This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection. / May 2006

No description available.

This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection.

This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection.

Laser thermal ablation (LTA) is an in situ ablative technique that induces heat destruction of liver tumours. Despite increasing clinical use of LTA, reports of long-term outcomes and limitation of treatment in specific cohorts of patients with liver tumours are lacking. In addition, the mechanisms of action of therapy have not been fully elucidated. This study highlights the long-term clinical results and limitations of LTA in the treatment of a cohort of patients with unresectable colorectal liver metastases and examines the mechanisms of action of thermal ablative injury in a murine model.

Liver metastases are the most common cause of death in colorectal cancer patients. The standard of care and potential for cure for colorectal liver metastases is resection, but often times disease it too extensive for this treatment. Over the years, cancer research has made way for advances in treating progressive disease through immunotherapy. By genetically modifying an individual’s immune system using virally transduced chimeric antigen receptor T cells (CAR-T), patients are better able to receive exquisitely specific T cells to target specific tumors. Furthermore, selective delivery strategies may enhance efficacy while limiting detrimental, systemic adverse effects. Not only this, CAR-Ts have also lead to complete remission in some liquid tumors while maintaining the potential for remission in solid tumors as well. This literature review takes readers through the emergence of the different generations of CAR-T and the various studies including clinical trials that have demonstrated the safety and efficacy of CAR-T. The second portion of this paper will outline the design for a phase II clinical trial using intrahepatic CAR-T therapy in addition to selective internal radiation therapy (SIRT) for refractory CEA+ colorectal liver metastases. Benefits and limitations of using these therapies are further discussed.

Recently, there has been an increase in the number of proton beam therapy (PBT) centers operating worldwide. For certain cases, proton beams have been shown to provide dosimetric and radiobiological advantages when used for cancer treatment, compared to the regular photon-beam based treatments. Under ideal circumstances, the dose given to the tissues surrounding a target can be reduced with PBT. The risk for side effects following treatment is then expected to decrease. Until present, mainly stationary targets, e.g. targets in the brain, have been treated with PBT. There is currently a growing interest to treat also target volumes in other parts of the body with PBT. However, there are sources of uncertainties, which must be more carefully considered when PBT is used, especially for PBT carried out with scanned proton beams. PBT is more sensitive to anatomical changes, e.g. organ motion or a variable gas content in the intestines, which requires that special precautions are taken prior to treating new tumour sites. In photon beam radiotherapy (RT) of moving targets, the main consequence of organ motion is the loss of sharpness of the dose gradients (dose smearing). When scanned proton beams are used, dose deformation caused by the fluctuations in the proton beam range, due to varying tissue heterogeneities (e.g., the ribs moving in and out of the beam path) and the so-called interplay effect, can be expected to impact the dose distributions in addition to the dose smearing. The dosimetric uncertainties, if not accounted for, may cause the planned and accurately calculated dose distribution to be distorted, compromising the main goal of RT of achieving the maximal local disease control while accepting certain risks for normal tissue complications. Currently there is a lack of clinical follow-up data regarding the outcome of PBT for different tumour sites, in particular for extra-cranial tumour sites in moving organs. On the other hand, the use of photon beams for this kind of cancer treatment is well-stablished. A treatment planning comparison between RT carried out with photons and with protons may provide guidelines for when PBT could be more suitable. New clinical applications of particle beams in cancer therapy can also be transferred from photon-beam treatments, for which there is a vast clinical experience. The evaluation of the different uncertainties influencing RT of different tumour sites carried out with photon- and with proton-beams, will hopefully create an understanding for the feasibility of treating cancers with scanned proton beams instead of photon beams. The comparison of two distinct RT modalities is normally performed by studying the dosimetric values obtained from the dose volume histograms (DVH). However, in dosimetric evaluations, the outcome of the treatments in terms of local disease control and healthy tissue toxicity are not estimated. In this regard, radiobiological models can be an indispensable tool for the prediction of the outcome of cancer treatments performed with different types of ionising radiation. In this thesis, different factors that should be taken into consideration in PBT, for treatments influenced by organ motion and density heterogeneities, were studied and their importance quantified. This thesis consists of three published articles (Articles I, II and III). In these reports, the dosimetric and biological evaluations of photon-beam and scanned proton-beam RT were performed and the results obtained were compared. The studies were made for two tumour sites influenced by organ motion and density changes, gastric cancer (GC) and liver metastases. For the GC cases, the impact of changes in tissue density, resulting from variable gas content (which can be observed inter-fractionally), was also studied. In this thesis, both conventional fractionations (implemented in the planning for GC treatments) and hypofractionated regimens (implemented in the planning for the liver metastases cases) were considered. In this work, it was found that proton therapy provided the possibility to reduce the irradiations of the normal tissue located near the target volumes, compared to photon beam RT. However, the effects of density changes were found to be more pronounced in the plans for PBT. Furthermore, with proton beams, the reduction of the integral dose given to the OARs resulted in reduced risks of treatment-induced secondary malignancies.

L’hétérogénéité tumorale (HT) est un trait caractéristique du cancer. Elle peut être rencontrée chez la majorité des tumeurs malignes solides, au travers de la clinique, la biologie, l’histologie, et la génétique. Au-delà de l’hétérogénéité inter-patient, on distingue l’hétérogénéité spatiale, qui regroupe l’hétérogénéité au sein de la tumeur primitive, entre tumeur primitive et métastases, entre métastases, au sein d’une métastase et l’hétérogénéité temporelle, qui fait référence à l’évolution de la tumeur au cours du temps de manière spontanée ou sous l’effet des traitements. L’HT explique la survenue inéluctable de la résistance aux thérapies anticancéreuses actuelles. L’objectif général de cette thèse était d’explorer l’hétérogénéité tumorale au plan clinique, histologique et génétique en utilisant le modèle d’hépatectomies pour métastases d’origine colo-rectales. Dans l’article 1, nous avons étudié la réponse histologique à la chimiothérapie chez des patients opérés de métastases hépatiques colo-rectales après chimiothérapie systémique ou intra-artérielle. Ainsi, nous avons montré que la réponse histologique complète était plus souvent observée après administration d’oxaliplatine par voie intra-artérielle et était associée à un meilleur pronostic. Cependant la réponse histologique complète n’est observée que chez une minorité de patients. Nous avons émis l’hypothèse qu’une réponse histologique incomplète représentent un groupe hétérogène de patients, ayant des pronostics différents. Ceci nous a conduit à proposer dans l’article 2 une méthode reproductible pour évaluer la réponse histologique, incorporant taille et nombre de nodules. La relecture des lames de pièces d’hépatectomie nous a conduit à observer une hétérogénéité de la réponse histologique au sein d’un même patient (hétérogénéité intermétastatique) et de l’aspect histologique (nécrose, fibrose). Nous avons ensuite exploré la valeur pronostique de cette hétérogénéité et chercher à identifier les facteurs prédictifs de cette hétérogénéité. Une réponse dissociée (une différence de réponse histologique > 50% entre deux nodules chez un même patient) a été observée chez 20% des patients et ne modifiait pas le pronostic. Chez les patients ayant une hétérogénéité pathologique, une discordance (mutation et absence de mutation pour les gènes KRAS, BRAF, NRAS et PI3K) entre les métastases a été mis en évidence dans 28% des patients analysés (article 3). Afin d’étudier l’hétérogénéité génétique selon le site tumoral et le type de prélèvements, nous avons utilisé les données disponibles de la plateforme de biologie moléculaire (article 4). Nous avons ainsi mis en évidence que les métastases hépatiques étaient moins souvent mutées pour KRAS, NRAS, BRAF que les tumeurs primitives ou les lésions pulmonaires. Nous avons ensuite recherché une hétérogénéité génétique intra-métastatique pour KRAS, NRAS, BRAF et PI3K au sein d’une métastase hépatique colo-rectale (article 5). Parmi les 54 patients ayant une tumeur unique analysable (2 prélèvements par tumeur), une discordance pour KRAS (N=2) et BRAF (N=1) a été mise en évidence chez 3 patients (5%). L’ensemble de ces travaux confirment que l’HT est observée à travers de nombreux points de vue. L’élaboration de nouvelles stratégies de prise en charge du cancer devra prendre compte cet aspect. / Tumor heterogeneity is a typical feature of cancer. It is observed in the majority of solid malignancies regardless of the point of view: clinical, biological, pathological, and genetic. Different levels of heterogeneity have been described: interpatient, spatial heterogeneity (within the primary tumor, between primary and distant lesion) and temporal heterogeneity (tumor evolution under the influence of treatment). Tumor heterogeneity widely explains the emergence of resistant clones to anticancer drugs. The objective of the current thesis was to explore tumor heterogeneity at a clinical, pathological and genetic level, by using the model of hepatectomy for colorectal liver metastases (CLM).In the article 1, we studied pathological response to chemotherapy in patients operated on for CLM after either systemic or intra-arterial hepatic oxaliplatin-based chemotherapy. We showed that complete pathological response was more often observed after intra-arterial chemotherapy and yield far better outcomes. However, complete response was observed in a minority of patients. We hypothesized that uncomplete pathological response encompass a large group of patients with different oncological outcomes. This lead us to propose a reproducible method (article 2) to assess pathological response, including size and number of nodules. Pathological review found heterogeneity in the response among nodules within the same patients and in the type of pathological features (necrosis, fibrosis). We then explore the prognostic value of pathological heterogeneity and sought to identify predictors of heterogeneity. A dissociated response (difference in pathological response > 50% between two nodules) was observed in XX and did not impact long-term outcomes. IN patients with dissociated response, genetic heterogeneity (mutation and no mutation for KRAS, NRAS, BRAF and PI3K) between metastases was shown in 28% of patients (article 3). To study genetic heterogeneity according to tumor location and the tumor tissue analyzed (specimen, biopsy), we used data from the department of molecular biology (article 4). We found that liver metastases were more often wild type for KRAS, NRAS, BRAF compared to lung metastases or primary tumors. In the article 5, we then sought to evaluate intrametastatic heterogeneity (KRAS, BRAF, NRAS, PI3K) within a single liver metastasis (2 samples per tumor). Among the 54 patients with single lesion analyzed, a discrepancy for KRAS (n=2) and BRAF (n=1) were observed un 3 patients (5%). This work confirms that tumor heterogeneity can be observed at various levels. Elaboration of new therapeutical strategies will have to take this aspect into consideration.

No / Background Oral administration of the omega-3 fatty acid eicosapentaenoic acid (EPA), as the free fatty acid (FFA), leads to EPA incorporation into, and reduced growth of, experimental colorectal cancer liver metastases (CRCLM). Design: We performed a Phase II double-blind, randomised, placebo-controlled trial of EPA-FFA 2 g daily in patients undergoing liver resection surgery for CRCLM. The patients took EPA-FFA (n=43) or placebo (n=45) prior to surgery. The primary end-point was the CRCLM Ki67 proliferation index (PI). Secondary end-points included safety and tolerability of EPA-FFA, tumour fatty acid content and CD31-positive vascularity. We also analysed overall survival (OS) and disease-free survival (DFS). Results The median (range) duration of EPA-FFA treatment was 30 (12–65) days. Treatment groups were well matched with no significant difference in disease burden at surgery or preoperative chemotherapy. EPA-FFA treatment was well tolerated with no excess of postoperative complications. Tumour tissue from EPA-FFA-treated patients demonstrated a 40% increase in EPA content (p=0.0008), no difference in Ki67 PI, but reduced vascularity in ‘EPA-naïve’ individuals (p=0.075). EPA-FFA also demonstrated antiangiogenic activity in vitro. In the first 18 months after CRCLM resection, EPA-FFA-treated individuals obtained OS benefit compared with placebo, although early CRC recurrence rates were similar. Conclusions EPA-FFA therapy is safe and well tolerated in patients with advanced CRC undergoing liver surgery. EPA-FFA may have antiangiogenic properties. Remarkably, limited preoperative treatment may provide postoperative OS benefit. Phase III clinical evaluation of prolonged EPA-FFA treatment in CRCLM patients is warranted. Trial Identifier: ClinicalTrials.gov NCT01070355. / The Cancer Research UK Clinical Trials Awards and Advisory Committee approved the Trial. PML and ADR were supported by Department of Health/Cancer Research UK Yorkshire Experimental Cancer Medicine Centre funding. The Trial was adopted by the UKCRN Clinical Trials Portfolio (UKCRN ID 8946) allowing West Yorkshire Comprehensive Local Research Network funding of Pharmacy costs. SLA Pharma AG funded some of the experimental work and provided EPA-FFA and placebo. SLA Pharma AG played no role in the design or execution of the Trial. Laboratory costs were also supported by the Leeds Teaching Hospitals Charitable Foundation (Rays of Hope).

Ziel der vorliegenden Arbeit ist die retrospektive Beurteilung der Sicherheit und Effektivität der Leberteilresektion bei der Behandlung von Lebermetastasen des kolorektalen Karzinoms sowie der Re-Resektion bei Patienten mit Rezidivlebermetastasen. Weiterhin soll das operative Vorgehen bei synchronen Lebermetastasen hinsichtlich simultaner Resektionsverfahren und zweizeitigen Vorgehens untersucht werden. Insgesamt wurden die Ergebnisse von 660 Patienten ausgewertet, die zwischen 1988 und 2004 mit 685 Leberteilresektionen behandelt wurden. Unter diesen waren 75 Patienten, die eine Re-Resektion erhielten sowie 202 Patienten, bei denen die Lebermetastasen synchron auftraten. Neben der Analyse der postoperativen Letalität und postoperativen Komplikationen sollen prognostische Faktoren für das Langzeitüberleben und das Auftreten von Tumorrezidiven nach Leberteilresektion identifiziert werden. Da sich die Studienpopulation aus einem Zeitraum von über 15 Jahren rekrutiert, sollen außerdem verschiedene Zeitabschnitte vergleichend analysiert werden. Die Leberteilresektion ist derzeit die einzige potentiell kurative Therapie bei kolorektalen Lebermetastasen. Als prognostisch günstige Parameter in der multivariaten Analyse zeigten sich die Radikalität des Eingriffes, die Anzahl der Metastasen, vorhandene ligamentäre Lymph-knotenmetastasen sowie das Jahr der Resektion. Auch bei Rezidiven kolorektaler Lebermetastasen ist das chirurgische Vorgehen derzeit die einzige kurative Intervention. Re-Resektionen weisen ein vergleichbares operatives Risiko und vergleichbare Langzeitüberlebensraten auf wie Erstresektionen. Als einziger prognostischer Parameter für das Langzeitüberleben erwies sich in der multivariaten Analyse die Radikalität des Eingriffes. Bei synchronen Lebermetastasen sind die wichtigsten Kriterien, um eine simultane Resektion durchzuführen, die Berücksichtigung des Alters sowie des Resektionsausmaßes. Simultane Resektionen sind bei synchronen kolorektalen Lebermetastasen dann so sicher und effizient durchführbar wie Resektionen im zweizeitigen Vorgehen.