The growth pattern of liver metastases on MRI predicts early recurrence in patients with colorectal cancer: a multicenter study
Qian Cai, Yize Mao, Siqi Dai, Feng Gao, Qian Xiao, Wanming Hu, Tao Qin, Qiuxia Yang, Zhaozhou Li, Du Cai, Min-Er Zhong, Kefeng Ding, Xiao-Jian Wu, Rong Zhang
Eur Radiol, 2022 Apr 14. doi.org/10.1007/s00330-022-08774-8
The liver represents the main metastatic site of colorectal cancer: approximately 50% to 60% of patients with colorectal cancer develop liver metastases during the course of the disease (1). For patients with isolated liver metastases, locoregional treatments can be curative, as an alternative or in association with systemic chemotherapy: the complete resection of liver metastases can achieve up to 50% 5-year and 20% 10-year survival rates (2,3). Anyway, in up to 60% of patients with colorectal cancer liver metastases (CRCLM) the disease recurs early after treatment. The Authors’ aim was to test the feasibility of a qualitative assessment of hepatic lesions focused on the growth pattern of liver metastases on preoperative MRI, in order to find a useful and simple tool to estimate recurrency risk after surgery.
In this multicentric retrospective study 348 CRCLM patients with 820 metastatic lesions were enrolled from three different Chinese hospitals, between January 2012 and November 2020. All patients underwent a liver MRI within 1 month before surgery and follow-up CT/MRI examinations to monitor recurrence; no enrolled patient was diagnosed with extrahepatic metastases, or other simultaneous malignancies.
Two radiologists in consensus analyzed all contrast enhanced preoperative MRIs and categorized each liver metastasis into four growth patterns based on tumor shape, with reference to the gross classification of HCC (4): rough type, smooth type, focal extranodular protuberant (FEP) type and nodular confluent (NC) type.
The endpoints of the follow-up program included disease-free survival (DFS) and intrahepatic disease free survival (IDFS).
Patients with FEP- and NC-type metastases had shorter DFS and a higher intrahepatic recurrence rate than patients without such metastases in the liver (FEP type: median DFS 5.5 vs. 20.6 months, p = 0.044; 6-month intrahepatic recurrence rate 50.0% vs. 16.0%, p = 0.005; NC type: median DFS, 6.4 vs. 28.0 months, p = 0.007; 6-month intrahepatic recurrence rate, 35.7% vs. 18.6%, p = 0.023). Since no significant differences in DFS or IDFS were observed between patients with rough- and smooth-type metastases and those without such metastases in the liver (p > 0.05), FEP and NC types were classified as high-risk types, while rough and smooth types were classified as low-risk types. Subsequently, patients with high-risk-type liver metastases were renamed as high-risk patients, while patients only with low-risk-type liver metastases were renamed as low-risk patients. High-risk patients had shorter DFS and a higher intrahepatic recurrence rate than low-risk patients (median DFS: 6.4 vs. 28.0 months, p = 0.005; 6-month intrahepatic recurrence rate: 37.5% vs. 13.4%, p = 0.003).
Univariate and multivariate Cox regression analyses proved that high-risk-type liver metastases (hazard ratio [HR]: 2.319, 95% confidence interval [CI]: 1.442– 3.728; p = 0.011) and the number of liver metastases (HR: 1.793, 95% CI: 1.062–3.027; p = 0.029) were independent risk factors for DFS; moreover, high-risk-type liver metastases (HR: 2.169, 95% CI: 1.293–3.639; p = 0.003) were an independent risk factor for IDFS.
A small sample of 53 patients with 177 liver metastases accepted chemotherapy before surgery and had a liver MRI at baseline; in those patients, the Authors analyzed changes in the growth pattern of liver metastases after chemotherapy, and they observed that approximately 79.3% of low-risk types remained low-risk types, while 40.5% of high-risk types were converted to low-risk types. In addition, patients with high-risk types after chemotherapy had shorter DFS and a higher intrahepatic recurrence rate than those with low-risk types (median DFS: 5.9 vs. 33.1 months, p = 0.014; 6-month intrahepatic recurrence rate: 52.4% vs. 9.4%, p = 0.027).
The Authors showed that the DFS of patients with FEP- and/or NC-type liver metastases was shorter than that of patients only with rough- and/or smooth-type liver metastases in three independent centers. Moreover, despite the small sample, the Authors proved that the growth pattern can be converted during chemotherapy.
The main limitation of this study is that a qualitative evaluation was used to determine liver metastases growth pattern, thus prone to inter-observer variability. A quantitative method, such as radiomics, could add clinical value to preoperative growth pattern evaluation.
Assessing the growth pattern of liver metastases on preoperative MRI may be important for surgical planning. Furthermore, the changes in growth patterns of liver metastases on MRI images during chemotherapy may have significance in predicting postoperative recurrence of CRCLM patients, and should be paid attention to in clinical practice.
References:
- Leung U, Gönen M, Allen PJ, Kingham TP, DeMatteo RP, Jarnagin WR, et al. Colorectal Cancer Liver Metastases and Concurrent Extrahepatic Disease Treated With Resection. Ann Surg. 2017 Jan;265(1):158–65.
- Creasy JM, Sadot E, Koerkamp BG, Chou JF, Gonen M, Kemeny NE, et al. Actual 10-year survival following hepatic resection of colorectal liver metastases: what factors preclude cure? Surgery. 2018 Jun;163(6):1238–44.
- Tomlinson JS, Jarnagin WR, DeMatteo RP, Fong Y, Kornprat P, Gonen M, et al. Actual 10-year survival after resection of colorectal liver metastases defines cure. J Clin Oncol. 2007 Oct 10;25(29):4575–80.
- Kanai T, Hirohashi S, Upton MP, Noguchi M, Kishi K, Makuuchi M, et al. Pathology of small hepatocellular carcinoma. A proposal for a new gross classification. Cancer. 1987 Aug 15;60(4):810–9. .
Francesca Mambrin is a fourth-year radiology resident at the Medical Imaging Department of the University of Verona, Italy. She graduated in 2017 in Medicine and Surgery at the University of Padua. She is affiliated to the Radiological Society of North America (RSNA) and the European Society of Radiology (ESR). Her interests include upper abdominal imaging, with particular focus on CT and MR assessment of postoperative complications after major pancreatic resections
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