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      Liver Stereotactic Ablative Radiotherapy: an Effective and Feasible Alternative to Surgery during the COVID-19 Pandemic

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          Abstract

          Madam — The COVID-19 pandemic is having an unprecedented impact on UK cancer services. Access to radical surgery has been severely restricted and resources for systemic therapy provision are being limited as the crisis unfolds. Radiotherapy resources are rightly being focused on patients being treated with curative intent. However, it is our experience that access to stereotactic ablative radiotherapy (SABR) is diminishing, predominantly due to staffing shortages. SABR offers a non-invasive, outpatient ablative approach with minimal hospital footfall and with lower immunosuppressive risks than chemotherapy. The recently published long-term outcomes of the SABR COMET study illustrate the ability of SABR to substantially impact survival across tumour types [1]. The NHS England Commissioning through Evaluation process has shown that SABR can be safely delivered in the UK [2,3]. SABR requires specialist multidisciplinary expertise. The majority of radiotherapy departments are planning to maintain their capacity for category 1–4 treatments [4] and many have therefore suspended SABR for oligometastatic disease. However, we are concerned that diminishing access to SABR, at a time when access to other curative local treatment modalities is already restricted, will result in poorer patient outcomes in the short and medium term when this need not be the case. Patients with liver-limited colorectal cancer have a 5-year survival of 40% following surgery [5]. Given the evidence supporting SABR for colorectal liver metastases [6], we believe that this should be prioritised if patients are unable to access surgery and interventional ablative techniques. Similarly, SABR should be considered for patients with hepatocellular carcinoma while access to other services (particularly transplant) is limited. We urge radiotherapy departments to preserve access to SABR for patients in these situations, particularly as the COVID-19 pandemic wanes and staffing levels allow the re-establishment of normal services. Conflicts of interest The authors declare no conflicts of interest.

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          Colorectal Liver Metastases: A Critical Review of State of the Art

          Background: Over 50% of patients with colorectal cancer will develop liver metastases. Only a minority of patients present with technically resectable disease. Around 40% of those undergoing surgical resection are alive five years after their diagnosis compared with less than 1% for those with disseminated disease treated with systemic chemotherapy. Surgical resection remains the only possibility for long-term survival for these patients and great efforts have been made to increase the rates of resection whilst improving long-term outcomes. Summary: This review considers current technical and oncological criteria for resection, as well as targeted approaches to stratify underlying tumor biology in order to better predict long-term benefit. The role of neoadjuvant and perioperative systemic chemotherapy is critically reviewed, with suggestions for patient stratification in order to identify those who are likely to derive the greatest benefit. The key role of multidisciplinary assessment and decision making for these complex patients is also discussed. Key Messages: Surgery remains the optimal treatment for colorectal liver metastases (CRLM). Despite the curative intent of surgical resection, the majority of patients develop recurrence. Surgical strategies should therefore be adopted to maximize the potential for repeat resections in the event of recurrence. Although a number of preoperative prognostic markers have been identified, none are absolute contraindications to resection. In order to reduce postoperative recurrence, neo-adjuvant chemotherapy is now the standard of care in a number of countries. The evidence base for this approach is contentious, and the potential benefit of such a strategy is likely to be greatest in patients with high oncological risk disease. Multidisciplinary care is essential to ensure the optimal management of these complex patients. In addition, all patients with CRLM should be discussed with specialist hepatobiliary surgeons.
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            Stereotactic body radiotherapy for colorectal cancer liver metastases: A systematic review

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              Author and article information

              Journal
              Clin Oncol (R Coll Radiol)
              Clin Oncol (R Coll Radiol)
              Clinical Oncology (Royal College of Radiologists (Great Britain)
              The Royal College of Radiologists. Published by Elsevier Ltd.
              0936-6555
              1433-2981
              1 May 2020
              1 May 2020
              Affiliations
              []The Royal Marsden NHS Foundation Trust, London, UK
              []University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
              []Department of Medical Physics and Biomedical Engineering, University College London, London, UK
              [§ ]Beatson West of Scotland Cancer Centre, Glasgow, UK
              []CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
              [|| ]Mount Vernon Cancer Centre, Northwood, UK
              [∗∗ ]The Christie NHS Foundation Trust, Manchester, UK
              Author notes
              []Address for correspondence: K. Aitken.
              Article
              S0936-6555(20)30192-8
              10.1016/j.clon.2020.04.012
              7252179
              32387045
              © 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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              Oncology & Radiotherapy

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