Limited Liver or Lung Colorectal Cancer Metastases. Systemic Treatment, Surgery, Ablation or SBRT
Abstract
:- Percutaneous ablation and stereotactic body radiotherapy of colorectal cancer liver and lung metastases.
- Systemic treatment of patients with colorectal cancer resectable liver metastases.
- Systemic treatment of patients with colorectal cancer potentially resectable liver metastases.
1. Percutaneous Ablation and Stereotactic Body Radiotherapy of Liver and Lung Metastases from Colorectal Cancer
- The size and localization of the metastases and therefore, access regarding selection of the best treatment method;
- The local control rates achieved (with greater local control for surgery than for the remaining options);
- The invasiveness of the technique;
- The non-tumor-related prognostic considerations and patient-relevant factors as well as patient preferences;
- The local expertise regarding the use of each ablative treatment method;
- Consideration of patient frailty and life expectancy [2].
1.1. Percutaneous Ablation
1.1.1. Types of Percutaneous Ablation
1.1.2. Lung Metastases Ablation
1.1.3. Liver Metastases Ablation
1.2. Stereotactic Body Radiotherapy (SBRT)
1.2.1. SBRT Technique
1.2.2. SBRT Dose
1.2.3. Criteria for Determining SBRT Suitability
1.2.4. SBRT Outcomes
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- Evaluate these patients with a multidisciplinary team of experts in colorectal cancer.
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- Local ablative treatments or SBRT must be considered to treat limited lung and liver CRC M1 smaller than or equal to 5 cm.
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- RFA is preferred in CRC M1 smaller than 3 cm. MWA could be considered in CRC M1 ≤ 5 cm.
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- There is no maximum limit on the number of lesions to treat with ablative treatments or SBRT, but the consensus from most studies recommends a maximum of 5 lesions.
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- Consider SBRT to treat lung and liver M1 close to vascular, biliary, or gastrointestinal structures;, laparoscopic ablative treatments also could be considered.
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- Take into account clinical and molecular tumor prognostic factors, patient preferences, patient comorbidities, and center experience.
2. Treatment of Patients with Resectable Liver Colorectal Metastases (Liver M1: Number <4 and Size <5 cm)
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- A perioperative schedule with FOLFOX is recommended in this population of patients.
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- Combinations of FOLFOX with bevacizumab or anti-EGFR cannot be recommended based on RCTs.
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- Stratification criteria in prospective RCTs should consider the number of liver nodules (1 vs. 2–4) and the DFI (disease free interval) <12 vs. >12 months.
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- In elderly and frail patients, consider SBRT or local ablative treatments alone or in combination with surgery. Take into account center experience and patient preferences.
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- Evaluate all of these patients with a multidisciplinary team of experts in colorectal cancer.
3. Treatment of Potentially Resectable Liver Metastases from Colorectal Cancer (Liver M1: Number >4 or Size >5 cm)
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- A highly active regimen in terms of ORR and tumor shrinkage is recommended for patients with potentially resectable CRC liver metastases.
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- For RAS wild-type patients, an anti-EGFR combination schedule is recommended regardless of sidedness, if conversion is the goal.
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- For RAS mutant patients, a bevacizumab combination-schedule is recommended regardless of sidedness, if conversion is the goal. For fit patients, FOLFIRINOX-bevacizumab is the preferred schedule.
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- In elderly and frail patients consider SBRT or local ablative treatments alone or in combination with surgery if good response is achieved with systemic treatment. Consider patient preferences and center experience.
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
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Author | N | Treatments | HR PFS/OS. <0.8 | Adequate Control Arm | Any Change in Primary End-Point or Sample Size | Achieved Pre-Specified Objective | Quality of Clinical Design | ESMO. MCBS/PFS | ESMO. MCBS/OS | ESMO/MCBS 1.1 |
---|---|---|---|---|---|---|---|---|---|---|
Randomized clinical trials in CRC with liver limited M1 (<4 M1) | ||||||||||
Portier, JCO 2006 | 173 | S vs. S plus 5FU/LV | 0.66/0.73/0.9 | 1 | 0 | 0 | 1 of 3 | B | A | A |
Mitry, JCO 2008 | 278 | S vs. S plus 5FU/LV | 1.32/1.32/1 | 1 | 1 | NA | NA | B | A | A |
Hasewaga, Plos One 2016 | 180 | S vs. S plus UFT/LV | 0.56/0.8/0,7 | 1 | 1 | 0 | 2 of 3 | A | C | A |
Nordlinger, Lancet Oncol 2013 | 364 | S vs. S plus FOLFOX | 0.79/0.88/0.89 | 1 | 1 | 0 | 2 of 3 | B | B | B |
Ychou, Ann Oncol 2009 | 321 | S plus FU/LV vs. S plus FOLFIRI | 0.89/1.09/0.81 | 0 | 0 | 0 | 0 of 3 | C | C | C |
Bridgewater JA. Lancet Oncol 2020 | 257 | S plus FOLFOX vs. S plus FOLFOX/CET | 1.17/1.45/0.8 | 1 | 0 | 0 | 1 of 3 | C | C | C |
Snoeren N. Neoplasia 2017 | 79 | S plus CAPOX vs. S plus CAPOX plus BEV | NA | 0 | 0 | 0 | 0 of 3 | C | C | C |
Kanemitsu. ASCO 2020 | 300 | S vs. S plus FOLFOX | 0.67/1.25/0.53 | 1 | 1 | 1 | 3 of 3 | B | C | B |
Randomized Clinical trials in CRC with liver limited M1 (≥4 M1) | ||||||||||
Ye LC, JCO, 2013 | 138 | CHT plus S vs. CHT/CET plus S | 0.6/0.54/1.11 | 1 | NA | 1 | 1 of 3 | A | A | A |
Gruenberger, Ann Oncol 2015 | 80 | FOLFOX/BVZ plus S vs. FOLFOXIRI/BVZ plus S | 0.43/0.35/1.22 | 0 | 1 | NA | 1 of 3 | A | NA | A |
Adding RF or SBRT to chemo | ||||||||||
Ruers T. JNCI 2017 | 119 | FOLFOX vs. FOLFOX plus RF ± S | 0.57/0.58/0.98 | 1 | 0 | 1 | 2 of 3 | 3 | 3 | 3 |
Palma, Lancet 2019 | 99 | CHT vs. CHT plus SBRT | 0.47/0.57/0.82 | 1 | 1 | 1 | 2 of 3 | 3 | 4 | 4 |
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Molla, M.; Fernandez-Plana, J.; Albiol, S.; Fondevila, C.; Vollmer, I.; Cases, C.; Garcia-Criado, A.; Capdevila, J.; Conill, C.; Fundora, Y.; et al. Limited Liver or Lung Colorectal Cancer Metastases. Systemic Treatment, Surgery, Ablation or SBRT. J. Clin. Med. 2021, 10, 2131. https://doi.org/10.3390/jcm10102131
Molla M, Fernandez-Plana J, Albiol S, Fondevila C, Vollmer I, Cases C, Garcia-Criado A, Capdevila J, Conill C, Fundora Y, et al. Limited Liver or Lung Colorectal Cancer Metastases. Systemic Treatment, Surgery, Ablation or SBRT. Journal of Clinical Medicine. 2021; 10(10):2131. https://doi.org/10.3390/jcm10102131
Chicago/Turabian StyleMolla, Meritxell, Julen Fernandez-Plana, Santiago Albiol, Constantino Fondevila, Ivan Vollmer, Carla Cases, Angeles Garcia-Criado, Jaume Capdevila, Carles Conill, Yliam Fundora, and et al. 2021. "Limited Liver or Lung Colorectal Cancer Metastases. Systemic Treatment, Surgery, Ablation or SBRT" Journal of Clinical Medicine 10, no. 10: 2131. https://doi.org/10.3390/jcm10102131