and CA 19.9 decreased significantly.Nearly three months later after the first surgery,LLS was performed and the patient was discharged without any postoperative complications.CONCLUSION According to this specific experience,TARE was used to induce liver hypertrophy and simultaneously control cancer progression in TSH settings for bilateral CRLM.

Oncologic aspects of the decision-making process for surgical approach for colorectal liver metastases progressing during chemotherapy

Colorectal cancer represents the third most diagnosed malignancy in the world.The liver is the main site of metastatic disease,affected in 30%of patients with newly diagnosed disease.Complete resection is considered the only potentially curative treatment for colorectal liver metastasis(CRLM),with a 5-year survival rate ranging from 35%to 58%.However,up to 80%of patients have initially unresectable disease,due to extrahepatic disease or bilobar multiple liver nodules.The availability of increasingly effective systemic chemotherapy has contributed to converting patients with initially unresectable liver metastases to resectable disease,improving long-term outcomes,and accessing tumor biology.In recent years,response to preoperative systemic chemotherapy before liver resection has been established as a major prognostic factor.Some studies have demonstrated that patients with regression of hepatic metastases while on chemotherapy have improved outcomes when compared to patients with stabilization or progression of the disease.Even if disease progression during chemotherapy represents an independent negative prognostic factor,some patients may still benefit from surgery,given the role of this modality as the main treatment with curative intent for patients with CRLM.In selected cases,based on size,the number of lesions,and tumor markers,surgery may be offered despite the less favorable prognosis and as an option for non-chemo responders.

Borderline resectable for colorectal liver metastases:Present status and future perspective

Surgical resection for colorectal liver metastases(CRLM)may offer the best opportunity to improve prognosis.However,only about 20% of CRLM cases are indicated for resection at the time of diagnosis(initially resectable),and the remaining cases are treated as unresectable(initially unresectable).Thanks to recent remarkable developments in chemotherapy,interventional radiology,and surgical techniques,the resectability of CRLM is expanding.However,some metastases are technically resectable but oncologically questionable for upfront surgery.In pancreatic cancer,such cases are categorized as"borderline resectable",and their definition and treatment strategies are explicit.However,in CRLM,although various poor prognosis factors have been identified in previous reports,no clear definition or treatment strategy for borderline resectable has yet been established.Since the efficacy of hepatectomy for CRLM was reported in the 1970 s,multidisciplinary treatment for unresectable cases has improved resectability and prognosis,and clarifying the definition and treatment strategy of borderline resectable CRLM should yield further improvement in prognosis.This review outlines the present status and the future perspective for borderline resectable CRLM,based on previous studies.

Diagnostic performance of abbreviated gadoxetic acid-enhanced magnetic resonance protocols with contrast-enhanced computed tomography for detection of colorectal liver metastases

BACKGROUND Although contrast-enhanced magnetic resonance imaging(MRI)using gadoxetic acid has been shown to have higher accuracy,sensitivity,and specificity for the detection and characterization of hepatic metastases compared with other modalities,the long examination time would limit the broad indication.Several abbreviated enhanced MRI(Ab-MRI)protocols without dynamic phases have been proposed to achieve equivalent diagnostic performance for the detection of colorectal liver metastases.However,an optimal protocol has not been established,and no studies have assessed the diagnostic performance of Ab-MRI combined with contrast-enhanced computed tomography(CE-CT),which is the preoperative imaging of colorectal cancer staging in clinical settings,to determine the best therapeutic strategy.AIM To compare the diagnostic performance of two kinds of Ab-MRI protocol with the standard MRI protocol and a combination of the Ab-MRI protocol and CE-CT for the detection of colorectal liver metastases.METHODS Study participants comprised 87 patients(51 males,36 females;mean age,67.2±10.8 years)who had undergone gadoxetic acid-enhanced MRI and CE-CT during the initial work-up for colorectal cancer from 2010 to 2021.Each exam was independently reviewed by two readers in three reading sessions:(1)Only single-shot fast spin echo(FSE)T2-weighted or fat-suppressed-FSE-T2-weighted,diffusion-weighted,and hepatobiliary-phase images(Ab-MRI protocol 1 or 2);(2)all acquired MRI sequences(standard protocol);and(3)a combination of an Ab-MRI protocol(1 or 2)and CE-CT.Diagnostic performance was then statistically analyzed.RESULTS A total of 380 Lesions were analyzed,including 195 metastases(51.4%).Results from the two Ab-MRI protocols were similar.The sensitivity,specificity,and positive and negative predictive values from Ab-MRI were non-inferior to those from standard MRI(P>0.05),while those from the combination of Ab-MRI protocol and CE-CT tended to be higher than those from Ab-MRI alone,although the difference was not significant(P>0.05),and were quite similar to those from standard MRI(P>0.05).CONCLUSION The diagnostic performances of two Ab-MRI protocols were non-inferior to that of the standard protocol.Combining Ab-MRI with CE-CT provided better diagnostic performance than Ab-MRI alone.

Retrospective cohort study of statin therapy effect on resected colorectal liver metastases

BACKGROUND Above and beyond their role in cardiovascular risk reduction,statins appear to have a chemopreventive role in some gastro-intestinal cancers.In the quest for new chemopreventive agents,some existing established drugs such as statins have shown potential for re-purposing as chemoprevention.Probing existing drugs,whose pharmacodynamics are familiar,for novel beneficial effects offers a more cost-effective and less time-consuming strategy than establishing brand new drugs whose pharmacodynamic profile is unfamiliar.Observational studies show statins decrease the risk of developing colorectal cancer but there are no published studies exploring the potential impact of statins on carcinogenesis in colorectal liver metastases(CRLM).AIM To evaluate impact of statins on outcomes of CRLM resection,and secondarily to assess if statins influence CRLM histo-pathology.METHODS We conducted a retrospective cohort study of patients operated for CRLM over a 13-year period from 2005 to 2017.Patients were identified from a prospective database maintained in our Tertiary care hospital.All 586 patients included the study had undergone resection of CRLM following discussion at multidisclipinary team meeting,some patients requiring neoadjuvant chemotherapy to downstage CRLM prior to surgery.We analysed patient demographics,operative details,CRLM histopathology,Index of Deprivation,neutrophil-to-lymphocyte ratio,platelet-to-lymphocyte ratio and chemotherapy use in relation to clinical outcome.Statistics were performed using SPSS version 16.0;significance taken at 5%.RESULTS Liver resection for CRLM was undertaken in 586 patients at a median age of 68(range 19 to 88)years.Statin therapy was used by 181 patients.Median follow-up time was 23(range 12-96)mo and further colorectal cancer metastases developed in 267 patients.A total of 131 patients died.Multi-variate analysis identified 6 independent predictors of poorer disease-free survival:Synchronous presentation,multiple tumours,tumour size≥5 cm,moderate-severe steatosis,peri-neural invasion,and R1-resection margin.Poorer overall survival was significantly associated with neo-adjuvant chemotherapy,major hepatectomy,peri-neural invasion and R1-resection margin.Neither histo-pathological nor radiological traits of CRLM were affected by statins,and,there was no demonstrable effect of statin therapy on patient outcomes.CONCLUSION Statin therapy does not affect patient survival following liver resection for CRLM.We postulate the reason for this key finding is that statins do not modulate tumour biology of CRLM.

Liver transplantation for non-resectable colorectal liver metastases

At present,there are no absolute practice guidelines for liver transplants in colorectal liver metastases(CRLM),and treatment protocols for unresectable CRLM are institution-specific(1).One of the first prospective studies evaluating the safety of liver transplants for CRLM was the SECA-I trial(1,2).A 5-year overall survival rate of 60% was observed in this trial,which far outperformed survival with chemotherapy alone(3).In the SECA-Ⅱ trial,enrollment was increased,and patients with better prognostic factors,including at least a 10% response to chemotherapy before the transplant,were selected.

Utility of circulating tumor DNA in patients undergoing hepatectomy for colorectal liver metastases

In this study recently published in Annals of Surgery,Newhook et al.studied the influence of circulating tumor DNA(ctDNA)in the management of patients undergoing hepatic resection for colorectal liver metastases(CRLM)(1).The primary objective was to study the association between the dynamic of ctDNA and somatic mutations with survival after resection of CRLM.The secondary objectives were to evaluate the impact of surgery on perioperative ctDNA dynamics and the impact of its detection on survival.

Liver transplantation for unresectable colorectal liver metastases (CRLM) using extended criteria donor (ECD) grafts: proceed with caution

Liver transplantation(LT)for colorectal liver metastases(CRLM)seems to be nowadays an established treatment,not only of unresectable CRLM(uCRLM)(1)but also for borderline resectable ones(2,3).For these patients,the benefit of LT vs standard modern advanced palliative therapies ranges between 40-80%(1).Notwithstanding the high rates of recurrence,LT can definitely be considered as a curative option,in particular considering the excellent long-term results recently published by the Oslo group(4).

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.

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 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.

The potential use of extended criteria donors and eligible recipients in liver transplantation for unresectable colorectal liver metastases in Central Sweden

Background:Unresectable colorectal liver metastases(CRLM)is a condition with poor prognosis.A recent treatment alternative improving survival in patients with unresectable CRLM,has emerged with the introduction of liver transplantation(LT),yet not uncontroversial with the current organ shortage.This study aimed to retrospectively investigate the potential of declined donors with acceptable risk as liver graft donors and patients with unresectable CRLM as potential recipients.Methods:All declined donors in central Sweden and all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital,January 2013-October 2018,were identified.Donors were classified according to the European Committee Guide to the quality and safety of organs for transplantation and potential recipients were evaluated by selection criteria,based on studies on the Norwegian Secondary Cancer study database.Results:Out of 1,462 evaluated potential donors,62(2.7 pmp)donors were identified,corresponding to 6-18%of the utilized donor pool.Out of 1,008 included patients with CRLM,25(2.1 pmp)potential recipients were recognized.Eligibility for LT and left-sided colon cancer were favorable prognostic factors.Conclusions:Today’s donor pool could increase with the use of extended criteria donors,which is sufficient and display an acceptable risk-benefit ratio for patients with unresectable CRLM.With current selection criteria a small subset of patients with unresectable CRLM are eligible recipients.This subset of patients has a better survival compared to patients ineligible for LT.