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Effect of Anterior Approach vs Conventional Hepatectomy in Resection of Colorectal Liver Metastases on Intraoperative Tumor Cell Dissemination


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In a German single-institution study reported in JAMA Surgery, Rahbari et al found that the anterior approach to the resection of colorectal liver metastases was not associated with a reduction in the detection of intraoperative circulating tumor cells vs conventional hepatectomy.

As stated by the investigators, “Tumor relapse after partial hepatectomy for colorectal liver metastasis remains an unsolved issue. Intraoperative manipulation of the liver during conventional hepatectomy might enhance hematogenous tumor cell spread. The anterior approach is an alternative approach that may reduce intraoperative tumor cell dissemination.”

“This randomized clinical trial found that the anterior approach was not superior to conventional hepatectomy in reducing intraoperative tumor cell dissemination in patients undergoing resection of colorectal liver metastases.”
— Rahbari et al

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Study Details

In the trial, 80 patients scheduled for potentially curative resection at a tertiary-care hospital (University of Heidelberg) enrolled up through March 2012 were randomly assigned to undergo conventional hepatectomy (n = 41) or the anterior approach (n = 39). Bone marrow and blood samples were analyzed for disseminated tumor cells and circulating tumor cells using cytokeratin 20 reverse transcriptase–polymerase chain reaction analysis.

The primary endpoint was intraoperative circulating tumor cell detection in central blood samples after liver resection. Patients with positive resection margins, excessive intraoperative blood loss, or preoperative circulating tumor cell detection were excluded from analysis of the primary endpoint.

Key Findings

Median follow-up among all 80 patients was 46 months (interquartile range = 0–116 months). Preoperative detection of circulating tumor cells occurred in 12 patients (32%) in the conventional hepatectomy group and 12 (32%) in the anterior approach group, and preoperative detection of disseminated tumor cells in bone marrow occurred in 9 (26%) and 12 (32%).

Among patients evaluable for the primary endpoint, intraoperative circulating tumor cell detection occurred in 5 (24%) of 21 patients in the conventional hepatectomy group and in 6 (27%) of 22 patients in the anterior approach group (P = .54). Apart from longer operating time in the anterior approach group (mean = 171 vs 221 minutes, P < .001), no significant differences in intraoperative and postoperative outcomes were observed between groups, including no significant difference in incidence of grade I to IV complications (39% vs 41%, P = .16).

Detection of circulating tumor cells vs no detection was associated with poorer overall survival (median = 46 vs 81 months, P = .03) and disease-free survival (median = 40 vs 60 months, P = .04). No difference in median overall survival (73 vs 55 months, P = .43) or median disease–free survival (48 vs 40 months, P = .88) was observed among the total conventional hepatectomy vs anterior approach groups.

At last follow-up, eight patients (20%) in the conventional hepatectomy group and six patients (15%) in the anterior approach group showed no evidence of disease (P = .47). Recurrence of colorectal cancer was observed in 23 patients (56%) and 17 patients (44%; P = .46).

The investigators concluded: “This randomized clinical trial found that the anterior approach was not superior to conventional hepatectomy in reducing intraoperative tumor cell dissemination in patients undergoing resection of colorectal liver metastases.”

Jürgen Weitz, MD, of University Hospital Carl Gustav Carus at the Technische Universitat Dresden, is the corresponding author for the JAMA Surgery article.

Disclosure: The study was supported by the Department of Surgery, University of Heidelberg. For full disclosures of the study authors, visit jamanetwork.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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